Role of stenting for maintenance of the extremity fistula/graft overview

Dialysis access interventions have undergone significant developments over the last few decades. Angioplasty has been the mainstay of therapy since the early interventions in the 1980s and 1990s, but poor long-term patency and early loss of access has led investigators to assess other devices to treat stenoses associated with dialysis access failure. Multiple retrospective studies of stents for treatment of stenoses that did not respond to angioplasty demonstrated that the long-term outcomes were not improved over angioplasty alone. Cutting balloons have been studied in a prospective randomized fashion but also showed no long-term improvement over angioplasty alone. Prospective randomized trials have demonstrated that stent-grafts have superior primary patency of the access and the target lesions than angioplasty. The purpose of this review is to summarize the current state of knowledge regarding stent and stent graft use in dialysis access failure. We will discuss the early observational data related to stent use in dialysis access failure including the earliest reports of stent use in dialysis access failure. This review will then focus the review on the prospective randomized data that supports the use of stent-grafts in specific areas of access failure. These include venous outflow stenosis related to grafts, cephalic arch stenoses, native fistula intervention, and the use of stent-grafts to revise in-stent restenosis. Each of these applications will be summarized and the current status of the data will be reviewed.