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Upper-extremity Approach for Secondary Access in Transfemoral Transcatheter Aortic Valve Implantation

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Why vascular access trials on flow surveillance failed.

Nikolai Krivitski¹

¹Transonic Systems Inc., Ithaca, NY - USA.

The Journal of Vascular Access

|May 13, 2014

Summary

Access flow surveillance accurately detects stenosis. Percutaneous transluminal angioplasty (PTA) yields better results in arteriovenous fistulas (AVFs) than arteriovenous grafts (AVGs), with inadequate flow increase and guideline non-adherence contributing to failed AVG trials.

Area of Science:

Vascular Surgery
Interventional Radiology
Nephrology

Background:

Access flow surveillance, introduced in 1995, is used for routine patient screening.
Over 30 clinical trials exist, yet some randomized control trials (RCTs) yielded inconclusive results for access surveillance.
This study analyzes data on the primary component of access surveillance: adequate access flow increase post-percutaneous transluminal angioplasty (PTA).

Purpose of the Study:

To analyze published data on access flow increase after PTA.
To identify factors contributing to the success or failure of access surveillance and PTA.
To evaluate the effectiveness of PTA in improving hemodynamics for arteriovenous grafts (AVGs) and arteriovenous fistulas (AVFs).

Main Methods:

Systematic review and analysis of nine studies for AVGs (350 accesses) and nine studies for AVFs (503 accesses) from 14 publications.

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Evaluation of access flow measurement sensitivity in predicting stenosis.

Comparison of mean access flow increase and relative flow increase between AVGs and AVFs post-PTA.

Main Results:

Access flow measurement shows high sensitivity (>90%) for predicting 50% stenosis.
Mean access flow increase post-PTA was 319 ml/min for AVGs and 331 ml/min for AVFs.
Relative flow increase was 1.6 times greater in AVFs compared to AVGs. Failed AVG RCTs often lacked patient selection based on KDOQI guidelines or adequate PTA flow analysis.

Conclusions:

Access flow surveillance effectively identifies hemodynamically significant stenosis.
PTA in AVFs demonstrates superior hemodynamic outcomes compared to AVGs.
Inadequate flow increases during PTA and non-adherence to KDOQI guidelines are key factors in failed AVG RCTs. Objective flow evaluation during PTA is recommended for radiologists.