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Monday, July 6, 2015

Stent-Graft placement after angioplasty demonstrates improved patency rates compared to angioplasty alone in cephalic arch stenosis

Cephalic arch stenosis is a common cause of fistula dysfunction that has poor patency rates with traditional angioplasty. Stenting has been suggested to improve patency rates; however, to date this is the first prospective study examining the outcomes of stent graft placement for cephalic arch stenosis. This was a randomized, prospective, single blinded study of 14 patients over a four year period, five of whom had PTA alone, and 9 of whom had PTA with placement of a Viabahn stent. The lesions studied showed greater than 50% stenosis, were treated with angioplasty to achieve less than 30% stenosis, and then if randomized to the stent arm, a Viabahn stent was placed and post dilated. Anatomic success (residual stenosis of less than 30%) and clinical success (at least one normal dialysis session post treatment) were achieved in all patients. The mean patency of angioplasty alone was 100 days (range 56-154 days) versus 300 days (range 201-504) in the angioplasty plus stent group. Circuit patency rates (time from intervention to next access thrombosis or intervention) were 0% at 6 months for PTA alone versus 67% at 6 months with PTA and stent (p<0.01).

Comment:
As compared to angioplasty alone, angioplasty plus stent shows improved patency rates in the setting of cephalic arch stenosis greater than 50%. While this study was limited by a small sample size, with enrollment failing to meet the calculated sample size, the results are compelling. Repeat studies are warranted to confirm the authors’ findings.


Click here to see the full abstract 


(a) Initial fistulogram demonstrates focal stenosis 4 50% near the junction of the cephalic vein with the axillary vein in a 65- year-old woman with right brachiocephalic fistula who presented with decreased access blood flow. (b) After placement of an 8-mm 60-mm stent graft in this patient, a fistulogram demonstrates preservation of flow in the axillary vein. Arrows mark the end point of the stent graft. (c) In another patient, fistulography 8 months after stent-graft placement demonstrates focal stenosis adjacent to the edge (arrow) of the stent graft.


Citation: Rajan, D. K. & Falk, A. A Randomized Prospective Study Comparing Outcomes of Angioplasty versus VIABAHN Stent-Graft Placement for Cephalic Arch Stenosis in Dysfunctional Hemodialysis Accesses. Journal of Vascular and Interventional Radiology (2015). doi:10.1016/j.jvir.2015.05.001


Post Author: Tim Huber, MD. VIR Pathway Resident at University of Virginia

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