Percutaneous transluminal angioplasty for dysfunctional femoral hemodialysis graft.

Diagn Interv Radiol 2015; 21:154–159 INTERVENTIONAL RADIOLOGY © Turkish Society of Radiology 2015 ORIGINAL ARTICLE Percutaneous transluminal angioplasty for dysfunctional femoral hemodialysis graft Eunsun Oh, Yong Jae Kim, Dong-Erk Goo, Seungboo Yang, Seongsook Hong PURPOSE We aimed to evaluate the safety and effectiveness of percutaneous transluminal angioplasty (PTA) for dysfunctional femoral arteriovenous graft and analyze clinical or anatomic predictors of graft patency. METHODS The records of 45 patients who underwent PTA or thromboaspiration for dysfunctional or thrombosed femoral arteriovenous graft from 2005 to 2012 were reviewed retrospectively. Primary and secondary patency rates were determined at three, six, and 12 months after PTA. The primary patency rate was analyzed according to the presence of diabetes mellitus, graft age from the time of creation to the first intervention (<12 months or ≥12 months), presence of thrombus, shape of graft (U-shape vs. straight-shape), anastomosis type of graft (femoral-femoral vs. femoral-saphenous), location of stenosis (central vs. peripheral), length of stenosis (<2 cm vs. ≥2 cm), degree of stenosis severity (<70% vs. ≥70%), and stent insertion. RESULTS A total of 124 PTAs were performed in 45 patients. The primary patency rate at three, six, and 12 months was 84.8%, 63.6%, and 24.2%, respectively. The secondary patency rate at three, six, and 12 months was 95.2%, 95.2%, and 85.7%, respectively. The mean duration of primary and secondary patency was 13.2 and 35.7 months, respectively. No significant clinical or anatomical predictors of primary patency could be identified. Stent placement had a negative effect on primary patency. CONCLUSION PTA is a safe and effective treatment for dysfunctional femoral arteriovenous grafts. Stent placement seems to improve technical success, but does not enhance the primary patency rate of dysfunctional femoral arteriovenous grafts. From the Department of Radiology (E.O.  , Y.J.K., D-E.G., S.H.), Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea; the Department of Radiology (S.Y.), Soonchunhyang University Gumi Hospital, Gyeongsangbuk-do, Republic of Korea. Received 29 May 2014, revision requested 9 July 2014, final revision received 7 September 2014, accepted 8 September 2014. Published online 3 February 2015. DOI 10.5152/dir.2014.14231 154 I n general, the upper extremity arteriovenous (AV) graft is the first choice for hemodialysis patients, but not all patients are indicated, and there is a limitation to maintain patency. Therefore, new vascular access is needed on other areas including the lower extremities (1). The lower extremity AV graft is not preferred due to high rate of infection (2), but recent studies report that the incidence of infection on a lower extremity AV graft is similar to an upper extremity AV graft (3–5). Maintaining the patency of an AV graft in hemodialysis patients is very important. Thrombosis and venous stenosis are as likely to occur in a lower extremity AV graft as in an upper extremity AV graft (6). Percutaneous transluminal angioplasty (PTA) may be useful for a dysfunctional lower limb AV graft as well as an upper limb AV graft, but a definite conclusion is hindered by the lack of direct studies. In 2004, Ryan et al. (1) described the outcomes of a percutaneous declotting technique used in 110 PTAs of 30 femoral AV grafts in 25 patients. They evaluated outcomes of percutaneous declotting procedures in patients with prosthetic femoral dialysis grafts. In 2001, Regina et al. (7) reported clinical and radiologic predictors of prosthetic AV grafts after PTA in 500 patients. However, their study was limited by the inability to classify the location of grafts in the upper or lower extremities. The purpose of our study was to retrospectively evaluate the safety and efficacy of PTA for dysfunctional femoral AV graft. We also analyzed the clinical and anatomic predictors of graft patency after PTA. Methods Patient population Institutional review board approval was obtained for this study (no. 2014-01-002) and the requirement for informed consent was waived. A retrospective analysis was performed with 45 patients (15 males, 30 females; age range, 42–87 years; mean age, 64.0±11.9 years) with a femoral AV graft, who were referred for PTA or thromboaspiration due to dysfunction or thrombosis of the graft, between January 2005 and December 2012. The institute’s picture archiving and communication system was searched for this timeframe. The most common cause of chronic renal failure was diabetes mellitus in 18 (40%) patients, followed by hypertension in 13 (28.8%), unknown in 11 (24.4%), chronic glomerulonephritis in two (4.4%), and polycystic kidney disease in one (2.2%). A total of 43 patients underwent femoral AV graft due to central occlusions bilaterally or unilaterally along with inadequate or exhausted peripheral veins in bilateral upper limbs. The remaining two patients required new access creation due to infection or abnormal sense on existing hemodialysis access. Procedures and techniques Diagnostic imaging was performed by two interventional radiologists with nine and 17 years of experience. Diagnostic fistulography was performed with a 21-gauge needle (Becton Dickinson). Fistulography was performed from an arterial anastomotic site through the right atrium. The arterial anastomotic site was checked through reflux of contrast material by means of hard compression supplied by the operator’s hand, when the arterial inflow was decreased. PTA was performed when there was >70% narrowing of the lumen compared to baseline (8) or in the presence of a clinical dysfunction, such as high pressure of the AV graft, and unstoppable bleeding. If the AV graft was thrombosed, thrombolysis using urokinase and/or mechanical thrombolysis were used for declotting without fistulography (7). Once a stenosis was identified on fistulography, the puncture sites were anesthetized with lidocaine hydrochloride. General or regional anesthesia was not applied. The AV graft was accessed using an 18-gauge needle and 0.018- inch guidewire directed toward the stenotic site. A 7 F or 8 F vascular introducer sheath (Terumo and Cook Medical) was placed. After roadmap imaging was obtained using a collateral pore of the vascular introducer sheath, lesion degree, length, and location were identified. Heparin was not routinely infused into the graft. For stenoses at venous anastomotic site and central vein, 4 cm × 7–14 mm balloon catheters (Blue Max/XXL/Cutting Balloon, Boston Scientific and Conquest/Atlas, BARD) were used. The balloon was inflated using an Encore 26 manual inflation device (Boston Scientific) to a pressure of 5–30 atm for 1–2 min (Fig. 1). After PTA, an immediate roadmap imaging was obtained and evaluated for residual stenosis. In cases where the residual stenosis exceeded 30%, 1–2 mm larger balloon catheters were used along with the cutting ballo (...truncated)