|Year : 2019 | Volume
| Issue : 3 | Page : 583-586
Role of percutaneous transluminal angioplasty for radiocephalic fistulae with junctional stenosis
Alhussein M Khedr, Sameh E Elimam, Mohamed Hamza
Vascular Surgery, Al Azhar University, Egypt
|Date of Submission||17-Apr-2019|
|Date of Decision||07-May-2019|
|Date of Acceptance||13-Jun-2019|
|Date of Web Publication||10-Feb-2020|
MD, AFMG Sameh E Elimam
134, 2nd District, 4th Area, 5th Settlement, New Cairo, 11835
Source of Support: None, Conflict of Interest: None
Background Morbidity from end-stage renal disease is primarily from vascular access. Access thrombosis is the main cause of arterio venous (AV) access failure. Decreased fistula blood flow leads to access thrombosis in arteriovenous fistulae, which occurs secondary to venous stenosis. Junctional stenosis is a complication of arteriovenous fistulas. Surgical correction and percutaneous transluminal angioplasty may correct it. Our study aimed to clarify factors for primary success of percutaneous transluminal angioplasty of radiocephalic fistulae with stenosis at the arteriovenous junction with long-term patency on follow-up. Radiocephalic junctional stenosis of fistulae involves both the radial artery and cephalic vein and site of bifurcation. Usually, radiocephalic fistula stenosis is located in the venous limb near the arteriovenous junction.
Patients and methods This prospective study included 50 percutaneous transluminal angioplasty cases with stenosis at the arteriovenous junction of radiocephalic fistulae. Demographic data including age, sex, site of fistula (right or left arm), and approach (radial artery or cephalic vein) were recorded. Analysis included primary percutaneous transluminal angioplasty success and long-term patency rates.
Results The total primary success rate was 88%. The existence of total occlusion was recognized as the only factor significantly associated with a high procedural failure rate (83.3 vs. 16.6%, P=0.03). For long-term patency rate, the only significant factor was the involvement of proximal radial artery dilatation (P=0.023). The 6, 12, and 18-month patency rates were 66.4, 46.8, and 23.1%, respectively, for all procedures.
Conclusion Percutaneous transluminal angioplasty for junctional stenosis at radiocephalic fistula involving both the radial artery and cephalic vein at the site of anastomosis without dilating the radial artery side of the arteriovenous junction reduces the long-term patency rate; however, the initial success rate will not be affected. Initial procedural failure depends on presence of occlusive lesion mainly.
Keywords: angioplasty, duplex guided, infragenicular angioplasty, ischemia, salvage
|How to cite this article:|
Khedr AM, Elimam SE, Hamza M. Role of percutaneous transluminal angioplasty for radiocephalic fistulae with junctional stenosis. Sci J Al-Azhar Med Fac Girls 2019;3:583-6
|How to cite this URL:|
Khedr AM, Elimam SE, Hamza M. Role of percutaneous transluminal angioplasty for radiocephalic fistulae with junctional stenosis. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2020 Feb 29];3:583-6. Available from: http://www.sjamf.eg.net/text.asp?2019/3/3/583/278033
| Introduction|| |
Percutaneous transluminal angioplasty with balloon dilatation of stenotic radiocephalic fistula can be used to dilate the vessels, eventually extending the durability of the fistula . The overall 1-year patency rates of dilated radiocephalic fistulae have been reported to be ∼40–64% ,,. Among the predictors of long-term patency, exact site of stenosis at the arteriovenous junction is associated with higher restenosis rates .
The target for correction of the fistula involves dilatation of distal cephalic vein , proximal cephalic vein , brachial artery , or radial artery. Till now the cause of lower long-term patency rates in percutaneous transluminal angioplasty for radiocephalic fistulae is still poorly identified.
| Patients and methods|| |
Study design and patient population
This study was approved by Al Azhar Ethical Committee. A total of 50 percutaneous transluminal angioplasty procedures were done for RC failed fistulae; this failure can be defined as low flow rate on hemodialysis, difficult cannulation, or absence of thrill on palpation. Stenosis located within 1 cm of the arterio venous (AV) anastomosis is expressed as junctional stenosis. Demographics of the patients, site of intervention, percutaneous transluminal angioplasty maneuver, and time of restenosis were recorded.
All patients signed an informed consent. After local anesthesia, the approach site was based on the anatomy of the anastomosis and exact site of stenosis. All procedures were done either by the transradial or by transcephalic approach guided by duplex ultrasound (US). Puncture of the cephalic vein proximal to the arteriovenous junction was for the transcephalic approach. Puncture of the radial artery distal to the arteriovenous junction was for the transradial approach. Steps included puncturing the vessel, and a 6-F sheath was inserted after introducing the guide wire. Heparin 3000 U was injected through the sheath. We used to cross the stenotic or occluded lesions with hydrophilic guide wires, and then balloon angioplasty was performed. Sizes of balloons used were approximately between 3 and 6 mm, and the pressure was ∼6–12 atm. Follow-up with duplex US was performed regularly.
Definition of success and patency
Less than 30% residual stenosis and adequate angiographic flow after dilatation is considered a success of the procedure. Patency duration was defined as the period from the date of procedure to the occurrence of restenosis of arteriovenous junction ([Figure 1]).
|Figure 1 Image shows dilatation of juxta-anastomotic narrowing of left upper brachiocephalic.|
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We used the SPSS package software (software package used for interactive, or batched, statistical analysis) (IBM, Armonk, New York City, United States of America) version 20 to analyze our data. Descriptive statistics were described as mean±SD or median (range), whereas categorical variables were described as number of cases and percentages. We compared the group means by using Student t-test and the group medians by using Mann–Whitney U-test. Categorical changes were evaluated by using Fisher’s exact test. The cumulative patency rates versus time of follow-up for individual variables and subgroups were calculated by using Kaplan–Meier survival curve and Cox regression methods, and the statistical difference between the survival curves was determined by means of Cox–Mantel and generalized Wilcoxon statistics. P value less than 0.05 was considered statistically significant for each variable.
| Results|| |
In total, 50 procedures for dilating junctional stenosis of radiocephalic fistula were analyzed, including 29 procedures in left arms and 21 in right arms. There were 44 stenotic and six totally occluded lesions. Overall, 28 procedures were performed with the transradial approach and 22 with the transcephalic approach. Dilatation of the proximal radial artery side of the arteriovenous junction was performed in 23 procedures but not in the other 27 procedures.
In the transradial approach, proximal radial artery side dilatation was performed in nine procedures but not in the other 19 procedures. In the transcephalic approach, proximal radial artery side dilatation was performed in 14 procedures but not in the other eight procedures. Procedural success was obtained in 44 (88%) cases.
According to clinical predictive factors of primary success, sex, age, side of the radiocephalic fistula (right or left arm), access site (transradial or transcephalic), and involvement of proximal radial artery side dilatation, there was no significant difference in procedural success between groups ([Table 1]).
|Table 1 Initial procedural success rates in radiocephalic fistula balloon dilatation|
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During the follow-up period, 21 restenoses over the arteriovenous junction of radiocephalic fistulae occurred (47.77%). No significant association was found between restenosis and sex, age, right or left arm side, and the presence of stenosis or total occlusion.
The existence of total occlusion was the only factor significantly associated with a high procedural failure rate (83.3 vs. 16.6%, P=0.03). Overall, five (83.3%) cases from the six failed procedures were performed in the totally occluded lesions.
During the follow-up period, 21 restenoses over the arteriovenous junction of radiocephalic fistulae occurred (47.77%). No significant association was found between restenosis and sex, age, right or left arm side, and the presence of stenosis or total occlusion ([Table 2]).
Dilatation of proximal radial artery was the only factor found significantly associated with long-term patency rate (P=0.023). The overall patency rates were 66.4, 46.8, and 23.1% at the 6, 12, and 18-month follow-ups, respectively. On 6-month follow-up, in patients with proximal radial artery side dilatation, the patency rate was 69.8%, whereas in patients without proximal radial artery side dilatation, the patency rate was 54.2%. On 12-month follow-up, in patients with proximal radial artery side dilatation, the patency rate was 58.1%, whereas in patients without proximal radial artery side dilatation, the patency rate was 36.7%. On 18-month follow-up, in patients with proximal radial artery side dilatation, the patency rate was 35.8%, whereas in patients without proximal radial artery side dilatation, the patency rate was 6.5% ([Table 3]).
|Table 3 Patency rates in relation to proximal radial artery side dilatation in the follow-up period|
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No significant complications such as vessel perforation, massive bleeding, or steal phenomenon were noted during or after the procedures.
| Discussion|| |
The end result of this study showed that the primary failure of dilatation occurred mainly in the totally occluded lesions rather than in the stenotic lesions (which is similar to a previous report ). The most significant predictive factor associated with long-term patency was proximal radial artery dilatation.
In this study, the initial success rate was 88%, which is approximate to previously reported rates ,,,. For the 12-month patency rate, the result of this study (46.8%) was similar to or better than previous reports (20, 46.1, and 45.3%) ,,. Subgroup analysis further showed that long-term patency rate is significantly affected by dilatation of proximal radial artery. Dilatation of the proximal radial artery showed better 1-year patency rate than those without (58.1 vs. 36.7%). Incorporation of proximal radial artery dilatation into the long-term patency rate analysis of dilating arteriovenous junction stenosis of radiocephalic fistulae was previously reported by Yang et al. .
Atherosclerosis and fibrosis are the primary causes of stenoses in the arterial limb and/or junctional sites . Progression of atherosclerosis process leads to fistula failure eventually.
Increasing flow from the dilated arteriovenous junction orifice will trigger adaptive remodeling of the fistula . This process also helps to maintain the long-term patency rate by increasing the diameter of the dialysis fistula.
According to our data analysis, transradial approach was not superior to transcephalic approach in relation to patency rate.
Proximal cephalic vein dilatation without the proximal radial artery had no significant effect on the primary procedural success in our findings.
Primary success with sufficient radiocephalic fistula flow in the procedure without proximal radial artery dilatation may be owing to adequate initial shunt flow derived from a high pressure gradient between the undilated proximal radial artery and the dilated proximal cephalic vein. Progressive atherosclerosis and stenosis will decrease the shunt flow more rapidly in the undilated proximal radial artery than in the dilated proximal radial artery resulting in decreasing the long-term patency rate of the fistulae.
| Conclusion|| |
Percutaneous transluminal angioplasty for junctional stenosis of radiocephalic fistula involving both the radial artery and cephalic vein at the site of anastomosis without dilating the radial artery side of the arteriovenous junction reduces the long-term patency rate. However, the initial success rate will not be affected. Initial procedural failure depends on presence of occlusive lesion mainly.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]