Treatment of hemodialysis access rupture during PTA with Wallstent implantation

To report the authors' experience in treatment of ruptures complicating percutaneous transluminal angioplasty (PTA) of hemodialysis access with implantation of a Wallstent.

Between January 1, 1990, and October 1, 1995, the authors performed 2,414 PTAs of angioaccesses. A severe rupture occurred in 40 (1.7%) of these procedures and was treated by means of stent placement. Wallstents were implanted in 37 of these ruptures. The angioaccesses comprised 22 grafts and 15 fistulas. The indications for stent placement were four isolated pseudoaneurysms and 33 cases of bleeding: 15 major leaks, five moderate leaks that persisted despite prolonged inflation at low pressure, seven leaks associated with greater than 50% residual stenosis, four leaks associated with pseudoaneurysm, and two leaks associated with both greater than 50% residual stenosis and pseudoaneurysm. Seventeen ruptures were located on a vein, 19 on the venous anastomosis of a graft, and one on a graft itself.

Stent placement stopped the bleeding immediately in 28 cases and after prolonged inflation within the stent in four cases. Residual bleeding required implantation of a covered Cragg stent within the Wallstent in one case. A pseudoaneurysm was still visible at the end of the intervention in 11 cases. Two complications occurred; one hematoma was drained surgically and one access occluded on day 2. Follow-up angiography showed a small pseudoaneurysm in only one patient with impaired platelet function. The primary and secondary patency of the angioaccesses were 48% and 86% at 1 year, respectively.

Wallstent implantation is very effective for both immediate and long-term treatment of rupture of angioaccess during PTA.