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The treatment of chronic hemodialysis vascular access by directional atherectomy
D Mizumoto1, Y Watanabe, S Kumon
1Third Department of Internal Medicine, Nagoya University School of Medicine, Japan.
Insights
Directional atherectomy (DA) effectively treats vascular access failure in hemodialysis patients, achieving high technical success rates. While restenosis can occur, repeated DA interventions maintain satisfactory patency, especially for eccentric native vein stenosis.
Area of Science:
- Interventional Cardiology
- Vascular Surgery
- Nephrology
Background:
- Vascular access failure is a significant complication in hemodialysis patients.
- Directional atherectomy (DA) is a novel therapeutic approach for coronary artery disease.
- DA has been applied to address vascular access failure, characterized by poor blood flow or high venous pressure.
Purpose of the Study:
- To evaluate the efficacy and safety of Directional atherectomy (DA) for treating vascular access failure.
- To assess the technical success, initial success, and patency rates following DA intervention.
- To identify factors influencing restenosis and determine the most suitable lesions for DA application.
Main Methods:
- DA intervention was performed on 27 lesions in 16 hemodialysis patients.
- Technical success was defined as stenosis reduction to <20%.
- Patency rates were assessed at 1, 3, 6, and 12 months post-intervention.
Main Results:
- Technical success rate was 84%, with all patients achieving adequate blood flow post-intervention.
- Short-term patency rates were high (100% at 1 month, 93% at 3 months).
- Long-term patency at 12 months was 75%; restenosis was less frequent in native vein lesions and eccentric stenosis.
Conclusions:
- Directional atherectomy (DA) is a safe and effective treatment for vascular access failure, offering satisfactory short-term and reasonable long-term patency.
- Eccentric stenosis in the native vein appears to be the most suitable lesion type for DA intervention.
- DA represents a valuable therapeutic option for managing vascular access failure in hemodialysis patients.
Abstract:
Directional atherectomy (DA) was developed as a new therapeutic modality for coronary artery disease. For the past 3 years, we have applied DA intervention to vascular access failure with either poor blood flow rate or high venous pressure. DA intervention was performed on 27 lesions of 16 hemodialyzed patients. A reduction of stenosis to less than 20% of that before treatment was judged a technical success, and the rate of technical success was 84%. All patients showed adequate blood flow rates after DA intervention, indicating initial success. Although restenotic events occurred frequently, repeated DA interventions could be performed successfully. The patency rate at 1 month after DA intervention was 100%, at 3 months 93%, at 6 months 92% and at 12 months 75%. The short-term patency rate of DA was more satisfactory than the results of percutaneous transluminal angioplasty as reported by several investigators. Regarding the site of stenosis, restenotic events were relatively fewer in the lesions occurring at the native vein compared to those at graft-venous anastomotic sites. Eccentric-type stenosis was also associated with fewer restenotic events than circumferential-type stenosis. These results suggest that eccentric-type stenosis at the native vein is the most suitable lesion for the application of DA intervention in terms of long-term patency. As no severe complications occurred after DA intervention, this would appear to be a useful therapeutic modality for the correction of vascular access failure.