Is Surgical Thrombectomy to Salvage Failed Autogenous Arteriovenous Fistulae Worthwhile?

The Dialysis Outcomes Quality Initiatives guidelines emphasize placement of autogenous arteriovenous (AV) fistulae for patients on hemodialysis. This recommendation is based on studies that demonstrate enhanced patency for AV fistulae compared with grafts. However, closer review of the data demonstrates that although primary patency of AV fistulae is superior to grafts, the secondary patency rates are equivalent. This suggests that secondary procedures to maintain fistula patency are inferior to those performed on arteriovenous grafts. Surgical thrombectomy of AV fistulae can be challenging. It is often difficult to completely remove thrombus adjacent to the anastomosis of the fistula, and pseudoaneurysms within the fistula can prevent passage of the thrombectomy catheter and complete removal of thrombus from the fistula. Consequently, some surgeons simply abandon thrombosed AV fistulae and place a new access. We have developed a method for completely clearing thrombus from failed AV fistulae by locating the fistulotomy close to the arterial anastomosis and using a technique to manually extract thrombus from the fistula before passing a thrombectomy catheter. The purpose of this study was to review our results with this procedure. Between 2001 and 2004, 10 patients with a previously functioning AV fistula presented with thrombosis. There were seven brachiocephalic fistulae and three radiocephalic fistulae. All patients underwent surgical thrombectomy and fistulography. Five patients underwent balloon angioplasty of a venous stenosis and one patient underwent surgical revision of an arterial stenosis. Technical success, defined as being able to completely clear thrombus from the fistula and treat the cause for fistula failure, was achieved in 70 per cent (7/10) of cases. Technical failure was caused by vein rupture during the balloon angioplasty in two cases and a central venous occlusion that could not be treated in one case. The 6-month primary and secondary patency for cases that were technically successful was 51 and 69 per cent, respectively. Our conclusion was that surgical thrombectomy can significantly extend fistula functionality in patients who present with thrombosis.

Download Full-text

Vacuum-assisted mechanical thrombectomy in extensively occlusive thrombosis of dialysis arteriovenous grafts with indigo system

The Journal of Vascular Access ◽

10.1177/1129729819899264 ◽

2020 ◽

Vol 21 (5) ◽

pp. 673-679

Author(s):

Filippo Piacentino ◽

Andrea Coppola ◽

Andrea Zaghetto ◽

Edoardo Macchi ◽

Giuseppe De Marchi ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Clinical Success ◽

Primary Patency ◽

Secondary Patency ◽

Technical Failure ◽

Arteriovenous Graft ◽

Venous Outflow ◽

Percutaneous Mechanical Thrombectomy ◽

Arterial Inflow ◽

Surgical Thrombectomy

Purpose: To present a selected series of extensively occlusive thrombosis of arteriovenous graft treated with the Penumbra’s Indigo System. Materials and Methods: Ten patients with acute (within 72 h) extensively occlusive thrombosis of arteriovenous graft (mean extension = 30.1 (range = 15–45) cm) were treated at our institution with the Indigo System. Of the 10 cases, thrombosis was extended to venous outflow in 7 cases and to both arterial inflow and venous outflow in 3 cases. Results: Both anatomic and clinical success were achieved in 8 of the 10 procedures (80.0%). In the 2 cases of technical failure, the patients underwent surgical thrombectomy with the finding of arteriovenous graft exhaustion, which was then replaced. The 6-month primary patency, primary-assisted patency, and secondary patency rates were 37.5% (3/8), 50.0% (4/8), and 62.5% (5/8). We reported 2 complications (one minor and one major adverse event). Conclusion: Percutaneous mechanical thrombectomy aspiration with Indigo System is a relatively safe and effective procedure and can be used even in extensively thrombosed arteriovenous graft.

Download Full-text

P1329STENTING VERSUS ISOLATED BALLOON ANGIOPLASTY FOR CENTRAL VEIN STENOSIS IN HEMODIALYSIS PATIENTS

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p1329 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Aleksei Zulkarnaev ◽

Zurab Kardanakhishvili ◽

Boris Baykov

Keyword(s):

Balloon Angioplasty ◽

Primary Patency ◽

Endovascular Intervention ◽

Time Interval ◽

Central Vein ◽

Secondary Patency ◽

Surgical Interventions ◽

Endovascular Interventions ◽

Vein Stenosis ◽

Central Vein Stenosis

Abstract Background and Aims comparative analysis of the results of isolated balloon angioplasty (BA) and BA with stenting of central veins stenosis in patients on hemodialysis. Method A retrospective study included 62 patients with confirmed stenosis of the central veins: subclavian, brachiocephalic veins, vena cava inferior, or multiple lesions. In 39 patients, stents are not used; isolated balloon angioplasty (BA) was performed. In 23 patients we used bare metal stents. Results Functional primary patency (the time interval between the start of AVF using and the first endovascular intervention) did not differ in the groups – fig. 1A; HR 1.142 [95% CI 0.6875; 1.897], p = 0.5994. The use of stents leads to increase primary patency (the time interval between the first and second endovascular interventions) – fig. 1B; HR 2.064 [95% CI 1.252; 3.404], p = 0.0017. The use of stents allows to increase the functional secondary patency (total duration of use of the AVF) – fig 1C; HR 2.099 [95% CI 1.272; 3.463], p = 0.0016. Secondary patency (the time interval between the first endovascular intervention and the complete cessation of the use of AVF) was higher after BA with stenting: HR 2.03 [95% CI 1.232; 3.347], p = 0.0021; fig 1D. The use of stents allows to increase functional primary assisted patency (non-occlusive period from the start of AVF use) – fig. 1E and primary assisted patency (non-occlusive period from the first surgical intervention) – fig 1F: HR 1.936 [95% CI 1.175; 3.188], p= 0.0053 and HR 2.0 [95% CI 1.213; 3.295], p = 0.0042. The need for open reconstructive interventions after the first BA or BA with stenting was the same 0.374 [95% CI 0.24; 0.556] and 0.45 [95% CI 0.291; 0.664] per 10 patient-months, incidence rate ratio (IRR)= 0.831 [95% CI 0.471; 1.464] р=0.521. The need for endovascular interventions did not differ between isolated BA and BA with stenting 1.137 [95% CI 0.8913; 1.43] and 0.827 [95% CI 0.606; 1.104] per 10 patient-months, IRR=1.374 [95% CI 0.952; 1.999] p=0.09. Total need for surgical interventions (open + endovascular) also did not differ: 1.511 [95% CI 1.225; 1.843] and 1.277 [95% CI 0.997; 1.611] per 10 patient-months, IRR 1.183 [95% CI 0.872; 1.612] p=0.2822. We found a strong negative correlation between functional primary patency and primary patency (r = -0.627; p <0.0001) – fig. 2, as well as a between functional primary patency and secondary patency in patients after isolated BA (= -0.53; p = 0.0005, respectively), but not after stenting (r = -0.351; p = 0.101 and r = -0.304; p = 0.159, respectively). In a case of isolated BA, the success of the first intervention largely determines the secondary patency, which is expressed in a strong, statistically significant positive correlation of primary patency and secondary patency. In a case of BA with stenting, the correlation between these estimates is also statistically significant, but significantly lower. Conclusion 1. The results of balloon angioplasty without stenting are significantly influenced by the duration of the period between the start of AVF use and the manifestation of central vein stenosis. 2. The use of stents can slightly improve the results of endovascular interventions in central vein stenosis, regardless the its time of development. 3. The use of stents leads to a moderate increase in the median patency of AVF and a significant increase in the proportion of patients with functional AVF in the late postoperative period. 4. The use of stents does not reduce the need for surgical interventions

Download Full-text

Long-Term Outcomes of Staged Basilic Vein Transposition for Hemodialysis Access in Children

The Journal of Vascular Access ◽

10.5301/jva.5000778 ◽

2017 ◽

Vol 18 (5) ◽

pp. 366-370 ◽

Cited By ~ 1

Author(s):

Elias Kfoury ◽

Christopher J. Demaree ◽

Mun J. Poi ◽

Jesus M. Matos ◽

Carlos F. Bechara ◽

...

Keyword(s):

Tertiary Care ◽

Primary Patency ◽

Secondary Patency ◽

Hemodialysis Access ◽

Basilic Vein ◽

Long Term Outcomes ◽

Av Fistula ◽

Functional Maturation

Introduction Children requiring long-term hemodialysis often face significant challenges due to their young age and small-vessel caliber for arteriovenous (AV) access creation. In this study, we report our experience of staged basilic vein transposition (BVT) in pediatric patients. Methods All patients undergoing staged BVT at a tertiary care pediatric hospital from 2003 to 2015 were reviewed. Indications for staged BVT included inadequate cephalic conduit or failed AV fistula using cephalic vein. Pertinent clinical variables were analyzed to determine treatment outcomes. Results Forty-two children (24 males, 57%) underwent 46 staged BVT during the study period. Median age was 12.8 ± 4.8 years (range 3-18). The mean weight was 47 ± 5.1 kg (range, 13-126 kg), with four children (10%) weighing ≤20 kg. Mean operative times for initial brachiobasilic AV fistula and staged BVT were 39 ± 12 minutes and 66 ± 17 minutes, respectively. Mean follow-up period was 5.4 ± 1.8 years. Functional maturation was achieved in 93% of BVTs. Early fistula thrombosis within 30 days following BVT occurred in four patients (10%). Late BVT thrombosis occurred in 13 patients (31%). Primary patency rates at 2 years and 4 years were 78% and 72%, respectively. Secondary patency rates at 2 years and 4 years were 86% and 82%, respectively. Conclusions Staged BVT is a durable and reliable autologous hemodialysis access in children who do not have adequate cephalic venous conduit.

Download Full-text

Primary and secondary patencies of transposed femoral vein fistulas are significantly greater than with the HeRO graft

The Journal of Vascular Access ◽

10.5301/jva.5000697 ◽

2017 ◽

Vol 18 (3) ◽

pp. 232-237 ◽

Cited By ~ 7

Author(s):

Eric D. Ladenheim ◽

Dzenan Lulic ◽

Craig Lum ◽

Sid Agrawal

Keyword(s):

Wound Healing ◽

Femoral Vein ◽

Primary Patency ◽

Secondary Patency ◽

Central Venous ◽

Av Fistula ◽

Central Venous Stenosis ◽

Venous Stenosis ◽

One Year ◽

The One

Introduction For access-challenged patients with bilateral upper extremity central venous stenosis, solutions include the Hemodialysis Reliable Outflow (HeRO) device or an autogenous AV fistula in the lower limb. We evaluated HeRO grafts and transpositions of the femoral vein in maintaining primary and secondary patency. Methods We retrospectively analyzed 40 patients with a HeRO device and 18 patients with superficial femoral artery to transposed femoral vein autogenous arteriovenous fistula (SFA-tFV). All patients had bilateral central venous obstruction. All procedures were outpatient performed by a single surgeon at one center between 2009-2015. Operative details, intraoperative flows, and flows at the first-week postoperative visit were analyzed, as were primary and secondary patency and intervention rates. Complications were compared between groups. Results The one-year cumulative primary patency was 30% for HeRO grafts and 79% for SFA-tFV fistulas (p = 0.0001); secondary patency was 71% for HeRO grafts and 93% for SFA-tFV fistulas (p = 0.03). To maintain patency, HeRO patients required a mean 2.1 interventions per year and thigh fistula patients required a mean 0.4 interventions per year. Thirty-seven percent of thigh fistula patients had a hematoma or seroma versus 5% of HeRO patients and 17% of thigh fistula patients experienced delayed wound healing versus 2.5% of HeRO patients (p<0.05). None of the thigh fistula patients had distal ischemia. Conclusions HeRO patients had lower primary and secondary patency rates versus thigh fistula patients and HeRO grafts required five-fold more interventions to maintain secondary patency. However, patients with thigh fistulas had significantly more wound healing problems. Thus, the SFA-tFV has become our access of choice for patients with bilateral central venous stenosis.

Download Full-text

SIroliMus coated angioPlasty versus plain balloon angioplasty in the tREatment of dialySis acceSs dysfunctION (IMPRESSION): study protocol for a randomized controlled trial

Trials ◽

10.1186/s13063-021-05920-3 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Suh Chien Pang ◽

Ru Yu Tan ◽

Edward Choke ◽

Jackie Ho ◽

Kiang Hiong Tay ◽

...

Keyword(s):

Arteriovenous Fistula ◽

Balloon Angioplasty ◽

Target Lesion ◽

Primary Patency ◽

Central Vein ◽

Secondary Patency ◽

Dialysis Access ◽

Residual Stenosis ◽

Randomized Controlled ◽

Link Type

Abstract Background Percutaneous transluminal angioplasty is the current standard treatment for arteriovenous fistula (AVF) stenosis. The mid- and long-term patency with plain balloon angioplasty (PBA) is however far from satisfactory. While paclitaxel-coated balloon angioplasty has been shown to be superior to PBA, concern over its safety profile has recently arisen after a reported possible increased mortality risk with a meta-analysis of large lower limb studies. An angioplasty balloon with a new type of drug coating, the sirolimus-coated balloon (SCB), has been proven to improve patency in the coronary arteries. However, its effect on AV access has yet to be studied. Methods/design This is an investigator-initiated, prospective, multicenter, double-blinded, randomized controlled clinical trial to assess the effectiveness of SCB compared to PBA in improving the patency of AVF after angioplasty. A total of 170 patients with mature AVF that requires PTA due to AVF dysfunction will be randomly assigned to treatment with a SCB or PBA at a 1:1 ratio, stratified by location of AVF and followed up for up to 1 year. The inclusion criteria include [1] adult patient aged 21 to 85 years who requires balloon angioplasty for dysfunctional arteriovenous fistula [2]; matured AVF, defined as being in use for at least 1 month prior to the angioplasty; and [3] successful angioplasty of the underlying stenosis with PBA, defined as less than 30% residual stenosis on digital subtraction angiography (DSA) and restoration of thrill in the AVF on clinical examination. The exclusion criteria include thrombosed or partially thrombosed access circuit at the time of treatment, presence of symptomatic or angiographically significant central vein stenosis that requires treatment with more than 30% residual stenosis post angioplasty, and existing stent placement within the AVF circuit. The primary endpoint of the study is access circuit primary patency at 6 months. The secondary endpoints are target lesion primary patency; access circuit-assisted primary patency; access circuit secondary patency at 3, 6, and 12 months; target lesion restenosis rate at 6 months; total number of interventions; complication rate; and cost-effectiveness. The trial is supported by Concept Medical. Discussion This study will evaluate the clinical efficacy and safety of SCB compared to PBA in the treatment of AVF stenosis in hemodialysis patients. Trial registration ClinicalTrials.govNCT04409912. Registered on 1 June 2020

Download Full-text

Stenting versus balloon angioplasty alone in patients with below-the-knee disease: A propensity score-matched analysis

PLoS ONE ◽

10.1371/journal.pone.0251755 ◽

2021 ◽

Vol 16 (6) ◽

pp. e0251755

Author(s):

Jihun Ahn ◽

JinSu Byeon ◽

Byoung Geol Choi ◽

Se Yeon Choi ◽

Jae Kyeong Byun ◽

...

Keyword(s):

Propensity Score ◽

Clinical Outcomes ◽

Balloon Angioplasty ◽

Limb Ischemia ◽

Primary Patency ◽

Secondary Patency ◽

Stent Group ◽

Below The Knee ◽

Procedural Success

Percutaneous transluminal angioplasty (PTA) is considered an effective treatment in patients with critical limb ischemia (CLI). However, the long-term durability of below-the-knee (BTK) PTA is known to be limited. This study sought to compare the 1-year clinical outcomes following stenting versus balloon angioplasty alone in BTK lesions. This study included 357 consecutive patients (400 limbs, 697 lesions) with BTK lesions who underwent PTA from September 2010 to December 2016. All enrolled patients were treated either by stenting (stent group; 111 limbs of 102 patients) or plain old balloon angioplasty (POBA group; 289 limbs of 255 patients). Stent group includes both primary and provisional stenting. Angiographic outcomes, procedural success, complications, and clinical outcomes were compared between the two groups up to 1 year. After propensity score matching (PSM) analysis, 56 pairs were generated, and the baseline and angiographic characteristics were balanced. The procedural success and complications were similar between the two groups; however, the incidence of procedure-related perforation was higher in the POBA group than in the stenting group [5(11.9%) vs.1 (0.9%), P = 0.009]. Six- to 9-month computed tomography or angiographic follow-up showed similar incidences of binary restenosis, primary patency, and secondary patency. In the 1-year clinical follow-up, there were similar incidences of individual hard endpoints, including mortality, myocardial infarction, limb salvage, and amputation rate, with the exception of target extremity revascularization (TER), which tended to be higher in the stenting group than in the POBA group [21 (20.8%) vs. 11 (10.9%), P = 0.054]. Although there was a trend toward a higher incidence of TER risk in the stenting group, stent implantation, particularly in bail-out stenting seemed to have acceptable 1-year safety and efficacy compared to POBA alone in patients undergoing BTK PTA.

Download Full-text

Rotational atherectomy with adjunctive balloon angioplasty in calcified chronic total occlusions of superficial femoral artery

Vascular ◽

10.1177/1708538120970817 ◽

2020 ◽

pp. 170853812097081

Author(s):

Aysen Y Engin ◽

Onur Saydam

Keyword(s):

Balloon Angioplasty ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Primary Patency ◽

Rotational Atherectomy ◽

Secondary Patency ◽

Technical Success ◽

Technical Success Rate ◽

The Mean ◽

Drug Coated Balloon

Objectives The aim was to report the mid-term outcomes of Jetstream™ rotational atherectomy device in complex femoropopliteal lesions. Methods Between November 2016 and April 2018, 55 patients who were treated with rotational atherectomy and adjunctive balloon angioplasty due to complex femoropopliteal lesions were retrospectively scanned. Results Fifty-five patients who underwent endovascular treatment with rotational atherectomy for chronic total occlusive femoropopliteal lesions were included in the study. Technical success rate was 100%. The mean age was 63 (±10.5) years. The cohort included 25 (45.4%) diabetics and 45 (81.8%) current smokers. The mean length of the lesions was 20.8 ± 11.2 cm. Chronic total occlusive lesions were detected in 35 (63.6%) patients, and mixed-type steno-occlusive lesions were detected in 20 patients (36.4%). Thirty-three (60%) lesions were moderate or severely calcified. Adjunctive balloon angioplasty was performed with plain old balloon angioplasty (POBA) on 31 (56.4%) patients and with drug-coated balloon angioplasty on 24 (43.6%) patients. After adjunctive balloon angioplasty, flow limiting dissection was observed in 20 (36.3%) patients, and 17 (30.9%) patients needed stent implantation. The Kaplan–Meier analysis method estimated that the overall primary patency rates at 12 and 24 months were 81.8% and 70.9%, respectively. Overall, secondary patency rates at 12 and 24 months were 94.5% and 80%. No statistically significant differences of 24-month primary patency and secondary patency rates were found between patients treated with drug-coated balloon angioplasty and POBA as an adjunctive therapy, even though primary patency (83.3% vs. 61.3%, p = .06) and secondary patency (91.7% vs. 71%, p = .56) rates of drug-coated balloon angioplasty were slightly higher than POBA. Patients with claudication had better primary patency (90.5% vs. 58.8%, p = .001) and secondary patency (100% vs. 67.6%, p = .004) rates than patients with critical limb ischemia at 24 months. Significant differences between patients who did and did not stop smoking were found in 24-month primary patency (57% vs. 88%, p = .007) and secondary patency (67% vs. 96%, p = .007). Six patients underwent unplanned amputation. There were eight (14.5%) mortalities during follow-up. Conclusions Rotational atherectomy with adjunctive balloon angioplasty has satisfactory technical success rates and mid-term outcomes. As an adjunctive method, there was no difference between drug-coated balloon angioplasty s and POBAs. Smoking cessation is always the first-step treatment to improve mid-term patency results. Patients with critical limb ischemia have worse patency results compared to the patients with claudication.

Download Full-text

Efficacy of Primary Stent-Graft Placement in the Treatment of Vascular Access Graft Outflow Tract Stenosis

Vascular and Endovascular Surgery ◽

10.1177/1538574419873176 ◽

2019 ◽

Vol 54 (1) ◽

pp. 25-35

Author(s):

Edoardo Macchi ◽

Federico Fontana ◽

Alessandro Beneventi ◽

Marco Curti ◽

Chiara Tagliaferri ◽

...

Keyword(s):

Stent Graft ◽

Clinical Success ◽

Transluminal Angioplasty ◽

Primary Patency ◽

Outflow Tract ◽

Secondary Patency ◽

Technical Success ◽

Venous Outflow ◽

Surgical Thrombectomy ◽

Early Restenosis

Purpose: The aim of this study is to present our personal experience using covered nitinol stent-graft in the treatment of outflow tract stenosis of arteriovenous grafts (AVGs) for hemodialysis access. Materials and Methods: Between May 2015 and October 2017, we retrospectively evaluated 36 (24 males, 12 females; mean age: 65.6 years) patients with AVGs on hemodialysis who underwent percutaneous angioplasty followed by endovascular stent-graft deployment for the treatment of stenosis of the venous outflow of the AVG. Indication for treatment included early restenosis (<3 months after previous percutaneous transluminal angioplasty [PTA]), long stenosis (stenoses >50% extending for a length >5 cm), and recoil of the stenosis after PTA performed with a noncompliant high-pressure balloon. Of 36 patients, 27 (75%) required surgical thrombectomy prior to endovascular procedure. Technical success, clinical success, primary and secondary patency, and safety were evaluated. Results: Technical success was 100%, and clinical success was 94.4%. Primary patency was 94.4%, 72.2%, 63%, 45.9%, and 45.9% at 1, 3, 6, 12, and 18 months (average: 215 days, range: 9-653 days); secondary patency was 94.4% and 86.1% at 1 and 3 months; 80.4% at 6, 12, and 18 months; and 53.6% at 24 months (average: 276.8 days, range: 9-744 days). No deaths were registered. Conclusions: In selected cases, the use of stent-graft represents an effective and safe solution for the treatment of stenotic complications of the venous outflow of AVGs, even in the setting of access thrombosis.

Download Full-text

Patency Rates After Successful Arteriovenous Fistula Thrombectomy: Relevance of the Flow/d-Dimer Ratio in the Decision-Making

Vascular and Endovascular Surgery ◽

10.1177/1538574420945064 ◽

2020 ◽

Vol 54 (8) ◽

pp. 670-675

Author(s):

Fatih Gumus

Keyword(s):

Risk Factors ◽

Arteriovenous Fistula ◽

Area Under The Curve ◽

Primary Patency ◽

Study Cohort ◽

Secondary Patency ◽

Characteristic Analysis ◽

Surgical Thrombectomy ◽

Independent Risk Factors ◽

D Dimer

Objectives: Surgical thrombectomy for acute arteriovenous fistula (AVF) thrombosis is one of the primary salvage intervention. The independent risk factors affecting the patency of AVF after a successful thrombectomy are yet unknown. Here, the author aimed to report the results of surgically corrected AVFs and the independent risk factors which may cause early failure following the surgical salvage. Methods: The study cohort comprised 24 patients who had acute AVF thrombosis and underwent successful surgical thrombectomy in the first 24 to 48 hours between January 2016 and April 2020 in our center. The study group was divided into patients with recurrent AVF thrombosis (n = 11, 45.8%) and without recurrent AVF thrombosis (n = 13, 54.1%) following surgical thrombectomy with a follow-up of 22.4 ± 6.8 months. Postthrombectomy primary and secondary patency of AVF were also evaluated. Results: The mean age of the cohort was 58.1 ± 15.2 years. A simple thrombectomy was performed for all cases. Only 2 cases have required a revision at the anastomosis due to severe intimal hyperplasia. Postthrombectomy primary patency rate was 45.5% for 18 months. Receiver operating characteristic analysis was performed with a resulting area under the curve value of 0.81 (95% CI: 0.35-0.94, P = .006) for flow (mL)/d-dimer (ng/mL) <0.63 in predicting recurrent AVF thrombosis following surgical thrombectomy. Conclusions: Flow (mL)/d-dimer (ng/mL) <0.63 was independent predictor of recurrent thrombosis (RT) of a surgically salvaged AVF. The patients at risk for RT or who may benefit from further intervention should be identified with predictive parameters.

Download Full-text

Covered stents versus balloon angioplasty for failure of arteriovenous access: a systematic review and meta-analysis

BMJ Open ◽

10.1136/bmjopen-2020-044356 ◽

2021 ◽

Vol 11 (6) ◽

pp. e044356

Author(s):

Benjamin Ng ◽

Magnus Fugger ◽

Igho Jovwoke Onakpoya ◽

Andrew Macdonald ◽

Carl Heneghan

Keyword(s):

Systematic Review ◽

Balloon Angioplasty ◽

Meta Analysis ◽

Primary Patency ◽

Secondary Patency ◽

Covered Stents ◽

Significant Difference ◽

Randomised Controlled ◽

Meta Analyses ◽

Stage Renal Disease

IntroductionPatients with end-stage renal disease may require arteriovenous (AV) access in the form of arteriovenous fistulae (AVFs) or arteriovenous grafts (AVGs) for haemodialysis. AV access dysfunction requires intervention such as plain balloon angioplasty or covered stents to regain patency.AimTo systematically review and meta-analyse the patency outcomes of covered stents in failing haemodialysis AV access, compared with balloon angioplasty.MethodsThe review was first registered on the International Prospective Register of Systematic Reviews (CRD42018069955) before data collection. We searched six electronic databases to identify relevant randomised controlled trials (RCTs) up until August 2020, without language restriction. Two reviewers assessed the suitability and quality of studies for inclusion using the Consolidated Standards of Reporting Trials guidelines. We meta-analysed data using a random-effects model.ResultsWe included seven studies including 1147 patients in the systematic review, of which 867 had AVGs and 280 had AVFs. One study was an ongoing RCT. In the meta-analyses, we assessed patients with failing AVGs only. Overall risk of bias was moderate. Covered stents were associated with lower loss of patency versus angioplasty alone at 6, 12 and 24 months (OR 4.48, 95% CI 1.98 to 10.14, p<0.001; OR 4.07, 95% CI 1.74 to 9.54, p=0.001; OR 2.24, 95% CI 1.17 to 4.29, p=0.01, respectively). Covered stents afforded superior access circuit primary patency compared with angioplasty alone at 6 and 12 months (OR 1.91, 95% CI 1.31 to 2.80, p<0.001; OR 1.97, 95% CI 1.14 to 3.41, p=0.02, respectively). This was not significant at 24 months. There was no significant difference in loss of secondary patency between groups at 12 or 24 months (OR 0.74, 95% CI 0.45 to 1.23, p=0.25; OR 0.67, 95% CI 0.29 to 0.154, p=0.34, respectively).ConclusionOur results support use of covered stents over angioplasty alone, at 6, 12 and 24 months in failing AVGs. Further clinical trials are warranted.

Download Full-text