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• Meta-analysis comparing open and endovascular repair of
popliteal artery aneurysm demonstrating no difference in
long-term patency. Endovascular repair was associated
with decreased operative time and length of stay, however,
with increased risk of thrombosis/reintervention at 30days.
Open Versus Endovascular Repair of Popliteal Artery
Aneurysm Trial. Available from: https://clinicaltrials.gov/ct2/
show/NCT01817660. NLM identifier: NCT01817660.
• The Open Versus Endovascular Repair of Popliteal Artery
Aneurysm (OVERPAR) trial was a highly anticipated,
prospective, multicenter, randomized clinical trial which
began in 2013 and was expected to be the largest study to
date to guide treatment in patients with popliteal artery
aneurysm. The study was unfortunately terminated in 2017
due to difficulty in recruiting patients.
• Nevertheless, since the beginning of this trial, multiple
studies have compared the outcomes of open versus endo-
vascular repair of popliteal artery aneurysm.
Endovascular versus open repair of asymptomatic popli-
teal artery aneurysm. Cochrane Rev. 2014.
• At the time of publication, only one randomized con-
trolled trial compared endovascular stent-grafting with
conventional open surgery for unilateral or bilateral repair
of asymptomatic popliteal artery aneurysm (n=15in each
group). Given no clear difference in patency rates after 1
and 4years between the two groups, it was concluded that
endovascular repair of popliteal artery aneurysm should
be a viable alternative to open repair on a case-by-case
basis.
Eslami MH, Rybin D, Doros G, Farber A.Open repair of
asymptomatic popliteal artery aneurysm is associated with
better outcomes than endovascular repair. J Vasc Surg.
2015;61(3):663–9.
• At the time of publication, this was the largest retrospec-
tive comparative analysis demonstrating increased
J. Chen and A. Ramjit
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375
frequency of major adverse limb events at 1 year with
endovascular repair compared to open repair.
Shahin Y, Barakat H, Shrivastava V. Endovascular versus
open repair of asymptomatic popliteal artery aneurysms: a
systematic review and meta-analysis. J Vasc Interv Radiol.
2016; 27:715–722.
• The authors concluded that although endovascular repair
is associated with shorter length of hospital stay, the rate of
12-month primary patency was better with open repair.
Additionally, there are superior perioperative outcomes
(graft occlusion and reintervention rate) with open repair.
Leake AE, Segal MA, Chaer RA, etal. Meta-analysis of
open and endovascular repair of popliteal artery aneurysms.
J Vasc Surg. 2017; 65(1): 246–56.
• At the time of publication, this study represented the larg-
est published analysis of popliteal artery aneurysms, dem-
onstrating that endovascular repair afforded fewer wound
complications and shorter length of stay, however, with the
cost of an inferior primary patency at 3years.
Common Questions
What is the
average dose of
thrombin needed in
ultrasound-guided
thrombin injection
of PSA?
An average of 300 u (0.3ml) of thrombin
will result in stasis within a PSA.
What is the
appropriate
duration of
antiplatelet therapy?
There is currently no specified duration
of antiplatelet therapy. Various studies
have described postoperative antiplatelet
therapy ranging from 3weeks to lifelong
treatment.
(continued)
30 Peripheral andVisceral Artery Aneurysm
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376
What is the
“double rupture”
phenomenon
regarding visceral
arterial aneurysm
(VAA)?
The initial sudden onset abdominal or
chest pain associated with aneurysm
rupture stabilizes secondary to temporary/
local tamponade. 6–96hours later, sudden
onset cardiovascular collapse results due to
internal hemorrhage.
What is the
most common
presentation
of renal artery
aneurysm?
Hypertension
Type II endoleak
after popliteal
artery aneurysm
repair is secondary
to backflow from
what vessel?
Geniculate artery
What is
Kommerell’s
diverticulum?
Aneurysmal origin of an aberrant left
subclavian artery in the setting of a right-
sided aortic arch
Which type of
aneurysm is more
likely to rupture:
True or false
aneurysm (PSA)?
False aneurysms, without all three layers of
arterial wall, are more likely to rupture.
Further Reading
Alemany J, Görtz H, Schaarschmidt K. Peripheral arterial aneu-
rysms. In: Chang JB, editor. Textbook of angiology. New York:
Springer; 2000.
Bajzer CT. Arterial supply to the upper extremities. In: Bhatt DL,
editor. Guide to peripheral and cerebrovascular intervention.
London: Remedica; 2004.
Dawson J, Fitridge R.Update on aneurysm disease: current insights
and controversies: peripheral aneurysms: when to intervene– is
rupture really a danger? Prog Cardiovasc Dis. 2013;56(1):26–35.
J. Chen and A. Ramjit
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377
Eslami MH, Rybin D, Doros G, etal. Open repair of asymptomatic
popliteal artery aneurysm is associated with better outcomes
than endovascular repair. J Vasc Surg. 2015;61(3):663–9.
Gupta PN, Basheer AS, Sukumaran GG, etal. Femoral artery pseu-
doaneurysm as a complication of angioplasty. How can it be
prevented? Heart Asia. 2013:144–7.
Hall HA, Minc S, Babrowski T. Peripheral artery aneurysm. Surg
Clin N Am. 2013;93:911–23.
Joshi D, James RL, Jones L. Endovascular versus open repair of
asymptomatic popliteal artery aneurysm. Cochrane Database
Syst Rev. 2014;(8):CD010149.
Leake AE, Segal MA, Chaer RA, etal. Meta-analysis of open and
endovascular repair of popliteal artery aneurysms. J Vasc Surg.
2017;65(1):246–56.
Lovegrove RE, Javid M, Magee TR, etal. Endovascular and open
approaches to non-thrombosed popliteal aneurysm repair: a
meta-analysis. Eur J Vasc Endovasc Surg. 2008;36:96–100.
Mohan IV, Stephen MS. Peripheral arterial aneurysms: open or
endovascular surgery? Prog Cardiovasc Dis. 2013;56(1):36–56.
Neglén P, Tackett TP Jr, Raju S.Venous stenting across the inguinal
ligament. J Vasc Surg. 2008;48(5):1255–61.
Open versus endovascular repair of popliteal artery aneurysm trial.
Available from: https://clinicaltrials.gov/ct2/show/NCT01817660.
NLM identifier: NCT01817660. Accessed 31 Aug 2018.
Patel SR, Hughes CO, Jones KG, et al. A systematic review
and meta-analysis of endovascular popliteal aneurysm repair
using the Hemobahn/Viabahn stent-graft. J Endovasc Ther.
2015;22(3):330–7.
Ronchey S, Pecoraro F, Alberti V.Popliteal artery aneurysm repair in
the endovascular era. Medicine (Baltimore). 2015;94(30):e1130.
Shahin Y, Barakat H, Shrivastava V. Endovascular versus open
repair of asymptomatic popliteal artery aneurysms: a systematic
review and meta-analysis. J Vasc Interv Radiol. 2016;27:715–22.
Uflacker R.Atlas of vascular anatomy, an angiographic approach.
Philadelphia: Lippincott Williams & Wilkins; 2007.
Wissgott C, Lüdtke CW, Vieweg H, etal. Endovascular treatment of
aneurysms of the popliteal artery by a covered endoprosthesis.
Clin Med Insights Cardiol. 2014;8(Suppl 2):15–21.
30 Peripheral andVisceral Artery Aneurysm
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379© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_31
Evaluating Patient
What are the important
factors to consider in
vascular access selection?
Life goals and life expectancy,
timing and length of HD therapy,
comorbidities, and risk of access-
related complications
What is the appropriate
imaging modality for
vascular access patency
surveillance?
Duplex ultrasound
What are the clinical
findings suggestive of
vascular access failure?
Pulsatile flow, absent or weak thrill,
low flows during dialysis, prolonged
bleeding after needle removal, and
increased venous pressures
What clinical finding
suggests central venous
stenosis?
Ipsilateral arm, chest wall, or facial
edema
Chapter 31
Hemodialysis Access
Interventions
RanaRabei
R. Rabei (*)
UCSF Interventional Radiology, San Francisco, CA, USA
e-mail: rana.rabei@ucsf.edu
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High Yield History
What is the
prevalence of
ESRD?
Over 650,000 annually in the United States
What are the two
major categories
of HD vascular
access?
Central venous catheters, referred to as
“temporary” access, and arteriovenous
access, referred to as “permanent” access
What is the
preferred mode of
access for HD?
Autologous AVF due to better patency rates
and lower rates of infection, associated with
lowest mortality rates and lowest rates of
re-intervention compared to AVG and CVC
What is the
significance of
Fistula First
Initiative?
A collaborative quality improvement
initiative between with the Centers for
Medicare and Medicaid Services (CMS)
and the ESRD Network that began in 2003
to increase AVF use among hemodialysis
patients
Indications/Contraindications
When is placement of non-
tunneled catheters for HD
indicated?
Temporary dialysis access for acute
HD needs, not recommended for
use longer than 1week
What are indications for
fistulogram?
Clinical signs of graft dysfunction,
decreased intra-access blood
flow during hemodialysis, and
evaluation of non-maturing fistulas
When is angioplasty of
dialysis graft or fistula
indicated?
A stenosis causing greater than
50% reduction in luminal diameter
and clinical indicator of graft
failure
What are the procedures
available to salvage a
thrombosed fistula?
Surgical thrombectomy and
endovascular catheter-directed or
mechanical thrombectomy
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Why is stent use limited in
treatment of AVF or AVG
stenosis?
Relative high complication rates
including stent migration, fracture,
and infection
What are the relative
contraindications for
endovascular access site
interventions?
Severe contrast allergy and
coagulopathy
What is an absolute
contraindication for venous
access intervention?
Active infection
Relevant Anatomy
What are the common sites
of AVF formation?
Wrist/forearm, radiocephalic;
upper arm, brachiocephalic or
brachiobasilic
What are the common sites
for AVG formation?
Forearm, brachiocephalic (looped);
upper arm, brachiobasilic or
brachioaxillary
What is the first choice for
AVF access?
Radiocephalic, due to relative
lower rates of steal syndrome and
preservation of future opportunities
for more proximal fistulas
What is the most
common site of stenosis
in a radiocephalic dialysis
fistula?
Juxta-anastomotic segment
What is the most common
site of stenosis in a
brachiocephalic dialysis
fistula?
Cephalic arch stenosis
What is the most common
site of stenosis in a
brachiobasilic dialysis
fistula?
Proximal swing segment
(continued)
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Hemodialysis Access Interventions
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What is the most common
site of stenosis in a dialysis
graft?
Venous anastomotic stenosis
Relevant Materials
What is the
preferred method
of intervention for
graft stenosis?
Percutaneous transluminal angioplasty
(PTA)
What are the
preferred types of
balloons for PTA of
stenotic lesions?
High-pressure noncompliant balloons.
Less commonly cutting balloons and drug-
coated balloons (DCBs). High-pressure
PTA and cutting balloons are popular in
in-stent restenosis. Recent data supports
use of DCBs in recurrent (< 90days)
stenoses or stenoses involving the swing
segment or cephalic arch.
What is the
recommended stent
type in salvage AV
access procedures?
Self-expanding covered stents
What are the two
FDA-approved
endovascular AVF
devices on the
market?
Ellipsys and WavelinQ EndoAVF which
use thermal energy to fuse arterial and
venous walls and create a percutaneous
anastomosis
General Step by Step
What imaging
modality is useful
to determine
optimal access site
for fistulogram?
Ultrasound
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What is the
most common
access point for
fistulogram?
Anterograde puncture toward the venous
outflow, just beyond the arterial anastomosis
What areas should
be evaluated
by diagnostic
fistulogram?
Entire access including arterial anastomosis,
fistula or graft, outflow veins including vena
cava, and right atrium
What angiography
finding is
suggestive
of significant
upstream
obstruction?
Presence of significant venous collaterals
What is the utility
of nitroglycerin in
fistulography?
Treatment of arterial or venous spasms
What is the basic
technique of
PTA for stenotic
lesions?
Angioplasty catheter is inserted over
guidewire and positioned across the lesion.
Balloon is then inflated until a waist is
visualized and eliminated. The balloon size
is chosen based on visual estimation of the
diameter of the vessel.
What is a
successful
angioplasty
procedure?
Increased luminal diameter, visualization
and elimination of waist angiographically,
improved physical exam, and resolution of
clinical symptoms
What factors
should be
considered in
stenting stenotic
lesions that fail
PTA?
The diameter, length and location of lesion,
and availability of surgical options
What medication
is typically given
during declot
procedure?
5000U of heparin and/or tissue plasminogen
activator (tPA)
(continued)
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Hemodialysis Access Interventions
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What are
examples of declot
techniques?
Balloon maceration of clot, infusion of
access with thrombolytic agents, catheter-
directed thrombectomy and thrombolysis
using devices such as Arrow-Trerotola
percutaneous thrombolytic device (PTD)
(Arrow International, a division of Teleflex,
Durham, NC), AngioJet Peripheral
Thrombectomy System (Boston Scientific,
Natick, MA), and Trellis-8 peripheral
infusion system (Covidien, Mansfield, MA)
What is a common
technique for
addressing arterial
anastomotic
stenosis/plug?
Advancing a Fogarty balloon (Edwards
Lifesciences; Irvine, California) through
the retrograde sheath across the arterial
anastomosis. Inflating the balloon and
pulling back across the arterial anastomosis
into the access
Complications
What is the most common
complication of CVC?
Infection
What is the management
for CVC infection?
Obtain cultures, perform appropriate
antibiotic therapy, and catheters
should be removed and replaced at a
different site.
What are possible
complications of PTA
treatment of failing
fistula?
Angioplasty-induced rupture (2–3%),
bleeding from access site, persistent
stenosis, and embolism
What is steal syndrome? Low blood flow or ischemia to the
extremity occurring due to flow into
the fistula
R. Rabei
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