Keywords: Vascular access, Hemodialysis, Percutaneous, Stenosis.
|How to cite this article:|
van der Linden J, van den Dorpel MA. Percutaneous Transluminal Angioplasty of Failing Hemodialysis Grafts and Fistulae. Saudi J Kidney Dis Transpl 2004;15:333-7
|How to cite this URL:|
van der Linden J, van den Dorpel MA. Percutaneous Transluminal Angioplasty of Failing Hemodialysis Grafts and Fistulae. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2020 Aug 3];15:333-7. Available from: http://www.sjkdt.org/text.asp?2004/15/3/333/32982
| Introduction|| |
Vascular access complications represent an ongoing contributor to patients' morbidity and even mortality. , In the United States, access complications cost close to $1 billion a year, and are responsible for 17-30% of all hospitalizations in dialysis patients. ,, Thrombosis is the leading cause among vascular access complications. It is almost always associated with the presence of stenosis, which is often located at, or close to, the venous anastomosis. Nowadays, percutaneous transluminal angioplasty (PTA) is considered a safe and effective treatment of stenotic lesions.  Routine surveillance programs for the early detection of stenoses are advocated by both American and European DOQI guidelines. If these are put into practice and combined with elective angioplasty, they have been shown to substantially reduce the number of thromboses per patient year. ,,, Also, the use of catheters, the duration of hospitalization, the number of missed dialysis treatments and even the total cost of treatment of thrombosis-related events for grafts can be substantially reduced by aggressive access surveillance. 
Based on the vast experience reported in the literature, the NKF-K/DOQI taskforce has suggested PTA as one of the preferred treatments for vascular access stenosis.  Compared with surgery, PTA has several advantages. PTA is an outpatient procedure, which preserves access sites and guarantees use of the access for dialysis immediately after the treatment. Also, even centrally located stenoses are accessible with PTA. This review will highlight the angioplastic findings and possibilities and reviews the results and complications of this technique.
| Localization of Stenoses|| |
In arterio-venous grafts (AVG), most thrombotic events result from one or more progressive stenoses in the venous outflow tract, typically at the venous anastomosis.,,, These stenoses are caused by intimal and fibromuscular hyperplasia, which may be induced by turbulent flow, increased shear stress and other factors. , Any obstruction of the outflow from the graft will result in an increase in venous pressure in the dialysis circuit with an accompanying decrease in blood flow.  Stenoses in arterio-venous fistula (AVF) tend to occur more centrally at vein bifurcations and venous valves, rather than close to the venous outlet. Stenoses in AVF frequently result in development of collateral veins draining the AVF. As a result, a venous stenosis will cause a reduction in blood flow but often without the increase in venous pressure. Arterial inflow stenoses account for less than five percent of lesions in accesses.  According to NKF-K/DOQI guidelines, stenotic lesions of 50% or more, associated with clinical or physiological abnormalities, should be treated. 
| Evaluation of the Effect of PTA|| |
K/DOQI recommends a residual stenosis of less than 30% after PTA. However, several studies have shown that the angiographic result of PTA is poorly related to its subsequent patency. ,,,, We found that the access flow prior to PTA, and the initial improvement in access flow after PTA were strong predictors of the decline in access flow after PTA.  Furthermore, the likelihood of access thrombosis is about 80% if angioplasty fails to improve access flow by at least 20%.  Recently, the SCVIR Technology Assessment Committee recommended that PTA success should be expressed in both angiographic and functional parameters.  A successful PTA procedure should lead to an increase in access flow of 250-300 mL/min. ,, The percentage of PTA procedures resulting in an access flow less than the threshold value of 600 mL/min, was 34% in AVG and 50% in AVF. Schwab et al defined failure of PTA as an increase in access flow of less than 20%, which occurred in 21% of grafts.  This lack of effect in a minority of patients may be caused by rapid recoil of the stenotic lesion, occurring in the period between PTA and the first access flow measurement. Intravascular ultrasound after PTA showed that immediate elastic recoil occurred in 50% of the stenotic lesions.  Access flow measurements, during or immediately after PTA, made in the intervention room, could be helpful to optimize procedure results.
| Patency Rates of PTA|| |
Numerous reports have demonstrated that PTA effectively improves access function. However, comparing patency rates is difficult because of differences in patient selection, access types and definitions of efficiency of the PTA procedure. Initial success rates of PTA, i.e. post-PTA rest-stenosis less than 30%, range from 80 to 94%. ,,, The highest rate of technical failure is associated with central lesions.  Primary patency rates at six months after PTA range from 43 to 77%, again with poorest long-term success in central lesions (ranging from nearly 25% to 42% at 6 months). ,,,,,
Only one controlled surveillance study evaluated PTA results in AVF.  With a sixmonth patency of more than 95%, PTA seems to be more successful in AVF than in AVG. Also, the mean time interval to re-PTA is longer for AVF than AVG (169 vs. 109 days), indicating a slower development of re-stenosis in AVF.  Recently, Beathard et al reported on the beneficial effect of PTA in AVF that failed to mature.  Angioplasty was performed to treat venous and arterial stenoses with a success rate of nearly 100%. In the great majority of AVF, hemodialysis could be initiated. The long-term effect of these early angioplastic corrections on AVF maturation still needs to be elucidated.
Results of PTA after vascular access thrombosis are generally worse, with a reported six-month patency rate of only 19% in one study including AVG only.  This finding suggests that the outcome of PTA of less severe stenoses is superior to the outcome of PTA of more severe stenoses that lead to thrombosis, emphasizing the importance of effective surveillance of access stenosis and pre-emptive PTA. Primary patency after surgical thrombectomy seems slightly better, but remains disappointing. ,, Dougherty et al stressed the fact that endovascular treatment is more expensive because of frequent secondary surgery after technical failure.  However, it is important to keep in mind that surgical thrombectomy is followed by reconstruction of the anastomosis in most cases. As a consequence, after several surgical revisions a new anastomosis often can no longer be created. Of course, the creation of a new access also results in extra costs and morbidity.
PTA results in substantial vascular injury, which may trigger development of restenosis. However, several authors found similar success rates after first, second or third PTA. , Still, the use of cutting balloons instead of circular dilatation balloons resulted in less intimal proliferation in an animal model, indicating less traumatic injury after cutting balloon angioplasty.  Uncontrolled data in hemodialysis patients indicate that this device may be useful in clinical practice  ,although no randomized studies comparing both balloon types in access stenosis have been published so far.
| Complications of PTA|| |
With a clinically significant morbidity rate of less than five percent, PTA can be considered a safe procedure. The most common complications are vein rupture at the angioplasty site, acute access thrombosis and pseudoaneurysm formation. If possible, self expanding stents are used to treat vein ruptures, otherwise surgical intervention is needed. Other reported complications include puncture site bleeding, bacteremia and allergic reactions to contrast medium.
| Use of Self-Expanding Stents|| |
The majority of trials reporting optimistic results of using self-expanding stents to treat venous stenoses are uncontrolled or retrospective. In a prospective randomized controlled trial, 87 patients with significant stenotic lesions were randomized to treatment with PTA or PTA and stent placement.  The sixmonth primary patency rate of peripheral venous stenoses was 31% in the PTA group and 27% in the PTA and stent group. Also, stent placement in central venous stenoses did not result in better patency rates. However, the number of central venous lesions was small in this study.  Another prospective randomized trial was conducted by Beathard et al.  Again, no benefit could be demonstrated of the use of a stent as an adjunct to PTA for anastomotic lesions in AVG.  Overall, additive placement of self-expanding stents should be considered only in a selected group of patients, with central-elastic-lesions not responsive to PTA, or recurrence within three months after successful PTA, and patients with vein rupture after PTA. Lesions that cannot be dilated with angioplasty should not be treated with stent placement. 
| Conclusions|| |
PTA is an effective and safe outpatient procedure in the treatment of hemodialysis access stenoses, and it can be repeated several times. When access thrombosis has occurred, surgical thrombectomy seems to have slightly better results. However, radiological thrombolysis has the advantage of angiographic imaging afterwards and immediate treatment of the underlying stenosis by angioplasty. Also, in contrast with surgical thrombectomy, the radiological approach makes revision of the anastomosis unnecessary, thereby preserving the access. Besides further fine-tuning of vascular access surveillance strategies, future studies should also be aimed at the further development of less traumatic angioplasty techniques, like cutting balloons. Foremost, the use of pharmacological inhibition of stenosis formation and recurrence after PTA, for instance with local drug delivery systems or gene therapy should be vigorously explored.
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Joke van der Linden
Department of Internal Medicine, Rijnmond-Zuid Medical Center, Location Clara, Olympiaweg 350, 3078 HT, Rotterdam, The Netherlands