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385
Landmark Research
Young, et al. The Dialysis Outcomes and Practice Patterns
Study (DOPPS): An international hemodialysis study. Kidney
International. 2000; 57(74):S-74–S-81.
• DOPPS is an international prospective observational
study of hemodialysis patients which began in 7 countries
including the United States and has since expanded to 12
countries. This study aims to identify practice patterns
associated with the best outcomes over time.
• DOPPS demonstrated that dialysis patients have a higher
mortality in the United States compared to Japan and
Europe which has been attributed to differences in prac-
tice patterns, particularly the type of vascular access at
initiation of dialysis and length of dialysis sessions.
Astor B C, Eustace J A, Powe N R, Klag M J, Fink N E,
Coresh J, CHOICE Study Type of vascular access and sur-
vival among incident hemodialysis patients: the Choices for
Healthy Outcomes in Caring for ESRD (CHOICE) Study. J
Am Soc Nephrol. 2005;16 (5):1449–1455.
• CHOICE is a longitudinal observational cohort study of
1041 incident dialysis patients funded by AHRQ to mea-
sure several aspects of patients’ experiences and outcomes
related to modality of renal replacement therapy.
• Survival rates stratified by the type of access in use dem-
onstrated annual mortality rates of 11.7% for AVF, 14.2%
for AVG, and 16.1% for CVC. Adjusted relative hazards
(RH) of death compared with AVF were 1.5 for CVC and
1.2 for AVG.These results strongly support existing clinical
practice guidelines that the use of venous catheters should
be minimized to reduce the complications and to improve
patient survival.
Lok CE, Huber TS, Lee T, etal.; KDOQI Vascular Access
Guideline Work Group. KDOQI clinical practice guideline
for vascular access: 2019 update. Am J Kidney Dis. 2020;75
(4)(suppl 2):S1–S164.
31 Hemodialysis Access Interventions
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• The latest evidence-based hemodialysis vascular access
guidelines provided by the multidisciplinary workgroup of
the National Kidney Foundation’s Kidney Disease
Outcomes Quality Initiative (KDOQI).
• The 2019 update introduces the concept of ESRD Life-
Plan, recommending a comprehensive evaluation of
patient’s needs and preferences and developing a contin-
gency plan on how to deal with vascular access complica-
tions during the initial planning of the first access. The
benefits of this patient-centered approach are preserving
vessels for future AV access, avoiding unnecessary proce-
dures, and limiting complications
Rajan DK, Ebner A, Desai SB, Rios JM, Cohn
WE. Percutaneous creation of an arteriovenous fistula for
hemodialysis access. J Vasc Interv Radiol. 2015;26
(4):484–490.
• Nonrandomized prospective study to evaluate safety and
efficacy of percutaneous system for creating AVF in dialy-
sis patients. The primary endpoints were successful cre-
ation of patent AVF, maturation over time, and adverse
events.
• 32 of 33 patients had successful AVF creation, cumulative
patency at 6months was 96%, mean time to maturation
was 58 days, and there was one series procedure-related
adverse event.
Lok CE, Rajan DK, Clement J, etal.; NEAT Investigators.
Endovascular proximal forearm arteriovenous fistula for
hemodialysis access: results of the prospective, multicenter
Novel Endovascular Access Trial (NEAT). Am J Kidney Dis.
2017; 70 (4): 486–497.
• Prospective, single-arm, multicenter study to evaluate
safety, efficacy, patency, and adverse effects of endovascu-
lar AVF creation.
• 80 patients enrolled, 98% with successful AVF creation,
8% had a serious procedure-related adverse event, func-
tional usability was 64% in participants who received
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dialysis, 12-month primary patency was 69%, and cumula-
tive patency was 84%.
Haskal ZJ, Trerotola S, Dolmatch B, Schuman E, Altman S,
Mietling S, Berman S, McLennan G, Trimmer C, Ross J,
Vesely T. Stent graft versus balloon angioplasty for failing
dialysis-access grafts. N Engl J Med. 2010 Feb 11;362
(6):494–503.
• Prospective, single-arm, multicenter trial to evaluate safety
and 6-month arteriovenous graft patency in patients with
venous anastomotic stenosis following balloon angioplasty
or stenting.
• Patients who underwent stenting had significantly greater
rates of patency at the site of the anastomotic stenosis and
overall patency of the access circuit at 6 months with
equivalent rates of adverse events.
Common Questions
What is a mature
fistula?
Fistula that can be repetitively
cannulated and provide adequate blood
flow for dialysis
How long does it
take for a fistula to
mature?
4–6weeks
What does primary
patency refer to?
Duration of access patency from the
date of vascular access creation/insertion
to thrombosis or any intervention to
facilitate, maintain, or re-establish
patency
What is the primary
complication that
leads to graft failure?
Stenosis with subsequent thrombosis
(continued)
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Hemodialysis Access Interventions
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What is the
underlying cause of
access stenosis?
Intimal hyperplasia as a result of injury
of the endothelium by surgical or
hemodynamic stress leading to reduction
of lumen size
What is the fistula
rule of 6s?
AVFs typically mature by 6weeks post
creation, should have a diameter of
6mm, be less than 6mm below the skin
surface, and have a flow rate greater than
600ml/min.
What is the life
expectancy of
autologous fistula
compared to graft?
3–7years compared to 1–2years
Further Reading
ACR-SIR practice parameters for endovascular management of
thrombosis or dysfunctional dialysis access. 2017. Available from:
https://www.acr.org/- /media/ACR/Files/Practice- Parameters/
Dysfunc-
DialysisMgmt.pdf?la=en.
Daugirdas JT, etal. K1DOQI clinical practice guideline for hemodi-
alysis adequacy: 2015 update. AJKD. 2015;66(5):884–930.
El Kassem M, etal. The role of endovascular stents in dialysis access
maintenance. Adv Chronic Kidney Dis. 2015;22(6):453–8.
Lee T. Fistula rst initiative: historical impact on vascular access
practice patterns and inuence on future vascular access care.
Cardiovasc Eng Technol. 2017;8(3):244–54.
Quencer KB, Arici M.Arteriovenous stulas and their characteristic
sites of stenosis. AJR Am J Roentgenol. 2015;205(4):726–34.
Sidawy AN, etal. The Society for Vascular Surgery: clinical practice
guidelines for the surgical placement and maintenance of arterio-
venous hemodialysis access. JVS. 2008;48(5 Suppl):2S–25S.
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389© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_32
Chapter 32
Hybrid andComplex
Aortic Aneurysm
Endovascular Repair
OmosalewaAdenikinju, SofiaC.D.Vianna,
andBrandonP.Olivieri
O. Adenikinju (*) · S. C. D. Vianna · B. P. Olivieri
Department of Vascular and Interventional Radiology, Mount Sinai
Medical Center, Miami Beach, FL, USA
Patient Evaluation
What preoperative
imaging should be
obtained for planning?
CT angiogram (CTA) of the chest and/
or abdomen and pelvis for chest and
abdominal aortic pathology.
CTA of the head and neck for aortic
arch pathology. This aids in evaluating
the integrity of the circle of Willis,
observing vertebral dominance, as well
as identifying anatomic variants, which
dictate treatment approach.
What are the indications
for complex aortic
repair?
Dissection, acute aortic injury
involving the arch (i.e., rupture), or
symptomatic or rapid growth of the
aneurysm, extending to involve branch
vessels or the proximal seal zone.
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What factors are
important in stratifying
patients to undergo
hybrid thoracic aortic
aneurysm repair over
open repair?
Patient factors: age> 65, renal failure,
CHF, and COPD
Surgical factors: unfavorable anatomy
for open repair and unable to tolerate
circulatory arrest
How is a complex hybrid
aortic repair staged?
Staging is appropriate when thoracic
and visceral or iliac artery treatments
are both needed or when a bypass
needs to be performed to maintain
branch vessel perfusion (carotid-
subclavian or external-internal artery
bypass).
What are the advantages
of thoracic aortic hybrid
procedures?
1.
Eliminate or decrease time
on extracorporeal membrane
oxygenation (ECMO) and
circulatory arrest
2. Decreased neurological
complications
3. Possibility of avoiding sternotomy
What are the
disadvantages of
thoracic hybrid
procedures?
1. Risk of bypass thrombosis
2. Technically challenging overall,
especially in patients with
unfavorable anatomy, such as steep
angulation which makes graft
deployment difficult
3.
Risk of interval aneurysmal
rupture between staged operative
interventions
What postoperative
factor makes staged
hybrid TEVAR ideal
over single-session
therapy?
Blood pressure management:
First stage (open repair): low
MAPs preferred postoperatively
in patients who have undergone
open repair with cardiopulmonary
bypass +/− hypothermia to prevent
postoperative bleeding
Second stage (endovascular): high
MAPs preferred to prevent cord
ischemia
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Relevant Anatomy
Complex Thoracic Aortic Aneurysm
Aortic Arch Variants
Arch type Branches (proximal to distal)
Normal arch 1. Brachiocephalic trunk
2. Left common carotid artery
3. Left subclavian
Bovine arch (10–20%) 1. Brachiocephalic trunk with left
common carotid artery
2. Left subclavian artery
Isolated vertebral
(2.5–6%)
1. Brachiocephalic trunk
2. Left common carotid artery
3. Left vertebral artery
4. Left subclavian artery
Aberrant right
subclavian (0.6%)
1. Right common carotid artery
2. Left common carotid artery
3. Left subclavian artery
4. Right subclavian artery
Type I Type II Type III
< 2 cm
> 2 cm
Types of Aortic Arch
• Type I: If the origins of all the great vessels arise within the
arc segment of the aortic arch subtended by the first paral-
lel reference line
• Type II: If the origins of all the great vessels are included
in the arc segment of the aortic arch subtended by the
second index line
• Type III: If the origins of all of the great vessels are
included in the arc segment of the aortic arch subtended
by the third index line
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Zone 0
Zone 1
Zone 2
Zone 3
Zone 4
LSA
LCCA
BCA
What are the landing zones for
thoracic aortic interventions
(Preventza, Xydas)?
Zone 0: Proximal to the right
brachiocephalic artery
Zone 1: Between the right
brachiocephalic and left
common carotid arteries
Zone 2: Between the left
common carotid and left
subclavian arteries
Zone 3: Proximal descending
aorta, distal to the LSA
Zone 4: Mid-descending aorta
Where is the aneurysm or
pathology located in a zone 0
repair?
Transverse arch and/or proximal
thoracic aorta
Where is the aneurysm or
pathology located in a zone 1
repair?
Mid to distal arch +/− into the
descending thoracic aorta
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Complex Abdominal Aortic Aneurysm
What
defines a
complex
AAA?
Neck length of < 15mm, an aortic neck diameter of
> 25mm, and aortic neck angulation of ≥ 45° and
< 10mm of infrarenal aorta free of aneurysm
Involvement of at least one of its visceral branches such
as renal, superior mesenteric, or celiac vessels
Crawford-type IV thoracoabdominal aortic aneurysm
(TAAA) aneurysm that extends from the 12th intercostal
space to the iliac bifurcation involving the visceral aortic
segment and the origins of the renal, superior mesenteric,
and celiac arteries (EVT type IV, etc.)
Crawford classification (TAAA 1986)
Type I Below the left subclavian artery to above renal arteries
Type II Below the left subclavian artery to aortic bifurcation
Type III 6th intercostal space to aortic bifurcation
Type IV 12th intercostal space to aortic bifurcation
Type V 6th intercostal space to above renal arteries
High Yield
What is the basic
principle of complex
thoracic hybrid repair?
Creating a way to maintain perfusion
of the great vessels after ligation/
embolization of their origin at the
arch, followed by aortic stent graft
delivery to treat underlying pathology
Most purely endovascular
thoracic aortic repairs are
performed for pathology
most commonly in which
zone?
Zone 4 (mid-descending aorta).
Current investigations are underway
examining technical success and
safety of treating arch aneurysms
and acute aortic injuries, including
dissections in zones 0–2.
What are the types
of EVAR options for
complex aortic repair?
The exclusively endovascular
repairs are divided into parallel
and nonparallel grafts, based on the
orientation of the branched stents in
comparison with the main aortic grafts.
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Endovascular Hybrid
Parallel Nonparallel
Debranching
EVAR
chEVAR (chimney
aka snorkel)
Fenestrated
Periscope or
reverse chimney
Branched
Sandwich
a
EVAS (endovascular
aneurysm sealing)
a
Reference: Hybrid Repair of Suprarenal Abdominal Aortic
Aneurysm: Antegrade Debranching with Endovascular Aneurysm
Repair
a
Denotes only in complex AAA repair
chEVAR
Gutter
Main aortic graft
Aorta
L renal artery
R renal ar
tery
Ch
Ch
What is a
chEVAR?
Chimney or snorkeling is also known as chEVAR
and involves the placement of single or multiple
stents in parallel to the main aortic graft. In order
to maintain perfusion to the visceral vessels, these
stents begin in the parent vessel adjacent to the
edge or sealing zone of the main aortic graft and
extend into branch vessels, which would normally
be excluded by the main aortic graft.
O. Adenikinju et al.
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