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.
Acute upper limb ischemia: 30 years’ experience
