Incidence and Management of Percutaneous Transluminal Angioplasty-induced Venous Rupture in the "Fistula First" Era

Department of Radiology, Division of Interventional Radiology, University of Pennsylvania Medical Center, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA.
Journal of vascular and interventional radiology: JVIR (Impact Factor: 2.15). 05/2009; 20(6):744-51. DOI: 10.1016/j.jvir.2009.03.013
Source: PubMed

ABSTRACT Percutaneous transluminal angioplasty (PTA)-induced venous rupture is a common complication of hemodialysis access interventions. The authors sought to determine if venous rupture rates and management differed between grafts and fistulas, and in the fistula subset, between transposed and nontransposed fistulas.
Patients experiencing venous rupture during hemodialysis PTA over a 5-year period were identified. Of 1,985 hemodialysis interventions, 75 ruptures occurred in 69 patients (46 women) with a mean age of 63 years (range, 31-88 y). Rupture rates, proportion of successful treatments, and treatment type and number (ie, balloon tamponade, stent, covered stent) were determined.
Rupture was more common in fistulas overall (5.6%, 39 of 693) compared with grafts (2.8%, 36 of 1,292; P = .002), in transposed (10.7%, 20 of 187) compared with nontransposed fistulas (3.8%, 19 of 506; P = .001), and in transposed fistulas compared with grafts (P = .0001). There was no significant difference between nontransposed fistulas and grafts. Treatment success (ie, resolution of extravasation) was the same among groups: 69% (27 of 39) in fistulas overall, 70% (14 of 20) in transposed fistulas, 68% (13 of 19) in nontransposed fistulas, and 72% (26 of 36) in grafts. There was a greater need for stents in grafts (38.9%, 14 of 36) compared with fistulas (12.8%, five of 39; P = .003).
PTA-induced rupture is more common in fistulas than grafts, and this effect seems nearly entirely driven by transposed fistulas. Although rupture treatment in fistulas of all types yielded similar success to grafts, and graft ruptures were more difficult to treat than fistula ruptures, the high rupture rates in transposed fistulas attest to the increased difficulty of treating this subset of fistulas.

  • [Show abstract] [Hide abstract]
    ABSTRACT: PURPOSE: To complement prior studies have shown that arteriovenous fistula (AVF) thrombectomies require more time and equipment than arteriovenous graft (AVG) thrombectomies by measuring work using established instruments to determine if there is also a difference in maintenance percutaneous transluminal angioplasty (PTA) of nonthrombosed AVFs versus AVGs. MATERIALS AND METHODS: PTA procedures performed on a consecutive cohort of 42 patients with AVFs and 27 patients with AVGs were prospectively compared. To quantify resource utilization, procedure time and disposable equipment were measured. Established instruments developed by the American Medical Association for Current Procedural Terminology code valuation were used to measure subjective "physician work," including mental effort and judgment, technical skill, physical effort, and psychological stress. These items were scored by 1 of 12 attending interventional radiology physicians performing the procedure. RESULTS: Mean PTA procedure time was 74 minutes (range, 18-183 minutes) for AVFs and 71 minutes (range, 28-204 minutes) for AVGs; hemostasis time was 12 minutes for AVFs and 11 minutes for AVGs. There was no significant difference in equipment use between groups. "Physician work" for AVFs scored significantly higher in four categories (P≤ .05). CONCLUSIONS: Using established subjective instruments, maintenance PTA of AVFs was scored as more cognitively, physically, and psychologically demanding than maintenance PTA of AVGs. However, there was no significant difference in resource utilization between maintenance PTA of AVFs versus AVGs, as has been previously shown with thrombectomy of thrombosed AVFs and AVGs.
    Journal of vascular and interventional radiology: JVIR 03/2013; 24(5). DOI:10.1016/j.jvir.2013.01.498 · 2.15 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The current study retrospectively evaluated whether the percutaneous N-butyl cyanoacrylate (NBCA) seal-off technique is an effective treatment for controlling the angioplasty-related ruptures, which are irresponsive to prolonged balloon tamponade, during interventions for failed or failing hemodialysis vascular accesses. We reviewed 1588 interventions performed during a 2-year period for dysfunction and/or failed hemodialysis vascular access sites in 1569 patients. For the angioplasty-related ruptures, which could not be controlled with repeated prolonged balloon tamponade, the rupture sites were sealed off with an injection of a glue mixture (NBCA and lipiodol), via a needle/needle sheath to the rupture site, under a sonographic guidance. Technical success rate, complications and clinical success rate were reported. The post-seal-off primary and secondary functional patency rates were calculated by a survival analysis with the Kaplan-Meier method. Twenty ruptures irresponsive to prolonged balloon tamponade occurred in 1588 interventions (1.3%). Two technical failures were noted; one was salvaged with a bailout stent-graft insertion and the other was lost after access embolization. Eighteen accesses (90.0%) were salvaged with the seal-off technique; of them, 16 ruptures were completely sealed off, and two lesions were controlled as acute pseudoaneurysms. Acute pseudoaneurysms were corrected with stentgraft insertion in one patient, and access ligation in the other. The most significant complication during the follow-up was delayed pseudoaneurysm, which occurred in 43.8% (7 of 16) of the completely sealed off accesses. Delayed pseudoaneurysms were treated with surgical revision (n = 2), access ligation (n = 2) and observation (n = 3). During the follow-up, despite the presence of pseudoaneurysms (acute = 1, delayed = 7), a high clinical success rate of 94.4% (17 of 18) was achieved, and they were utilized for hemodialysis at the mean of 411.0 days. The post-seal-off primary patency vs. secondary patency at 90, 180 and 360 days were 66.7 ± 11.1% vs. 94.4 ± 5.4%; 33.3 ± 11.1% vs. 83.3 ± 8.8%; and 13.3 ± 8.5% vs. 63.3 ± 12.1%, respectively. Our results suggest that the NBCA seal-off technique is effective for immediate control of a venous rupture irresponsive to prolonged balloon tamponade, during interventions for hemodialysis accesses. Both high technical and clinical success rates can be achieved. However, the treatment is not durable, and about 40% of the completely sealed off accesses are associated with developed delayed pseudoaneurysms in a 2-month of follow-up. Further repair of the vascular tear site, with surgery or stent-graft insertion, is often necessary.
    Korean journal of radiology: official journal of the Korean Radiological Society 01/2013; 14(1):70-80. DOI:10.3348/kjr.2013.14.1.70 · 1.81 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: PURPOSE: Cephalic arch stenosis (CAS) is an important and common cause of dysfunction in autogenous haemodialysis fistulas that requires multiple reinterventions and aggressive surveillance. We evaluated the safety and efficacy of the Viabahn stent-graft for the management of CAS. METHODS: Between April 2005 and October 2011, 11 consecutive patients [four men and seven women (mean age 56.7 years)] with CAS and dysfunctional fistulas were treated with insertion of 11 Viabahn stent-grafts. Six stent-grafts were inserted due to residual stenosis after angioplasty and five for fistuloplasty-induced rupture. No patient was lost to follow-up. RESULTS: The technical and clinical success rate was 100 %. Primary access patency rates were 81.8 % [95 % confidence interval (CI) 0.482-0.977] at 6 months and 72.7 % (95 % CI 0.390-0.939) at 12 months. Secondary access patency rates were 90.9 % at 6 months (95 % CI 0.587-0.997). There were no procedure-related complications. Mean follow-up was 543.8 days (range 156-2,282). CONCLUSION: The use of the Viabahn stent-graft in the management of CAS is technically feasible and, in this small series, showed patency rates that compare favorably with historical data of angioplasty and bare stents.
    CardioVascular and Interventional Radiology 06/2012; DOI:10.1007/s00270-012-0433-x · 1.97 Impact Factor