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Patch Angioplasty in the Rat Aorta or Inferior Vena Cava
Published on: February 27, 2017
Postintervention Patency: A Comparison of Stenting versus Patch Angioplasty for Dysfunctional Hemodialysis Access
Khoi N Trinh1, Samuel E Wilson1, Ian L Gordon1
1Department of Surgery, Veterans Administration Long Beach Healthcare System, Long Beach, CA; University of California, Irvine.
Insights
Stent placement and patch angioplasty show similar initial patency for hemodialysis access salvage. However, stents may offer better outcomes for secondary interventions, and early intervention before thrombosis is crucial for prolonged access patency.
Area of Science:
- Vascular Surgery
- Nephrology
- Interventional Radiology
Background:
- Arteriovenous access dysfunction, often due to venous outflow stenosis, leads to thrombosis and loss of limited hemodialysis access sites.
- Preserving existing access sites is critical for patients requiring long-term hemodialysis.
- This study evaluates interventions for thrombosed or dysfunctional upper arm hemodialysis access.
Purpose of the Study:
- To compare the efficacy of balloon angioplasty and stent placement versus surgical patch angioplasty for salvaging thrombosed or dysfunctional upper arm hemodialysis access sites.
- To assess initial postintervention patency (PIP1) and patency after secondary reintervention (PIP2) for both procedures.
- To determine the impact of intervention timing on access patency.
Main Methods:
- Retrospective analysis of 52 consecutive patients undergoing hemodialysis access salvage.
- Interventions included stent placement (34 patients) or patch angioplasty (15 patients).
- Outcomes were assessed by calculating postintervention patency rates at 1, 3, and 6 months.
Main Results:
- Initial postinterventional patency (PIP1) was not statistically different between patch angioplasty and stent placement at any time point up to 6 months (e.g., 67.65% vs. 60% at 1 month).
- Patency after secondary reintervention (PIP2) was numerically longer for initial stent placement compared to patch angioplasty, but without statistical significance.
- Intervention before graft occlusion showed significantly better PIP1 at 6 months compared to intervention after occlusion (40% vs. 10%).
Conclusions:
- While not statistically significant, stent placement may offer longer PIP1 than patch angioplasty for hemodialysis access salvage.
- Secondary interventions (PIP2) showed better patency prolongation when the initial procedure was stent placement.
- Intervention prior to graft thrombosis is associated with significantly better patency, highlighting the importance of timely treatment. Patch angioplasty may be less favorable due to procedural complexity.
Background:
Arteriovenous access dysfunction is commonly caused by venous outflow stenosis, leading to thrombosis of the conduit. Given that there are limited lifetime hemodialysis access sites, the preservation of existing sites through novel means is of high priority. This study compares the efficacy of balloon angioplasty and stent placement to surgical patch angioplasty for upper arm (brachium) thrombosed or dysfunctional hemodialysis access sites in a group of patients at a single institution.
Methods:
Using the operating room log and electronic medical record system, we retrospectively examined the outcomes of 52 consecutive patients (3 were lost to follow-up), who had either stent placement (34 patients) or patch angioplasty (15 patients) for hemodialysis access salvage to calculate postintervention patency.
Results:
Initial postinterventional patency (PIP1) for patch angioplasty compared with stent placement was not statistically significant at any time during a mean 6-month follow-up (60% vs. 67.65% at 1 month, 33.33% vs. 41.18% at 3 months, and 13.33% vs. 17.65% at 6 months, respectively; P = 0.75). Patency after secondary reintervention (PIP2) was longer for patients who had stent placement as the initial intervention (n = 15) than patients who had patch angioplasty (n = 5; 100% vs. 80% at 1 month, 66.68% vs. 80% at 3 months, and 46.67% vs. 40% at 6 months, respectively), but again there was no statistically significant difference between the 2 groups (P = 0.84). At last, the initial PIP1 of arteriovenous fistula (AVF) and arteriovenous graft (AVG) salvaged before occlusion was significantly different from that of occluded access sites (40% vs. 10% at 6 months, P = 0.024).
Conclusions:
Our data suggest that AVF had a longer postinterventional primary patency than AVG though the difference did not reach statistical significance. Stents extended PIP1 for the thrombosed or failing arteriovenous access longer than patch angioplasty, but the difference was not statistically significant. Patency is longer if intervention is made before graft thrombosis. Our data also indicate better prolongation of patency with a second reintervention (PIP2) if the first intervention was a stent placement. Patch angioplasty appears to be a less attractive alternative for correction of venous outflow stenosis given the more invasive and occasionally technically difficult procedure.
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