Incidence and management of percutaneous transluminal angioplasty-induced venous rupture in the "fistula first" era.
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.
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ABSTRACT: The ratio of intragraft venous limb pressure (VLP) to systemic pressure (S) has been proposed to help determine the endpoint of hemodialysis access interventions. It was hypothesized that physical examination of the access could be used in the same way and these techniques were compared as predictors of outcome. With use of a quality-assurance database, records from 117 hemodialysis access interventions were retrospectively reviewed. Only interventions in grafts were included. The database included physical examination (to establish thrill, thrill with slight pulsatility [TSP], pulse with slight thrill [PST], and pulse) at three locations along the graft (proximal, midportion, and distal), normalized pressure ratio calculated with S from a blood pressure cuff (S(cuff)) and S within the graft with outflow occluded (S(direct)), graft configuration and location, indication, operator, and time to next intervention (outcome of primary patency). Only procedures with complete follow-up data were included in the analysis (n = 97; declotting, n = 51; prophylactic percutaneous transluminal angioplasty [PTA], n = 46). Statistical analysis was performed with use of Cox proportional-hazards regression. Graft configuration, location, side, VLP, S(direct), and S(cuff) did not affect outcomes. An operator effect was noted for two physicians and was adjusted for in all analyses. Pressure ratios were weak predictors of outcome (VLP/S(direct), P =.07; VLP/S(cuff), P =.08) and suggested that patency increased with increasing pressure ratio, contrary to earlier studies. Procedure type predicted outcome (declotting, median patency of 50 days; PTA, median patency of 105 days; P =.01). Thrill at distal physical examination was predictive of outcome (P =.04) and even more so when thrill and TSP combined were compared with PST and pulse combined (P =.03). Similar but less-pronounced effects were seen at midportion and proximal physical examinations. The presence of a thrill or slightly pulsatile thrill at the distal (venous) end of a dialysis graft is the best predictor of outcome after percutaneous intervention. Based on the present study, the authors believe that physical examination of dialysis access should supplant pressure measurements as an endpoint of intervention and should serve as an essential component of quality assurance of access interventions.Journal of Vascular and Interventional Radiology 12/2003; 14(11):1387-94. · 2.00 Impact Factor
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ABSTRACT: This study was undertaken to evaluate percutaneous transvenous angioplasty (PTVA) for the treatment of all types of vascular access stenosis in a large population of dialysis patients. Stenoses were identified by venography in patients who met a set of clinical criteria indicating the need for evaluation. The lesions were classified by location and type. Data were collected prospectively and analyzed separately for each lesion type. A total of 536 PTVA procedures was performed in 285 patients. This included 107 cases of long venous stenosis (> 6 cm) and 149 cases of mid-graft stenosis. In the total group, an initial success rate of 94% was obtained (80% or greater dilatation). A decrease in VPm (venous pressure measured on dialysis) of 35.9%, 32.4%, and 22.6% was seen at one week, one month, and three months, respectively. At 90 days, 180 days, and 360 days 90.6%, 61.3%, and 38.2%, respectively, of the treated grafts were continuing to be patent and functional with no need for repeat PTVA treatment. Repeat treatments for recurrent lesions were as successful as the initial treatment. It is concluded that vascular access stenosis can be easily diagnosed and that all categories of stenotic lesion can be effectively treated with PTVA.Kidney International 12/1992; 42(6):1390-7. · 7.92 Impact Factor
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ABSTRACT: To report midterm follow-up after implantation of covered stents for hemodialysis access. Over a 2-year period, a Cragg Endopro stent was placed in 14 patients (mean age, 66.6 years +/- 15) to treat angioplasty-induced ruptures (n = 3), pseudoaneurysm (n = 1), postangioplasty residual stenosis (n = 2), and early restenosis (n = 8, four of them in a Wallstent). Initial placement was successful in all cases. A clinical inflammatory reaction was observed in all three cases of placement in the forearm. When the covered stent was placed in a stenotic vessel, restenosis always occurred within 6 months. Primary and secondary patencies were 28.5% +/- 13.9 and 67.8% +/- 14.5, respectively, at 6 months. Covered stents were of undoubtable benefit in one case of rupture after Wallstent failure and in one case of restenosis in a Wallstent. Covered Cragg stents are effective in controlling angioplasty- induced rupture and sometimes for maintaining patency after restenosis in a Wallstent. They do not prevent restenosis and are responsible for an inflammatory reaction of unknown origin and long-term effect.Journal of Vascular and Interventional Radiology 01/1996; 7(3):335-42. · 2.00 Impact Factor