Insufficient hemodialysis access fistulas: 18 months' experience in laser-supported dilation

Patients with end-stage renal failure disease frequently develop venous stenoses or occlusions in their hemodialysis access fistulas caused by intimal fibrosis. A complete dilation with high pressure balloons up to 20 atm may be unsuccessful in those cases. We investigated two new pulsed dye laser devices for the ablation of obstructions, which were not adequately treatable with a previous balloon angioplasty. From November 1990 to April 1992 a total of 154 percutaneous transluminal angioplasties (PTAs) of hemodialysis access fistulas were performed. In 23 of them an additive laser angioplasty was necessary. Twenty patients with Cimino fistulas presented 28 stenoses and two occlusions, and three Goretex loops presented all occlusions. Two pulsed dye laser devices emitting at 504 nm and 595 nm wavelength were tested. Technical success was achieved in 22/23 cases, but clinical success was obtained in 20/23 patients because two early reocclusions caused by thrombosis appeared. Five restenoses occurred 2, 3, 10, and in two cases 14 months after angioplasty with a mean follow-up period of 13.5 (5-18) months. Pulsed dye laser ablation in hemodialysis access fistula lesions due to intimal fibrosis is a valuable enrichment of radiological recanalization techniques and an alternative to surgery if stand alone balloon PTA fails.