Journal List > J Korean Soc Radiol > v.73(1) > 1087555

Jeon, Shin, Ohm, and Ahn: Stent Graft Placement for Dysfunctional Arteriovenous Grafts

Abstract

Purpose

This study aimed to evaluate the usefulness and outcomes of stent graft use in dysfunctional arteriovenous grafts.

Materials and Methods

Eleven patients who underwent stent graft placement for a dysfunctional hemodialysis graft were included in this retrospective study. Expanded polytetrafluoroethylene covered stent grafts were placed at the venous anastomosis site in case of pseudoaneurysm, venous laceration, elastic recoil or residual restenosis despite the repeated angioplasty. The patency of the arteriovenous graft was evaluated using Kaplan-Meier analysis.

Results

Primary and secondary mean patency was 363 days and 741 days. Primary patency at 3, 6, and 12 months was 82%, 73%, and 32%, respectively. Secondary patency at the 3, 6, 12, 24, and 36 months was improved to 91%, 82%, 82%, 50%, and 25%, respectively. Fractures of the stent graft were observed in 2 patients, but had no effect on the patency.

Conclusion

Stent graft placement in dysfunctional arteriovenous graft is useful and effective in prolonging graft patency.

Figures and Tables

Fig. 1

A 68-year-old man with a dysfunctional arteriovenous graft.

A. A venogram reveals thrombosis (arrowheads) related with the stenosis at the venous anastomosis (arrow).
B. Follow-up venogram obtained 18 months later after expanded poly-tetrafluoroethylene stent graft placement (8 mm in diameter × 70 mm in length) reveals preserved patency of the arteriovenous graft (AVG) and mild stenosis at the end of the stent graft (arrow). Patency of the AVG is pre-served until 1351 days (45 months) after repeat balloon angioplasty.
jksr-73-11-g001
Fig. 2

Primary (solid line) and secondary (dotted line) patency curve of arteriovenous grafts treated with stent graft placement.

jksr-73-11-g002
Fig. 3

A 55-year-old woman with a dysfunctional arteriovenous graft.

A. A follow-up venogram obtained 4 months later after expanded polytetrafluoroethylene stent graft placement (8 mm in diameter × 40 mm in length) across the elbow joint reveals mild stenosis at the end of the stent graft and long segmental stenosis in the drainage vein (arrowheads). After balloon angioplasty, we have to place a bare metal stent (8 mm in diameter × 120 mm in length) from the mid-portion of the stent graft to the drainage vein because of elastic recoil and focal venous laceration.
B. A follow-up venogram obtained 7 months later reveals restenosis in the stent graft and in the more proximal drainage vein beyond the bare stent, necessitating repeat balloon angioplasty.
C. Fracture and disruption of stent wire is suspected at the mid-portion of the stent graft (arrows). Fracture may have been related to the strength of the bare metal stent and its position (across the elbow joint).
D. A venogram after repeat angioplasty and additional bare metal stent reveals patent lumen without residual stenosis. Patency of the arteriovenous graft is preserved until 854 days (28 months).
jksr-73-11-g003
Table 1

Primary and Secondary Patency in Relation to Patient and Procedural Data

jksr-73-11-i001
Characteristics Primary Patency Secondary Patency p-Value Primary, Secondary
Age ≥ 60 years (n = 5) 388 ± 173 682 ± 207 0.860, 0.977
< 60 years (n = 6) 330 ± 109 782 ± 199
Sex Male (n = 4) 391 ± 111 733 ± 172 0.890, 0.647
Female (n = 7) 347 ± 157 728 ± 253
Diabetes Diabetics (n = 8) 285 ± 68 783 ± 148 0.319, 0.572
Non-diabetics (n = 3) 527 ± 302 605 ± 347
Antiplatelet agent Medication (n = 5) 389 ± 150 850 ± 183 0.807, 0.559
No medication (n = 6) 313 ± 119 654 ± 209
Graft location Left arm (n = 8) 402 ± 132 882 ± 161 0.579, 0.060
Right arm (n = 3) 269 ± 144 424 ± 192
Graft location Forearm (n = 7) 264 ± 60 641 ± 112 0.216, 0.334
Upper arm (n = 4) 498 ± 227 840 ± 297
Graft configuration Loop (n = 8) 382 ± 128 747 ± 141 0.882, 0.702
Straight (n = 3) 312 ± 182 704 ± 374
Stenosis length ≥ 4.0 cm (n = 4) 301 ± 79 458 ± 89 0.563, 0.099
< 4.0 cm (n = 7) 411 ± 160 871 ± 173
Graft thrombosis Thrombotic (n = 9) 335 ± 108 751 ± 156 0.543, 0.634
Non-thrombotic (n = 2) 510 ± 0 510 ± 0
Across the joint Yes (n = 6) 255 ± 61 628 ± 120 0.152, 0.272
No (n = 5) 531 ± 216 892 ± 264
Stent fracture Yes (n = 2) 649 ± 409 1062 ± 184 0.252, 0.445
No (n = 9) 291 ± 74 658 ± 158

Data are presented as days (mean survival time ± standard error). Continuous data have been converted to categorical data according to the mean value.

References

1. Ravari H, Kazemzade GH, Modaghegh MH, Khashayar P. Patency rate and complications of polytetrafluoroethylene grafts compared with polyurethane grafts for hemodialysis access. Ups J Med Sci. 2010; 115:245–248.
2. Clark TW, Hirsch DA, Jindal KJ, Veugelers PJ, LeBlanc J. Outcome and prognostic factors of restenosis after percutaneous treatment of native hemodialysis fistulas. J Vasc Interv Radiol. 2002; 13:51–59.
3. Tessitore N, Mansueto G, Bedogna V, Lipari G, Poli A, Gammaro L, et al. A prospective controlled trial on effect of percutaneous transluminal angioplasty on functioning arteriovenous fistulae survival. J Am Soc Nephrol. 2003; 14:1623–1627.
4. Rajan DK, Clark TW. Patency of Wallstents placed at the venous anastomosis of dialysis grafts for salvage of angioplasty-induced rupture. Cardiovasc Intervent Radiol. 2003; 26:242–245.
5. Kariya S, Tanigawa N, Kojima H, Komemushi A, Shomura Y, Shiraishi T, et al. Peripheral stent placement in hemodialysis grafts. Cardiovasc Intervent Radiol. 2009; 32:960–966.
6. Maya ID, Allon M. Outcomes of thrombosed arteriovenous grafts: comparison of stents vs angioplasty. Kidney Int. 2006; 69:934–937.
7. Sreenarasimhaiah VP, Margassery SK, Martin KJ, Bander SJ. Salvage of thrombosed dialysis access grafts with venous anastomosis stents. Kidney Int. 2005; 67:678–684.
8. Haskal ZJ, Trerotola S, Dolmatch B, Schuman E, Altman S, Mietling S, et al. Stent graft versus balloon angioplasty for failing dialysis-access grafts. N Engl J Med. 2010; 362:494–503.
9. Webb KM, Cull DL, Carsten CG 3rd, Johnson BL, Taylor SM. Outcome of the use of stent grafts to salvage failed arteriovenous accesses. Ann Vasc Surg. 2010; 24:34–38.
10. Nassar GM, Suki D, Rhee E, Khan AJ, Nguyen B, Achkar K. Outcomes of arteriovenous grafts following simultaneous thrombectomy and stent graft placement across the venous anastomosis. Semin Dial. 2014; 27:639–644.
11. Karnabatidis D, Kitrou P, Spiliopoulos S, Katsanos K, Diamantopoulos A, Christeas N, et al. Stent-grafts versus angioplasty and/or bare metal stents for failing arteriovenous grafts: a cross-over longitudinal study. J Nephrol. 2013; 26:389–395.
12. Chan MG, Miller FJ, Valji K, Bansal A, Kuo MD. Evaluating patency rates of an ultralow-porosity expanded polytetrafluoroethylene covered stent in the treatment of venous stenosis in arteriovenous dialysis circuits. J Vasc Interv Radiol. 2014; 25:183–189.
13. Dolmatch BL, Duch JM, Winder R, Butler GM, Kershen M, Patel R, et al. Salvage of angioplasty failures and complications in hemodialysis arteriovenous access using the FLUENCY Plus Stent Graft: technical and 180-day patency results. J Vasc Interv Radiol. 2012; 23:479–487.
14. Bent CL, Rajan DK, Tan K, Simons ME, Jaskolka J, Kachura J, et al. Effectiveness of stent-graft placement for salvage of dysfunctional arteriovenous hemodialysis fistulas. J Vasc Interv Radiol. 2010; 21:496–502.
15. Vesely TM, Amin MZ, Pilgram T. Use of stents and stent grafts to salvage angioplasty failures in patients with hemodialysis grafts. Semin Dial. 2008; 21:100–104.
16. Dale JD, Dolmatch BL, Duch JM, Winder R, Davidson IJ. Expanded polytetrafluoroethylene-covered stent treatment of angioplasty-related extravasation during hemodialysis access intervention: technical and 180-day patency. J Vasc Interv Radiol. 2010; 21:322–326.
17. Gupta M, Rajan DK, Tan KT, Sniderman KW, Simons ME. Use of expanded polytetrafluoroethylene-covered nitinol stents for the salvage of dysfunctional autogenous hemodialysis fistulas. J Vasc Interv Radiol. 2008; 19:950–954.
18. Shemesh D, Goldin I, Zaghal I, Berlowitz D, Raveh D, Olsha O. Angioplasty with stent graft versus bare stent for recurrent cephalic arch stenosis in autogenous arteriovenous access for hemodialysis: a prospective randomized clinical trial. J Vasc Surg. 2008; 48:1524–1531. 1531.e1–1531.e2.
19. Anaya-Ayala JE, Smolock CJ, Colvard BD, Naoum JJ, Bismuth J, Lumsden AB, et al. Efficacy of covered stent placement for central venous occlusive disease in hemodialysis patients. J Vasc Surg. 2011; 54:754–759.
20. Jones RG, Willis AP, Jones C, McCafferty IJ, Riley PL. Long-term results of stent-graft placement to treat central venous stenosis and occlusion in hemodialysis patients with arteriovenous fistulas. J Vasc Interv Radiol. 2011; 22:1240–1245.
21. Kundu S, Modabber M, You JM, Tam P, Nagai G, Ting R. Use of PTFE stent grafts for hemodialysis-related central venous occlusions: intermediate-term results. Cardiovasc Intervent Radiol. 2011; 34:949–957.
22. Welber A, Schur I, Sofocleous CT, Cooper SG, Patel RI, Peck SH. Endovascular stent placement for angioplasty-induced venous rupture related to the treatment of hemodialysis grafts. J Vasc Interv Radiol. 1999; 10:547–551.
23. Vogel PM, Parise C. SMART stent for salvage of hemodialysis access grafts. J Vasc Interv Radiol. 2004; 15:1051–1060.
24. Yoon YC, Shin BS, Ahn M, Park MH, Ohm JY, Kim HJ. Comparison of a nitinol stent versus balloon angioplasty for treatment of a dysfunctional arteriovenous graft. J Korean Soc Radiol. 2012; 66:519–526.
25. Liang HL, Pan HB, Lin YH, Chen CY, Chung HM, Wu TH, et al. Metallic stent placement in hemodialysis graft patients after insufficient balloon dilation. Korean J Radiol. 2006; 7:118–124.
26. Kakisis JD, Avgerinos E, Giannakopoulos T, Moulakakis K, Papapetrou A, Liapis CD. Balloon angioplasty vs nitinol stent placement in the treatment of venous anastomotic stenoses of hemodialysis grafts after surgical thrombectomy. J Vasc Surg. 2012; 55:472–478.
27. Vogel PM, Parise C. Comparison of SMART stent placement for arteriovenous graft salvage versus successful graft PTA. J Vasc Interv Radiol. 2005; 16:1619–1626.
28. Chan MR, Bedi S, Sanchez RJ, Young HN, Becker YT, Kellerman PS, et al. Stent placement versus angioplasty improves patency of arteriovenous grafts and blood flow of arteriovenous fistulae. Clin J Am Soc Nephrol. 2008; 3:699–705.
29. Wong G, Li JM, Hendricks G, Eslami MH, Rohrer MJ, Cutler BS. Inhibition of experimental neointimal hyperplasia by recombinant human thrombomodulin coated ePTFE stent grafts. J Vasc Surg. 2008; 47:608–615.
30. Saxon RR, Coffman JM, Gooding JM, Ponec DJ. Long-term patency and clinical outcome of the Viabahn stent-graft for femoropopliteal artery obstructions. J Vasc Interv Radiol. 2007; 18:1341–1349. quiz 1350
31. Kedora J, Hohmann S, Garrett W, Munschaur C, Theune B, Gable D. Randomized comparison of percutaneous Viabahn stent grafts vs prosthetic femoral-popliteal bypass in the treatment of superficial femoral arterial occlusive disease. J Vasc Surg. 2007; 45:10–16. discussion 16
TOOLS
Similar articles