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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 8
| Issue : 1 | Page : 66-71 |
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A prospective observational study to evaluate utility of USG (ultrasound)-guided arteriovenous fistuloplasty in our institute
Shrikant Pandurang Ghanwat, Svrkrishna Yeramsetti, Tapish Sahu, Virender Sheorain, Tarun Grover, Rajiv Parakh
Department of Vascular and Endovascular Sciences, Medanta the Medicity, Gurgaon, Haryana, India
| Date of Submission | 04-Nov-2020 |
| Date of Acceptance | 07-Dec-2020 |
| Date of Web Publication | 20-Feb-2021 |
Correspondence Address:
Shrikant Pandurang Ghanwat
Department of Vascular and Endovascular Sciences, Medanta the Medicity, Gurgaon, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijves.ijves_145_20
Introduction: In chronic kidney disease patients, arteriovenous fistula (AVF) is now increasingly and widely accepted as a vascular access for long-term hemodialysis, so their surveillance and maintenance is of paramount importance. In endovascular procedures, fistulogram and fistuloplasty are being most commonly used for the treatment of malfunctioning AVFs, however, Ultrasound-guided fistuloplasty also now has been established, so here we had evaluated its utility in our institute. Materials and Methods: A prospective, observational study of 67 patients who underwent? USG (ultrasound)-guided fistuloplasty in failing AVF was conducted from April 2019 to April 2020. The outcome of USG-guided fistuloplasty was assessed in terms of technical success rate using Doppler-derived volume flow (VF) criteria, complications, and primary patency at the end of 6 months. Observation and Results: Post fistuloplasty, all our cases showed a 100% procedural and clinical success rate with a significant increase in VF. Mean preprocedure volume flow (VF) was 160 ml / min +/- 47 standard deviation (SD) increased to mean post procedue VF of 399 ml/min +/- 102 SD. The most common complication noted was fistuloplasty site hematoma. Complications were fewer and managed using ultrasound. The primary patency at the end of 1, 3, and 6 months was 100%, 88.1%, and 77.6%, respectively. Conclusion: Ultrasound-guided fistuloplasty is a safe and effective treatment option with low morbidity rates for the treatment of failing AVF. This technique is safe, feasible, and reliable as it facilitates to reduce intervention time and achieve better results so should be used more frequently and effectively. Doppler-derived VF is a very useful and remarkable criterion to assess technical outcome.
Keywords: Arteriovenous fistula, fistuloplasty, ultrasound guided, volume flow
How to cite this article:
Ghanwat SP, Yeramsetti S, Sahu T, Sheorain V, Grover T, Parakh R. A prospective observational study to evaluate utility of USG (ultrasound)-guided arteriovenous fistuloplasty in our institute. Indian J Vasc Endovasc Surg 2021;8:66-71 |
How to cite this URL:
Ghanwat SP, Yeramsetti S, Sahu T, Sheorain V, Grover T, Parakh R. A prospective observational study to evaluate utility of USG (ultrasound)-guided arteriovenous fistuloplasty in our institute. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Feb 25];8:66-71. Available from: https://www.indjvascsurg.org/text.asp?2021/8/1/66/309700 |
| Introduction | |  |
End-stage renal disease population is on the rising trend, and chronic kidney disease (CKD) is increasingly being recognized as a global public health problem. The United States has seen a 30% increase in the prevalence of CKD in the last decade.[1] Now, diabetes mellitus and hypertension are the leading causes of chronic renal failure (CRF). Today, in India, diabetes and hypertension account for 40%–60% of CKD cases.[2]
Earlier, the focus in CRF was to treat a terminally ill patient, now which has been changed to dealing with a person with a manageable chronic disease that requires long-term hemodialysis. The changes in focus are the result of the technical advances in dialysis and improved surgical techniques. The National Kidney Foundation issued the Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for vascular access which emphasized that vascular access patency and adequate hemodialysis are essential to the optimal management of patients with CKD Stage 5.[3]
Stenosis is the most common problem with the arteriovenous fistula (AVF), which leads to a problematic fistula with inadequate dialysis or can precipitate fistula occlusion. Hence, surveillance is of paramount importance for longevity of AVF.[4] These lesions can be managed by surgical revision or endovascular intervention (fistuloplasty) of AVF. Endovascular interventions are widely being performed for immature and malfunctioning AVF using contrast medium and fluoroscopy.
Recently, we have observed an increasing role of ultrasonography (USG) in imaging of AVF. Superficial location of AVF allows for simple and reliable visualization of vessels, guidewire, catheter, balloon, etc., with significant technical advantages including the ability to directly visualize puncture sites, stenosis, thrombus, spasm, and extravascular flow in real time.[5] The use of Doppler ultrasound allows the identification of more than 50% AVF stenosis with 92% sensitivity and 84% specificity.[6]
Recent studies[7],[8],[9] showed that ultrasound-guided percutaneous transluminal angioplasty can be performed under only sonographic guidance without using a fluoroscopic machine and it is as effective as conventional percutaneous transluminal angioplasty.
Motive and objectives of the current study
Since more than a decade of described ultrasound-guided angioplasty, many small series have been published till date, but most of them studied small number population or without any definitive applicable criteria for technical success, while some used fluoroscopic assistance to access success and manage complications. To overcome these limitations and further evaluate the utility of ultrasound, we had taken Doppler-derived volume flow (VF) criteria to assess technical outcome. Ultrasound utility also expanded with its use for preoperative planning access, balloon sizing, and intraoperative management of complications.
As required equipment along with ultrasound machine are readily available, over the last few years, we have adopted ultrasound-guided fistuloplasty as our primary modality for failing AVFs without central venous stenosis. Hence, here we had conducted a study on CKD patients with malfunctioning AVFs, who have undergone fistuloplasty under USG guidance with respect to its technical success rate using VF criteria, complications, and patency rate.
| Materials and Methods | | |
Inclusion criteria
- Nonmaturing arteriovenous (AV) access
- Dampened thrill or pulsatile flow on clinical examination
- Flow disturbance picked up by dialysis technician
- Blood flow <400 ml/min
- High venous pressures (>200 mm hg) during dialysis
- VF <250 ml/min and stenosis (>50%) of AV access on ultrasound examination.
Exclusion criteria
- Thrombosed or completely occluded fistula or outflow vein
- Suspected central vein stenosis – arm swelling or Doppler-detected suspicion of the same.
Technique
Equipment
- Portable ultrasound machine
- Access needle and sheath (5–11 Fr)
- Catheters (multipurpose and support)
- Guidewires – 0.035”–0.014” (regular, stiff, j-tip, straight)
- Angioplasty balloons (5–8 mm size, normal and high pressure).
Procedure details
- After informed valid consent, all procedures were performed by the same team
- The procedure was performed under local anesthesia
- Position: Supine with arm abducted 60°–90° [Figure 1]
- Cleaning and draping was done keeping the entire upper limb sterile which includes AVF side-hand, arm, shoulder, axilla, and the same side of the chest with neck. Ultrasound probe was covered with a sterile camera/protection cover
- Duplex ultrasound evaluation was performed, preoperative VF was recorded [Figure 2], and stenosis was defined [Figure 3]
- Under all aseptic precautions and USG guidance, either antegrade/retrograde arterial or outflow vein access was taken based on the location of stenosis and extent of stenosis
- Sheath was placed and 40–50 Units/kg heparin was given through sheath
- The stenosis was negotiated with a 0.035/0.014-in. hydrophilic-coated guidewire and a diagnostic catheter, followed by the balloon catheter passed over the guidewire
- The size of the balloon was chosen depending on the diameter of the normal vessel adjacent to the area to be dilated (balloons were arranged on the basis of preoperative duplex evaluation)
- The balloon sizes used in our study ranged from 5 to 8 mm, with 6 mm balloon being the most commonly used size. Normal and/or high-pressure balloons were used depending on the degree of stenosis
- Under pressure control, the balloon was inflated, waist was noted on ultrasound [Figure 4], and pressure was increased slowly until the waist disappeared [Figure 5]
- Duplex ultrasound confirmation of widely opened stenotic lesion and continuous segment of dilated vein with VF >250 ml/min signified the end point of procedure
- Postoperative VF was recorded [Figure 6] for each procedure on duplex ultrasound
- Access site hemostasis was achieved with manual compression.
 | Figure 6: Post fistuloplasty volume flow measured using duplex ultrasound
Click here to view |
Data collection and statistical methods
- Patient demographic data were recorded. Data regarding associated comorbid illnesses were collected
- Duplex ultrasound was performed for evaluation of fistula for need of intervention. Pre- and postoperative VF and residual stenosis were recorded for each procedure. On follow-up, patency of target lesion and complications were evaluated
- Quantitative data were presented in terms of means and standard deviation. Qualitative/categorical data were presented as absolute numbers and percentage/proportions. Cross table was generated, and the paired Student t-test was used for testing mean value between preprocedure VF (Mean Pre VF) and postprocedure VF (Mean Post VF). P < 0.05 was considered statistically significant. SPSS software version 24.0 (SPSS-Statistical Package for the Social Sciences System Version 24 (IBM SPSS For Windows, Version 24.0; Armonk, NY: IBM Corp.) was used for statistical analysis.
| Results | | |
Patient demographics
Age and sex distribution
We observed that majority of the patients were between 61 and 70 years of age –23 patients which accounted for 34.3% of cases. The mean age was 61.99 years ± 11.988 SD, with 62.69% of the patients being males (42).
Associated comorbidities/risk factors
All 67 patients showed one or more associated comorbidity/ies. Hypertension was the highest associated comorbidity being prevalent in 61 out of 67 cases studied which accounted for 91%. The second most common was diabetes mellitus which was seen in 48 (71.6%) cases. Dyslipidemia was associated in 42 (62.7%) cases. CAD and smoking were observed in 23 (34.3%) and 13 (19.4%) cases, respectively [Figure 7].
Distribution of fistula
Most of the fistulas requiring plasty were brachiocephalic (BC) fistula (55.2%, i.e., 37 cases), and 30 patients had radiocephalic (RC) fistulas [Figure 8].
Location of lesion
64.2% of the patients (43 cases) had juxta-anastomotic lesion, i.e., within 3 cm of anastomotic site. 31.3% (21) of the patients had lesion in the outflow vein (V) (beyond 3 cm from the site of anastomosis), while 4.5% (3) of the patients had lesion at both juxta-anastomotic site and outflow vein site (JXA + V) [Figure 9].
Volume flow
Pre- and postprocedure VF was measured for each patient using ultrasound. Mean Pre VF was found to be 160 ml/min with SD of 47, while Mean Post VF was 399 ml/min with SD of 102 [Figure 10].
Success rates
100% technical and clinical success was noted.
Complications
In this study, the most common complication noted was fistuloplasty site hematoma, which was observed in 5 (7.5%) patients out of 67. Access site hematoma and acute intraluminal thrombotic occlusion were noted in 3% (2) patients each, while rupture/pseudoaneurysm was noted in 1 patient account for 1.5%. Fifty-seven (85%) patients had no procedural complications [Figure 11].
The primary patency rate is shown in [Table 1] and [Figure 12].
| Discussion with Review of Literature | | |
This is a prospective observational study of 67 patients who underwent ultrasound-guided fistuloplasty for A-V fistula salvage.
In our study, the mean age was 61.99 years ± 11.99 SD with a male preponderance. Regarding concomitant comorbidities, hypertension and diabetes mellitus were most common, followed by dyslipidemia and smoking. Their values are consistent with several studies done on CKD patients in the past. These results of our study are comparable with a study done by Ascher et al. in which the mean age was 65.1 years ± 9.11 SD; 14 out of 25 patients (56%) were male while hypertension was seen in all patients (100%), diabetes in 15 patients (60%), coronary artery disease in 8 patients (32%), and history of smoking in 7 patients (28%).[10]
We found that the occurrence of juxta-anastomotic stenotic lesions was more than outflow vein lesions. This might be because flow dynamics that most commonly affect the swing segment of AVF. These findings are consistent with many studies. Cho et al. in their study of 53 cases reported that 75.5%, i.e., 40 cases, had juxta-anastomotic stenosis and 24.5%, i.e., 13 cases, had outflow vein stenosis while 31 (58.5) patients had RC fistula, 17 (32.1%) had BC fistula, and 1 patient had basilic vein transposition.[11]
A prospective study done by Kamper and Haage noted 63.9% juxta anastomotic, 55.8% outflow vein, 8.4% central venous, and 5.1% arterial inflow stenosis.[12]
A comparison between Mean Pre VF and Mean Post VF demonstrated an increase in VF by 149%, which was statistically significant with P < 0.0001. Considering median value, the median preprocedure VF was 168 ml/min. The median final VF was increased to 382 ml/min. The VF increased by 127% post fistuloplasty. Our results are comparable with a study done by Kim and Cho.[13] In a study done by Fox et al. for all interventions, the VF increased by 95%, while for immature autogenous AV access, VF increased by 131% post intervention.[14] Marks et al. also reported a significant increase in VF[15] [Table 2]. | Table 2: Clinical reports of studies done using volume flow criteria for duplex.guided arteriovenous access interventions
Click here to view |
In our study, we were able to achieve 100% procedural and clinical success in the form of significant increase in VF + <30% residual stenosis on duplex scan and palpable thrill at the end of the procedure, respectively. Technical success overall appears to be excellent and is consistent across the reported series [Table 2]. The principal technical endpoint reported was an increase in VF. Fox et al. in their study reported technical success in 219 out of 223 interventions, i.e., 98.2%.[14]
As we used ultrasound for access, vascular access site-related complications were less frequent. Fisuloplasty site hematoma was the most common complication. Both fistuloplasty and access site hematomas were nonexpanding and were managed conservatively, and they regressed over a period of 3–5 days. Tiny rupture/pseudoaneurysm in one patient was managed by direct pressure and balloon occlusion. Two cases (3%) had acute thrombotic occlusion at access and plasty site which was managed by giving additional heparin, thromboaspiration using Indigo CAT8 device (penumbra system) and over-the-wire Fogarty's catheter. Both were managed successfully using ultrasound although angiographic machine was always kept on standby.
A case series by Fox et al. involving 223 procedures reported minor complications in 17 cases (7.6%) and major complications in 2 cases (.89%). Intraluminal thrombus was seen in 8 cases managed by additional heparin and maceration thrombectomy, angioplasty site rupture in 3 cases, small introducer site pseudoaneurysm in 4 cases, and access-related complications in 2 cases.[14] Leskovar et al. in their study noted that the complication rate was 5.7%, in which the main complications were venous rupture (3.5%) followed by postprocedural thrombosis (1%), pseudoaneurysm at puncture site (0.5%), and balloon rupture with conversion to surgical procedure (0.5%),[16] while Aurshina et al. recently (2018) studied the effectiveness of percutaneous transluminal angioplasty for salvage of acute AVF occlusion in a series of 14 patients who underwent 18 procedures. The success rate was 72%. In 14 cases (78%), full restoration of fistula flow was established.[17] The quality improvement guidelines recommend <4% of vessel rupture during angioplasty.[18] In our study, we observed it in 1.5% of cases, which is far better compared to other studies. Our primary patency rates were also comparable to international studies done worldwide [Table 2].
In our study, 10 patients were lost to follow-up and 2 patients expired before the 6 months follow-up period due to unrelated cause. Hence, these 12 patients were not included in the final study population.
| Conclusion | | |
Ultrasound-guided fistuloplasty for AVF salvage is a safe and effective way of endovascular management as superficial location of AV access facilitates duplex scan visualization while careful ultrasound examination allows to recognize early stenosis, prompt treatment, and reduce vascular access loss which is crucial in CKD patients. Precise preoperative planning can be done including size of balloon, access, etc.
Duplex-derived VF can be effectively used as objective criteria for technical success of USG-guided fistuloplasty without any extra efforts or investigation modality which expands its further utility.
Intraoperative ultrasound use facilitates in managing complications, reducing intervention time, and achieving better results. This technique is feasible and reliable and hence should be used more frequently and effectively.
It offers many advantages over conventional fluoroscopic/angiographic interventions which include the absence of radiation exposure and lack of nephrotoxic contrast use.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2]
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