|Year : 2015 | Volume
| Issue : 1 | Page : 7-11
Predictors of Patency Following Fistulography and Percutaneous Interventions in the Treatment of Nonfunctioning Native Vascular Access
Brendan Hermenigildo Dias, Santosh Antony Olakkengil
Department of Surgery, St. John's Medical College, Bengaluru, Karnataka, India
|Date of Web Publication||5-Mar-2015|
Dr. Brendan Hermenigildo Dias
Department of Surgery, St. John's Medical College, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Aim: The aim was to evaluate the various factors predicting patency following fistulography and percutaneous interventions in the management of nonfunctioning native vascular access.
Materials and Methods: Retrospective analysis of 61 patients with native arteriovenous fistulae (AVF) who underwent fistulography and percutaneous interventions from January 2010 to December 2013. Mean patient age was 47 (23-78) years. 69% (42 of 61) of the patients were males. 56% (34 of 61) of patients underwent elbow AVF creation, and the remaining were forearm AVFs. Median time from fistula creation to fistulography was 9 months. On fistulography, hemodynamically significant (>50%) stenosis were identified in 93% (57 of 61) of patients. Angioplasty was attempted in 88% (54 of 57) of fistulae. In 14% (8 of 54) of cases, stent was placed.
Results: Technical success was achieved in 98% (53 of 54) of fistulae following angioplasty. Clinical success (ability to use the AVF for successful hemodialysis) was noted in 87% (47 of 54) of cases. About 52% (32 of 61) of the fistulae had multiple stenosis. The most common location of stenosis was the venous limb of the fistula (70%). The primary patency rates were 75.4%, 68.9%, and 30% at 3, 6 and 12 months. The secondary patency rates were 100%, 89%, and 70% at 3, 6 and 12 months. The absence of palpable thrill postprocedure was found to be a risk factor for both primary, as well as secondary patency rates.
Conclusions: Our results demonstrate that fistulography and percutaneous interventions in the form of angioplasty and stenting are helpful in maintaining the patency of nonfunctioning native vascular access. We found that the most important predictor of fistula patency following percutaneous interventions is the presence of palpable thrill. Our study also showed that stent placement is effective in treating venous stenotic lesions in native arteriovenous fistula hemodialysis patients after unsatisfactory balloon dilatation.
Keywords: Angioplasty, arteriovenous fistula, dialysis access fistulogram, percutaneous interventions, vascular access
|How to cite this article:|
Dias BH, Olakkengil SA. Predictors of Patency Following Fistulography and Percutaneous Interventions in the Treatment of Nonfunctioning Native Vascular Access. Indian J Vasc Endovasc Surg 2015;2:7-11
|How to cite this URL:|
Dias BH, Olakkengil SA. Predictors of Patency Following Fistulography and Percutaneous Interventions in the Treatment of Nonfunctioning Native Vascular Access. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2019 Jan 15];2:7-11. Available from: http://www.indjvascsurg.org/text.asp?2015/2/1/7/152824
| Introduction|| |
For patients with end-stage renal disease undergoing chronic hemodialysis, a functioning dialysis access fistula with a sufficient flow rate is crucial. Failure of these fistulas is typically due to shunt vein stenosis, which if inadequately treated is followed by thrombotic occlusion.  Surgical correction of stenoses has the major drawback of involving the loss of a few centimeters of vessel each time and of extending vascular access farther up the limb, thereby minimizing sites for future placement of vascular access.  Autogenous fistulas are the superior form of hemodialysis access because of longer duration of patency, fewer infections, lower mortality, and higher quality of life.  Data suggests that as many as 30% of native fistulas, however, will never mature to enable cannulation and successful hemodialysis. ,,, Preoperative venous imaging can reduce the proportion of patients with nonmaturing fistulas. , Percutaneous treatments have been used to salvage nonmaturing native fistulas. ,,, Percutaneous transluminal angioplasty (PTA) has also been used as an alternative to surgery and has proved to be efficacious in the treatment of dialysis access stenosis. ,,
The aims of this retrospective study were to estimate the clinical outcomes including the success rate, patency, and procedure-related complications after fistulography and percutaneous interventions in nonfunctioning native arteriovenous fistulae (AVF).
| Materials and Methods|| |
The patients who underwent arteriovenous fistulograms from January 2010 to December 2013 in St. Johns Medical College Hospital, Bangalore, India, were included in this retrospective study. In our setup, management of fistula patency is a multi-disciplinary approach involving the dialysis technician, nephrologists, sonologist, an interventional radiologist and vascular surgeon. Active surveillance through monthly physical examination of the fistula is practiced. Patients with nonfunctioning fistulae are referred to the sonologist for a Doppler study and then subsequently referred for fistulography to the interventional radiologist. Indications for fistulography included absence of thrill or altered pulse/thrill, inability to achieve adequate dialysis through the fistula, inadequate flow detected on color Doppler, inability to cannulate the fistula, nonmaturing fistulae, prolonged bleeding after needle withdrawal and nonresolving arm edema. Postintervention patients are followed up using monthly physical examination and monthly Doppler assessment of the fistula.
Patient demographics, clinical, and radiographic data of the study population, including the findings of initial fistulogram and any subsequent interventions, concerning the location and severity of the stenotic lesions on fistulogram and the status of AVF function, was obtained by review of medical records. Variables including age; gender; co-morbidities such as diabetes and hypertension; age of AVF; side of the AVF; type of AVF; a number of lesions; were collected for analysis of factors affecting outcomes. The study was approved by the institutional review board and informed consent was waived.
Definitions and classifications
Venous stenosis was defined as a 50% or greater decrease in lumen diameter compared to the adjacent segment of the AVF vein as seen on the fistulogram. Procedure outcomes were analyzed according to the guidelines and reporting standards of the Society of Interventional Radiology (SIR) Technology Assessment Committee.  Technical success was defined on angiography as a less than 30% residual diameter stenosis, and clinical success was defined as at least one successful dialysis using the AVF after the endovascular treatment.
Definitions of patency according to the American College of Radiology-Society of Interventional Radiology guidelines
Primary patency (intervention-free access survival) was defined as the interval from time of access placement to any intervention designed to maintain or reestablish patency or to access thrombosis or the time of measurement of patency. Assisted primary patency (thrombosis-free access survival) was defined as the interval from time of access placement to access thrombosis or time of measurement of patency, including intervening manipulations (surgical or endovascular interventions) designed to maintain the functionality of a patent access. Secondary patency (access survival until abandonment) was defined as the interval from time of access placement to access abandonment or time of measurement of patency, including intervening manipulations (surgical or endovascular interventions) designed to reestablish the functionality of thrombosed access. 
Access for PTA was either through the radial or femoral artery. In 13 cases access was also achieved through the venous limb of the fistula. Location of the stenosis was classified according to the system used by Clark et al.  Stenoses in the anastomotic and juxta-anastomotic area were treated with 3-6-mm-diameter balloons (median diameter, 5 mm); stenoses in the draining vein were treated with 6-9-mm-diameter balloons (median diameter, 7 mm), and stenoses in the central veins were treated with 10-14-mm-diameter balloons (median diameter, 12 mm). After delineation of the lesion, the lesion was crossed using a straight or a J tipped guide wire. The balloon was inflated for a total of 3 min each time up to a maximum of 5 dilatations/lesion. 5F PTA catheters were used in most cases. However, in some cases high pressure balloons (17 atm burst pressure) through 7F PTA catheters had to be used to achieve technical success. 5000 U heparin was given intravenously as a routine to all the patients before the procedure.
The patency outcome was analyzed using the Kaplan-Meier method. To identify the possible prognostic factors for postprocedural primary and secondary patency rates, variables including age, gender, presence of co morbidities, type of AVF, fistula age, side of AVF, multiple stenotic lesions, maximum balloon diameter used for angioplasty and presence of a palpable thrill postprocedure were entered the into the Cox proportional hazards model as potential risk factors for the primary and secondary patency rates of AVF. SPSS 16.0 software for Windows (SPSS, An IBM Company, Chicago, Illinois, USA) was used.
| Results|| |
Between 2010 and 2013 a total of 61 patients underwent fistulograms in our hospital. Although all 61 patients had stage V chronic kidney disease and were on maintenance hemodialysis; 10 were initiated with continuous ambulatory peritoneal dialysis (CAPD) which was later changed to hemodialysis. These 10 patients who were initiated on CAPD had to be switched to hemodialysis due to various reasons. Seven out of the 10 patients expressed financial difficulty in continuing CAPD and hence needed a cheaper alternative. The remaining 3 patients were unable to achieve adequate dialysis on CAPD as they had multiple episodes of CAPD peritonitis and hence had fistulae created. The patient and fistula characteristics are shown in [Table 1]. All 61 patients had temporary HD catheters inserted in to the internal jugular or subclavian vein at some point in time. Catheter related sepsis requiring admission, IV antibiotics and removal of temporary catheter was seen in 41 patients during the study period. The median time to fistulography was 9 months. All patients underwent Doppler evaluation of their access and were subsequently referred for fistulography based on Doppler findings of venous stenosis or thrombosis or flow of <500 mL/s. Indications for fistulography were venous stenosis in 38 cases, inadequate flow in 22 cases and persistent arm edema in 1 case.
The fistulography findings are shown in [Table 2]. In 54 (88%) out of the 57 detected lesions angioplasty was attempted. In 1 (2%) case, angioplasty failed due to the inability to pass the guide wire across the lesion. In the other 2 (4%) cases the there were multiple stenosis and collaterals that would make multiple angioplasties challenging and of questionable benefit and hence these AVFs were referred for surgical correction. Technical success after angioplasty was achieved in 53 out of the 54 attempted cases. Clinical success with ability to use the fistula for successful hemodialysis was noted in 47 out of the 54 cases. No major complications were encountered. Minor complications in the form of a puncture site hematomas were seen in 7 (11.5%) patients.
Role of stent placement in the management of native arteriovenous hemodialysis access
We had to place stents in 8 out of the 54 cases in which angioplasty was attempted [Table 3].
In 6 out of the 8 cases we used a balloon expandable covered stent (V12, Maquet Vascular Systems, Hudson, NH, USA); while in the remaining 2 cases we used a self-expandable metallic stent (Zilver 518, COOK Medical, Bloomington, IN, USA). The indication for stenting in these cases was residual stenosis following angioplasty of the stenotic lesions in 7 patients and 1 patient underwent stent placement in view of a large adherent thrombus in an outflow aneurysm of a thrombosed AVF. 7 of these stenotic lesions requiring stenting were located in the central veins and 7 stents were placed in the subclavian vein. One patient who had a thrombosed AVF with a large adherent thrombus had a stent placed in the venous outflow vein. One patient had a stent fracture which was treated using the stent within a stent technique [Table 3].
Postintervention primary and secondary patency and their predictors
The mean postprocedural primary and secondary patency rates were 7.7 ± 1.0 months and 10.7 ± 0.6 months respectively (P < 0.001). The primary patency rates were 75.4% at 3 months, 68.9% at 6 months, 41% at 9 months and 30% at 1-year. The secondary patency rates were 100% at 3 months, 89% at 6 months, 85% at 9 months and 70% at 1-year. The Kaplan-Meier curves showing postprocedural primary and secondary patency are shown in [Figure 1].
|Figure 1: Kaplan-Meier curves showing primary and secondary patency (n = 61)|
Click here to view
The variables age, gender, presence of co morbidities, type of AVF, fistula age, side of AVF, multiple stenotic lesions, maximum balloon diameter used for angioplasty and presence of a palpable thrill postprocedure were evaluated in the univariate analysis as potential risk factors for the primary and secondary patency rates of AVF [Table 4]. Absence of palpable thrill postprocedure was found to be the most important risk factor associated with both the primary as well as secondary patency rates. Presence of hypertension and increasing number of stenosis were found to be associated with the primary patency rates of the AVFs in our study [Table 4].
| Discussion|| |
This study shows that use of fistulography and percutaneous interventions in the form of angioplasty and stenting improves patency rates in native AVF. We classified the location of stenosis in a manner described by Clark et al.  In our study the most common location of stenosis was in the venous limb (future cannulation zone) of the AVF which showed a significant stenosis in 70% of our fistulograms. Clark et al.  found that the most common location of stenosis was the juxta-anastomotic area. This area was the second most common location of stenosis in our study.
Reports of large studies 18-22 in which outcomes for autogenous hemodialysis fistulas were examined indicated success rates ranging from 91% to 98% and 1-year primary patency rates ranging from 26% to 64% ,,,, .
Similar to the results of Clark et al.,  our results did not show any significant difference in outcome between right-sided and left-sided fistulas or between brachiocephalic and radiocephalic fistulas, nor did patient age or presence of diabetes make a significant difference.
Rajan et al.  observed significantly different primary patency rates in radiocephalic and brachiocephalic fistulae. However, no such differences were observed in the secondary patency rates. In our study, the location of the fistula did not affect the patency rates.
In our study, we found that the presence of a palpable thrill postprocedure was associated with significantly better patency rates. A study by Clark et al.  concluded that patients without thrill following angioplasty were more than twice as likely to lose patency when compared to patients with a palpable postprocedure thrill.
Pan et al.  placed stents in 12 patients and demonstrated good primary patency rates of 92%, 81%, 31%, and 31% at 3, 6, 12 and 24 months respectively; and secondary patency of 92%, 82% and 82% at 3 and 12, and 24 months each. These patency rates are similar to our results of stenting.
We have reported a case of subclavian vein stent fracture in one of our 8 patients who underwent stenting. This was treated using the "Stent within a stent technique". 
| Conclusions|| |
Our results show that arteriovenous fistulography and percutaneous interventions help in maintaining the patency of native AVF as an access for long term successful hemodialysis. We found that presence of a palpable thrill postangioplasty as a predictor of a successful outcome following percutaneous treatment of nonfunctioning AVF. Our study also showed that stent placement is effective in treating venous stenotic lesions in native AVF hemodialysis patients after unsatisfactory balloon dilatation.
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[Table 1], [Table 2], [Table 3], [Table 4]