Juxta-Anastomotic Stenosis of Native Arteriovenous Fistulas: Surgical Treatment versus Percutaneous Transluminal Angioplasty

Abstract

Purpose

Juxta-anastomotic stenosis (JAS) is a complication of arteriovenous fistulas (AVFs). Both surgical revision (SR) and percutaneous transluminal angioplasty (PTA) may correct JAS. In this study we compare the results for SR treatment versus PTA.

Methods

From January 2005 until December 2008, 66 PTA and 68 SR were performed in 43 and 57 uremic pts with JAS of the native AVF, respectively. Efficacy of SR and PTA was evaluated measuring brachial arterial flow (BAF) by CDU. The Kaplan-Meier table of primary and assisted primary patency was analyzed.

Results

PTA was attempted in 50 patients. PTA failed in 7 patients and they were switched to SR. In 43 pts, PTA produced a favorable effect, with a mean increase of 99 ± 70% (p<0.001) in blood flow. Restenosis occurred in 17 pts: 2 were treated by SR and 15 by PTA. Restenosis occurred again in 6/15 pts: after second restenosis, 5/6 pts received a third PTA with stenting, 1 patient underwent SR. The failure of access occurred after 12–17 months in 3 pts. In 57/57 JAS treated by SR, a new well-functioning fistula was created upstream of the stenosis, with a mean increase of 102 ± 71% in blood flow (p<0.001). Restenosis occurred in 15 pts: 9 were treated by SR and 6 by PTA. Access failure occurred after 3–36 months in 9 pts. The Kaplan-Meier table showed a better primary patency for SR (p<0.05) without difference in assisted primary patency.

Conclusions

SR showed a better primary patency then PTA, confirming the trend to stenosis relapse after PTA. So, as PTA does not exclude a later correction of the JAS, the similar assisted patency suggests to perform a PTA first, reserving SR for after its failure.

Keywords

Juxta-anastomotic stenosis Native arteriovenous fistula Percutaneous transluminal angioplasty Stent Surgery for failed fistula

References

National Kidney Foundation. NKF-K/DOQI clinical practice guidelines for vascular access: update 2006. Am J Kidney Dis 2006; 48(Suppl 1): 177–332.

Roy-Chaudhury

PTA versus surgery for juxta-anastomotic stenosis. J Vasc Access 2008; 9: 185.

Asif

, Lenz

, Gherla

. Percutaneous management of perianastomotic stenosis in arteriovenous fistulae: results of a prospective study. Kidney Int 2006; 69: 1904–9.

Beathard

G.A.

, Arnold

, Jackson

. Aggressive treatment of early fistula failure. Kidney Int 2003; 64: 1487–94.

Rajan

D.K.

, Bunston

, Misra

, Pinto

, Lok

C.E.

Dysfunctional autogenous hemodialysis fistulas: outcomes after angioplasty: are there clinical predictors of patency?

Radiology 2004; 232: 508–15.

Clark

T.W.

, Hirsch

D.A.

, Jindal

K.J.

, Veugelers

P.J.

, LeBlanc

Outcome and prognostic factors of restenosis after percutaneous treatment of native hemodialysis fistulas. J Vasc Interv Radiol 2002; 13: 51–9.

Guerra

, Raynaud

, Beyssen

. Arterial percutaneous angioplasty in upper limbs with vascular access devices for haemodialysis. Nephrol Dial Transplant 2002; 17: 843–51.

Raynaud

, Novelli

, Bourquelot

, Stolba

, Beyssen

, Franco

Low-flow maturation failure of distal accesses: treatment by angioplasty of forearm arteries. J Vasc Surg 2009; 49: 995–9.

Asif

, Gadalean

F.N.

, Merril

. Inflow stenosis in arteriovenous fistulas and grafts: a multicenter, prospective study. Kidney Int 2005; 67: 1986–92.

10.

Turmel-Rodriguez

, Pengloan

, Baudin

. Treatment of stenosis and thrombosis in haemodialysis fistulas and grafts by interventional radiology. Nephrol Dial Transplant 2000; 15: 2029–36.

11.

Oakes

D.D.

, Sherk

J.P.

, Cobb

L.F.

Surgical salvage of failed radiocephalic arteriovenous fistulae: techniques and results in 29 patients. Kidney Int 1998; 53: 480–7.

12.

Tordoir

J.H.

, Canaud

, Haage

. EBPG on vascular access. Nephrol Dial Transplant 2007; 22(Suppl 2): ii88–117.

13.

Lipari

, Tessitore

, Poli

. Outcomes of surgical revision of stenosed and thrombosed forearm arteriovenous fistulae for hemodialysis. Nephrol Dial Transplant 2007; 22: 2605–12.

14.

Tessitore

, Mansueto

, Lipari

. Endovascular versus surgical preemptive repair of forearm arteriovenous fistula stenosis: analysis of data collected prospectively from 1999 to 2004. Clin J Am Soc Nephrol 2006; 1: 448–54.

15.

Nonnast-Daniel

, Martin

R.P.

, Linder

. Color Doppler ultrasound assessment of arteriovenous hemodialysis fistulas. Lancet 1992; 339: 134–45.

16.

Besarab

, Hall

, El-Ajei

. The relation of brachial artery-flow to access flow. J Am Soc Nephrol 1995; 6: 192–7.

17.

Besarab

, Sherman

The relationship of recirculation to access blood flow. Am J Kidney Dis 1977; 29: 223–9.

18.

Lomonte

, Casucci

, Antonelli

. Is there a place for duplex screening of the brachial artery in the maturation of arteriovenous fistulas? Semin Dial 2005; 18: 243–6.

19.

Basseau

, Grenier

, Trillaud

. Volume flow measurement in hemodialysis shunts using time-domain correlation. J Ultrasound Med 1999; 18: 177–83.

20.

Wiese

, Nonnast-Daniel

Colour Doppler ultrasound in dialysis access. Nephrol Dial Transplant 2004; 19: 1956–63.

21.

Chiang

W.C.

, Lin

S.L.

, Tsai

T.J.

, Hsieh

B.S.

High resistive index of the radial artery is related to early primary radiocephalic hemodialysis fistula failure. Clin Nephrol 2001; 56: 236–40.

22.

Koseoglu

, Akar

, Cildag

, Ozsunar

, Gayret

Resistive index measurement of native hemodialysis arteriovenous fistula feeding artery as a predictor for fistula dysfunction. ASAIO J 2004; 50: 577–80.

23.

Roca-Tey

, Rivas

, Samón

, Ibrik

, Martínez Cercós

, Viladoms

Noninvasive assessment of forearm vessels by color Doppler ultrasonography (CDU) before and after radiocephalic fistula (RCF) placement. Nefrologia 2007; 27: 489–95.

24.

Koseoglu

, Akar

, Eraslan

Color Doppler US evaluation of feeding artery after balloon angioplasty of the drainage vein in dysfunctional hemodialysis AVA. Ren Fail 2008; 30: 801–7.

25.

Haskal

Z.J.

Covered stent for access intervention: what we know and where we're going. J Vasc Access 2009; 10: 259–60.

26.

Dumars

M.C.

, Thompson

W.E.

, Bluth

E.I.

, Lindberg

J.S.

, Yoselevitz

, Merritt

C.R.

Management of suspected hemodialysis graft dysfunction: usefulness of diagnostic US. Radiology 2002; 222: 103–7.