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[Role of percutaneous angioplasty in keeping vascular access for hemodialysis]
1Istituto di Radiologia II, Ospedale Civile, Udine.
Insights
Percutaneous angioplasty effectively treats stenoses in vascular hemodialysis accesses, offering a repeatable solution to prolong fistula life. This minimally invasive procedure demonstrates high initial success rates and low complication incidence, making it a preferred choice over surgery.
Area of Science:
- Interventional Radiology
- Vascular Surgery
- Nephrology
Context:
- Vascular access stenosis is a common cause of hemodialysis access failure.
- Percutaneous angioplasty offers a minimally invasive option for managing these stenoses.
- Previous surgical interventions may not provide long-term solutions.
Purpose:
- To evaluate the efficacy and safety of percutaneous angioplasty for treating stenoses in vascular hemodialysis accesses.
- To assess the long-term outcomes and relapse rates of angioplasty in this patient population.
- To establish angioplasty as a primary treatment modality for access-related stenoses.
Summary:
- A study involving 46 patients (43 treated) from 1985-1991 evaluated 59 angioplasty procedures to treat 96 stenoses in vascular hemodialysis accesses (71 Brescia-Cimino fistulas, 25 Gore-Tex prostheses).
- The optimized technique involves specific balloon catheter use for anastomotic and efferent vein lesions, achieving an 88.7% initial success rate.
- Follow-up data indicated high early relapse rates (over 50% in the first year) for lesions typically caused by fibrosis and endarterial hyperplasia, decreasing to under 10% annually thereafter.
Impact:
- Percutaneous angioplasty is a safe, simple, and effective treatment for vascular access stenoses, with a low complication rate.
- Angioplasty can be repeated, prolonging the functional lifespan of hemodialysis accesses and potentially delaying the need for surgical revision.
- This approach represents a valuable therapeutic option, complementing rather than replacing surgical interventions, and improving patient management.
Abstract:
The stenoses of anastomosed vessels or of implantation grafts are among the most frequent causes of insufficiency of vascular hemodialysis accesses. Percutaneous angioplasty allows the interventional radiologist too to participate in the salvage of shunts. From 1985 to 1991, 46 patients underwent the procedure. Angioplasty could be performed in 43 of them, and had to be repeated in some cases because of either relapse or malfunctioning new vascular access. On the whole, 59 maneuvers were performed, and 96 stenoses treated, 71 in Brescia-Cimino fistulas and 25 in Gore-Tex prostheses. The optimized standard technique employs access through the efferent vein and a diagnostic evaluation after blocking the flow with an inflatable cuff; 2-3 distensions lasting 2-3 minutes are performed with a 3.5-4 mm x 20 mm balloon catheter for the anastomosis. One or more 15-20-minute distensions follow, with a 6-8 mm x 20-40 mm Zijlstra balloon catheter (Schneider) for the lesions in the efferent vein. Our initial success rate was 88.7% (55 of 62 procedures). Follow-up results at 3, 6, 12, 24 months proved that for this type of lesion, which is usually supported by fibrosis and endarterial hyperplasia, estimated relapse rates exceed 50% in the first year and are lower than 10% a year in the following years. Complications are quite rare and can be partly prevented if the correct indications are followed, overdistension is avoided and the proper material is used. On account of the good results it yields, of its relative simplicity and of the very low incidence of complications, angioplasty should be considered as the treatment of choice for stenoses and their relapses in vascular hemodialysis accesses. As for treatment protocol, angioplasty is not a procedure to occasionally replace surgery, but a therapeutic approach which can be repeated at regular time intervals and can prolong the life of hemodialysis fistulas, thus delaying surgical reconstruction.