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Directional atherectomy treatment for hemodialysis access: early results
R J Gray1, B L Dolmatch, M K Buick
1Department of Radiology, Washington Hospital Center, Washington, DC 20010.
Insights
The Simpson atherectomy device effectively treated hemodialysis access stenoses, showing good patency for intragraft lesions and subclavian occlusions. Venous outflow stenoses had similar recurrence rates to balloon angioplasty.
Area of Science:
- Vascular Surgery
- Interventional Nephrology
- Medical Devices
Background:
- Vascular access complications, such as stenosis and occlusion, are common in patients undergoing hemodialysis.
- Intragraft stenoses, subclavian vein occlusions, and venous outflow stenoses significantly impair hemodialysis access function.
- Effective treatment options are crucial to maintain long-term vascular access patency.
Purpose of the Study:
- To evaluate the efficacy and safety of the Simpson atherectomy device for treating various types of hemodialysis access lesions.
- To assess the long-term clinical and angiographic outcomes of atherectomy in this patient population.
- To analyze the histological findings of atherectomy specimens.
Main Methods:
- A prospective study involving 24 patients with hemodialysis access lesions treated with the Simpson atherectomy device.
- Treatment included intragraft stenoses, subclavian vein occlusions, and venous outflow stenoses.
- Patients were followed clinically and with venography up to 12 months; 28 atherectomy specimens were examined histologically.
Main Results:
- Initial technical success was achieved in 81% of 32 lesions.
- At a mean follow-up of 5.0 months, 58% of intragraft stenoses and 21% of venous outflow stenoses remained angiographically patent.
- Histology revealed neointimal fibromuscular hyperplasia in 26 of 28 lesions, with directional atherectomy showing effectiveness for intragraft stenoses and some subclavian occlusions.
Conclusions:
- Directional atherectomy is an effective therapy for intragraft stenoses in hemodialysis access.
- It shows promise for certain catheter insertion-related subclavian occlusions when combined with balloon angioplasty.
- The recurrence rate for venous outflow stenoses treated with atherectomy is comparable to balloon angioplasty.
Abstract:
The Simpson atherectomy device was used to treat 12 intragraft stenoses, six complete subclavian vein occlusions, and 14 venous outflow stenoses in 24 patients undergoing hemodialysis. Patients were followed up clinically and by means of venography at approximately 1, 3, 6, 9, and 12 months after treatment. Twenty-eight atherectomy specimens were examined histologically. Twenty-six (81%) of 32 lesions were treated with initial technical success. Including technical failures, seven (58%) of 12 intragraft stenoses are angiographically patent at a mean of 5.0 months and five (50%) of 10 are clinically patent at 6 months. Three (50%) of six subclavian veins are angiographically patent at a mean of 5.6 months, and four (67%) of six are clinically patent at 6 months. Three (21%) of 14 venous outflow stenoses are angiographically patent at a mean of 5.0 months and five (38%) of 13 are clinically patent at 6 months. Histologic examination showed neointimal fibromuscular hyperplasia in 26 of 28 lesions. When 30% or less angiographic residual stenosis is used as the criterion for initial technical success, directional atherectomy appears to be effective therapy for intragraft stenoses and, with balloon angioplasty, for some catheter insertion-related subclavian occlusions. Directional atherectomy appears to have a recurrence rate for venous outflow stenoses similar to that for balloon angioplasty when the same criterion is used.