Upper thigh loop prosthetic arterio-venous grafts (AVG) for dialysis access: An Indian perspective

2021 ◽  
pp. 112972982110556
Author(s):  
Sekar Natarajan ◽  
Jithin Jagan Sebastian
Keyword(s):  
Upper Limb ◽  
Limb Ischemia ◽  
Primary Patency ◽  
Central Vein ◽  
Secondary Patency ◽  
Dialysis Access ◽  
Venous Grafts ◽  
Vein Stenosis ◽  
Central Vein Stenosis

Introduction: Hemodialysis forms the most common replacement therapy for majority of Indians suffering from chronic kidney disease (CKD). Multiple access failure and central vein stenosis has become commonplace in Indian dialysis access patients and there is a burgeoning need for more advanced hemodialysis (HD) access options. Upper thigh arterio-venous grafts (AVG) are seldom inserted due to fear of infection and limb ischemia. Materials and methods: This is a single institutional, retrospective, descriptive case study of consecutive patients who underwent upper thigh prosthetic AVG over a period of 7 years. All these patients had exhausted options of upper limb access and or had central vein stenosis. AVG from the proximal superficial femoral artery (SFA) to the proximal great saphenous vein (GSV) in a loop configuration using polytetrafluoroethylene (PTFE) was carried out in the upper thigh. Results: A total of 24 patients had undergone upper thigh loop AVG. Their age varied from 24 to 77 years. The median follow-up period was 3 years. Five of these grafts developed infection (21%) which led to primary failure. A primary patency of 71% (17/24 patients) was achieved at 1 year. Thrombosis developed at a mean of 16.7 months after the primary procedure. Adjunctive procedures such as thrombectomy, segmental replacement of graft, patch angioplasty, balloon angioplasty, and stenting were required in 75% of patients to achieve a secondary patency of 86% at 1 year. Three grafts were explanted without limb loss. Conclusion: Upper thigh loop AVG forms a reliable alternate dialysis access option for patients with failed upper limb access sites or central vein occlusion. Adjunctive procedures are key to maintaining patency in these grafts. Good secondary patency is achievable, and the infection rates are similar to arm AVG. Close follow-up and timely intervention are key to long term dialysis through these grafts.

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

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

scholarly journals Percutaneous intervention for symptomatic central vein stenosis in patients with upper limb arteriovenous dialysis access

2018 ◽  
Vol 70 (5) ◽  
pp. 690-698 ◽  
Author(s):  
Ashwal AJ ◽  
Abdul Razak UK ◽  
Padmakumar R ◽  
Umesh Pai ◽  
Sudhakar M
Keyword(s):  
Upper Limb ◽  
Percutaneous Intervention ◽  
Central Vein ◽  
Dialysis Access ◽  
Vein Stenosis ◽  
Central Vein Stenosis

MILLER Banding Procedure for Treatment of Dialysis Access–Related Steal Syndrome, Pulmonary Hypertension, and Heart Failure

2021 ◽  
pp. 000313482110562
Author(s):  
Ahmad Alqassieh ◽  
Patrick B. Dennis ◽  
Veena Mehta ◽  
June Shi ◽  
Angello Lin ◽  
...  
Keyword(s):  
Heart Failure ◽  
Pulmonary Hypertension ◽  
Vascular Access ◽  
Primary Patency ◽  
Secondary Patency ◽  
Dialysis Access ◽  
Long Term Follow Up ◽  
Steal Syndrome

A Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) banding procedure has been used for treating patients with dialysis access–related steal syndrome (DASS) and high-flow vascular access–related pulmonary hypertension (PHT) and heart failure (HF). We performed a retrospective analysis of patients undergoing the MILLER procedure performed for DASS, HF, and PHT from our Vascular Access Database from September 2017 to October 2019. Outcomes included primary patency of banding, primary assisted patency, and secondary patency, using time-to-event analyses with Kaplan-Meier curves and life tables to estimate 6- and 12-month rates. A total of 13 patients (6 men and 7 women, mean age 60 ± 14 years) underwent the MILLER procedure, 6 patients for DASS and 7 patients for pulmonary hypertension and heart failure (PHT/HF). Technical success was achieved in all patients. The longest duration of follow-up was 28 months (median 12 months [IQR 7, 19]). One patient died at 1 month after the intervention due to stroke. One patient developed access thrombosis of the graft 3 days after the procedure. Repeat banding was required in 1 patient 8 months after the first procedure. The 6-month primary patency rate of banding following this procedure was 83% while the 12-month rate was 66%. The 6- and 12-month secondary patency rates were 87% and 75%, respectively. The MILLER procedure can be performed for DASS and PHT/HF with improvement of symptoms and good long-term patency rates. Additional interventions to maintain patency and efficacy are required on long-term follow-up.

P1319AMBIGUOUS RESULTS OF CENTRAL VEIN STENOSIS ENDOVASCULAR TREATMENT IN HEMODIALYSIS PATIENTS

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Aleksei Zulkarnaev ◽  
Zurab Kardanakhishvili ◽  
Boris Baykov
Keyword(s):  
Blood Flow ◽  
Median Survival ◽  
Balloon Angioplasty ◽  
Primary Patency ◽  
Main Group ◽  
Control Group ◽  
Time Interval ◽  
Central Vein ◽  
Vein Stenosis ◽  
Central Vein Stenosis

Abstract Background and Aims Balloon angioplasty (BA) without the use of stents has unsatisfactory results, which may cast doubt on its expediency. At the same time, BA is a very expensive treatment method. We conducted a comprehensive comparative analysis of the native arteriovenous fistula (AVF) patency rates in hemodialysis patients with central venous stenosis (CVS) after endovascular BA and «open» palliative surgery. Method A retrospective study included 80 patients with confirmed central vein stenosis: subclavian, brachiocephalic veins, vena cava inferior, or multiple lesions. The main group included 39 patients who underwent percutaneous balloon angioplasty. The control group included 41 patients who did not have balloon angioplasty for various reasons. In this patients we performed only «open» palliative interventions: thrombectomy, proximalization of arteriovenous anastomosis, AVF blood flow reduction. Results Functional primary patency (the time interval between the start of AVF using and the first intervention) did not differ: groups were comparable in time of stenosis manifestation (fig. 1A). Primary patency (the time interval between the first and second interventions) after BA was statistically significantly better than in the main group (fig. 1B), but difference was minimal: median survival in the study group of 8 months [95% CI 6; 10] vs. - 6 months [95% CI 4.9; 7.1]. There was the strong negative correlation between the primary patency and functional primary patency in the main group (r = –0.627 [95%CI –0.787; –0.388], p <0.0001) but not in the control group (r = 0.049 [95%CI –0.262; –0.351], p = 0.7599). Thus, the later manifestation of CVS related with lower effectiveness of BA. The functional secondary patency (total duration of AVF use) in the main group was significantly better: median survival was 47 months [95% CI 40.9; 53.1] vs. 34 months [95% CI 29.8; 38.2] as well as secondary patency (the time interval between the first intervention and the complete cessation of AVF use): median survival was 16 months [95% CI 12.5; 19.5] vs. 7 months [95% CI 4.9; 9.1] (fig. 1 C and D). The occlusion-free period from the moment of starting the AVF use (functional primary assisted patency – fig. 1E) was higher in the main group, but difference was minimal: median survival was 39 months [95% CI 36.5; 41.5] vs. 32 months [95% CI 27.5; 36.5], as well as occlusion-free period from the moment of the first surgical intervention (primary assisted patency – fig. 1F) median survival was 9 months [95% CI 7; 11], in the control group - 7 months [95% CI 5.6; 8.4]. The need for open interventions was lower in the main group: 0.374 [95% CI 0.24; 0.556] and 2.451 [95% CI 1.1963; 3.023] per 10 patient-months, incidence rate ratio (IRR)= 0.153 [95% CI 0.095; 0.237], р<0.0001; as well as overall need for interventions: 1.511 [95% CI 1.225; 1.843] and 2.451 [95% CI 1.963; 3.023] per 10 patient-months, IRR 0.617 [95% CI 0.461; 0.825] p=0.0011. The value of AVF volume blood flow had a strong negative correlation with the primary patency in both groups (r = –0.529, p =0.0027; r = –0.419, p =0.0101). Conclusion 1. Central vein stenosis is inevitably leads to loss of vascular access on the ipsilateral side. 2. Balloon angioplasty allows to extend the period of AVF use but it is not a radical treatment method of CVS. 3. The results of balloon angioplasty are significantly affected by the length of the period from the start of AVF use to the CVS manifestation. 4. Multiple repeated BA are apparently justified in patients for whom the possibility of creating a new vascular access is doubtful. 4. The AVF volume blood flow is an important factor determining the severity of CVS clinical manifestations and the need for repeated surgical interventions.

Preliminary six-month outcomes of LIMBSAVE (treatment of critical Limb IscheMia with infragenicular Bypass adopting in situ SAphenous VEin technique) registry

Vascular ◽  
2020 ◽  
pp. 170853812096612 ◽  
Author(s):  
Nicola Troisi ◽  
Giovanni De Blasis ◽  
Mauro Salvini ◽  
Stefano Michelagnoli ◽  
Carlo Setacci ◽  
...  
Keyword(s):  
Limb Salvage ◽  
Critical Limb Ischemia ◽  
Saphenous Vein ◽  
Limb Ischemia ◽  
Primary Patency ◽  
Secondary Patency ◽  
Bypass Patency ◽  
The Mean

Objectives Guidelines recommend open bypass surgery for long occlusions of infrainguinal arteries. In situ saphenous vein bypass is a standardized technique. The aim of this study was to report preliminary six-month outcomes of a national, multicenter, observational, prospective registry based on the examination of treatment of critical Limb IscheMia with infragenicular Bypass adopting the in situ SAphenous VEin technique (LIMBSAVE). Methods From January 2018 until October 2019, 428 patients from 41 centers were enrolled in the LIMBSAVE registry. Data were prospectively collected in a dedicated database, including demographics, preoperative risk factors, clinical and diagnostic preoperative assessments, intraoperative measures (including safety and effectiveness of the valvulotome during the surgical procedures), and 30-day follow-up data. Furthermore, estimated six-month outcomes according to Kaplan–Meier curves in terms of primary patency, primary assisted patency, secondary patency, and limb salvage were evaluated. Results Patients were predominantly male ( n = 332, 77.6%) with a mean age of 73.3 years (range 39–95). Technical success, defined as bypass pulse after use of the valvulotome, was obtained in all cases. The proximal anastomosis could be reached by the valvulotome in all cases. The mean number of valvulotome uses was 2.5 (range 1–5). No vein perforation was reported. In nine cases (2.1%), a vein lesion with intramural hemorrhage occurred. The mean length of hospital stay was 11.1 days (range 1–60). At 30-day follow-up, the overall bypass patency rate was 97.4%, and the rate of open or endo reinterventions for failing bypass was 5.4%. At six-month follow-up, the estimated primary patency, primary assisted patency, secondary patency, and limb salvage were 78.1%, 86.2%, 92.1%, and 94.7%, respectively. Conclusions Preliminary intraprocedural outcomes of the LIMBSAVE registry show that the in situ technique with the valvulotome is safe and effective in disrupting valves and obtaining pulsatility in the saphenous vein. The complication rate related to the use of the valvulotome is low. The six-month preliminary outcomes in terms of overall patency and limb salvage are promising. Further examinations and continuous follow-up are needed to evaluate long-term outcomes.

MO764AVF VOLUME BLOOD FLOW REDUCTION AS THE FIRST STAGE OF TREATMENT OF CENTRAL VEIN STENOSIS IN HD PATIENTS

2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
Aleksei Zulkarnaev ◽  
Vadim Stepanov ◽  
Andrey Vatazin ◽  
Ekaterina Parshina ◽  
Mariya Novoseltseva ◽  
...  
Keyword(s):  
Blood Flow ◽  
Clinical Manifestations ◽  
Central Vein ◽  
Secondary Patency ◽  
Endovascular Interventions ◽  
Blood Flow Reduction ◽  
Volume Blood ◽  
Volume Blood Flow ◽  
Vein Stenosis ◽  
Central Vein Stenosis

Abstract Background and Aims It is well-known that central vein stenosis (CVS) significantly reduces the time of AVF functioning. At the same time, according to current guidelines (KDIGO, European Vascular Surgery Society, European Best Clinical Practice), only clinically significant CVS should be treated. Often, CVS becomes clinically manifest due to a significant increase of AVF volume blood flow (Qa) through the matured dialysis access. Aim: to assess the effect of Qa reduction on the CVS clinical course. Method We performed a retrospective study included 56 patients who underwent Qa reduction as the first step of treatment, and 62 patients who received endovascular interventions without Qa reduction (balloon angioplasty supplemented with stenting if necessary). Blood flow reduction was performed using banding under intraoperative ultrasound control. Results Surgical banding leads to a clinically obvious and statistically significant decrease in Qa in all patients – fig. 1. In contrast, after endovascular intervention most of the patients show a modest but statistically significant increase in Qa - fig. 2. All surgeries were performed to reduce the severity of clinical manifestations of CVS. AVF was better available for immediate cannulation after endovascular interventions than after banding: RR=4,537 [95%CI 1,416; 14,84], p=0,0116. However, the probability of successful cannulation at the third postoperative HD session did not differ between groups: RR=3.024 [95%CI 0.674; 13.67], p=0.2126. Taking in consideration these findings, we can conclude that the short-term results of Qa reduction are satisfactory. After Qa reduction in case of recurrence of CVS symptoms or absence of their complete resolving, we supplemented the treatment with endovascular interventions. Both primary and secondary patency were significantly better than in the case of endovascular interventions without Qa reduction – fig. 3. Moreover, in patients who underwent endovascular interventions without Qa reduction, higher Qa values were associated with decrease of the primary and secondary patency – fig. 4. So, increasing or maintaining large Qa values after endovascular intervention may be an important risk factor for CVS relapse and AVF function loss. Conclusion Qa is an important factor of CVS clinical manifestation. When determining treatment strategy, it is necessary to evaluate Qa first and reduce it, if necessary. Manage of Qa allows to transfer manifest CVS into its subclinical course, which itself leads to improved treatment results. Endovascular interventions are the preferred treatment of CVS with clinical manifestations in a case of underlying normal or suboptimal Qa.

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

Trials ◽  
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

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

PLoS ONE ◽  
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.

Use of Surfacer, an inside-out device, in tandem with HeRO graft for creation of vascular access: Case report of three patients with 18-months follow up

2021 ◽  
pp. 112972982110414
Author(s):  
Teo Qi Tian ◽  
Yap Hao Yun ◽  
Tay Jia Sheng ◽  
Tang Tjun Yip ◽  
Edward Choke Tieng Chek
Keyword(s):  
Upper Limb ◽  
Vascular Access ◽  
Primary Patency ◽  
Central Vein ◽  
Access Methods ◽  
Technical Success Rate ◽  
Vein Occlusion ◽  
Novel Approach ◽  
Inside Out

The Surfacer Inside-Out Access Catheter System (Surfacer) is a novel approach to restore access in total central vein occlusion (TCVO). We report a series of three cases, with mean 18-months follow up, in our institution where this technique was safely and effectively used in tandem with Hemodialysis Reliable Outflow (HeRO) graft for creation of upper limb vascular access in patients with TCVO. Although there have been reports describing the simultaneous combination of Surfacer and HeRO graft, to our knowledge, this is the first time where the outcomes with 18-months mean follow-up are reported. All three patients had failed prior conventional attempts at TCVO crossing and had exhausted most conventional upper limb vascular access methods. The above technique yielded a 100% technical success rate with mean operative time of 140 min. Cannulation rate was 100% with all undergoing successful early cannulation by post-operative day 3. Mean primary patency of 199 days was achieved. Average intervention rate of 1.2 a year was required to maintain patency. The Surfacer device used together with HeRO graft is a feasible technique to avoid femoral catheter in patients where conventional attempts to cross the TCVO have failed.

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