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Friday, April 3, 2020

Treatment of Arm Swelling in Hemodialysis Patients with Ipsilateral Arteriovenous Access and Central Vein Stenosis: Conversion to the Hemodialysis Reliable Outflow Graft versus Stent Deployment


Clinical question
How do outcomes after conversion to arteriovenous (AV) access to Hemodialysis Reliable Outflow (HeRO) graft vs stent deployment in patients with arm swelling due to central vein stenosis compare?

Take-away point
Both HeRO graft conversion and stent deployment are effective in alleviating arm swelling in the short term in these patients, but the HeRO graft has more durable results.

Reference
Cline, Brendan C. et al. Treatment of Arm Swelling in Hemodialysis Patients with Ipsilateral Arteriovenous Access and Central Vein Stenosis: Conversion to the Hemodialysis Reliable Outflow Graft versus Stent Deployment. Journal of Vascular and Interventional Radiology, Volume 31, Issue 2, 243 – 250.

Click here for abstract

Study design
Retrospective review

Funding source
Self-funded or unfunded

Setting
Single institution






Summary


Arm swelling can cause significant morbidity for AV access patients with central venous stenosis. Angioplasty is often performed to improve symptoms and to maintain satisfactory function of the AV access; however, central lesions have the propensity to resist angioplasty or to recur. Additionally, patients with treatment resistant central lesions may require access ligation in order to resolve symptoms. Therefore, the authors of this study evaluated two methods for symptom relief and access salvage in the AV access patient with central venous stenosis: HeRO graft creation vs central venous stent placement.

The authors reviewed 192 patients who underwent HeRO graft insertion over a 10-year period in addition to 27 patients who underwent central venous stent placement over the same time period. All patients studied had a central venous stenosis (with central veins being defined as the superior vena cava, brachiocephalic vein or subclavian vein) and documented clinically significant arm swelling. Factors favoring HeRO graft placement included patients with concerns about the quality of the existing cannulation segment, the presence of pacemaker leads, predicted poor central venous patency due to bony compression, or excessive length or multifocality of stenosis, although such factors were infrequently documented. The patients in the 2 treatment groups had similar characteristics, however, patients undergoing HeRO conversion were statistically significantly more likely to have > 1 stenotic segment than the stent group (43% vs 11%, P=.02) and also more likely to have SVC occlusions than the stent group (43% vs 15%, P=05). The outcomes of interest were symptomatic improvement in arm swelling, primary access patency and secondary access patency.

All HeRO graft insertions and stent deployments were technically successful. After stent deployment, improvement or resolution in arm swelling was found in 86% of patients compared with 95% after conversion to a HeRO graft (P =.35). Swelling recurred within 1 year in 16 patients (59%) treated with stents compared with 1 patient (5%) who underwent HeRO conversion (P < .001). Median primary access patency was significantly longer for HeRO conversions than stent deployments (15.6 months vs 5.4 months, P < .001). Primary patency for HeRO graft placement at 6, 12, and 24 months was 89%, 72%, and 9% and for stent deployment was 47%, 11%, and 0%. Secondary patency was also longer for HeRO conversions than stent deployment (P=.006), with 6-, 12-, and 24- month secondary patency rates of 95%, 95%, and 89% for HeRO grafts and 79%, 58%, and 51% for stent deployment. Finally, mean number of interventions to maintain secondary patency was 2.9 per 1,000 access days for HeRO conversions and 6.2 per 1,000 access days for stent deployments. There was only 1 severe complication observed in the analysis, which occurred in a patient in the HeRO group who had an anastomotic dehiscence 1 week after surgery. No severe complications occurred in the stent group.

Commentary


The data presented here suggests that, while both conversion to HeRO graft and stent deployment are effective for treating arm swelling in the short term, HeRO grafts are less likely in the long term to result in return of arm swelling and are associated with longer primary and secondary patency rates. This may be attributed to the high level of experience with HeRO graft implantation at the authors’ institution and the question remains as to whether or not this is generalizable. Should better patency be expected in the HeRO conversion patient considering that culprit central venous lesions, oftentimes exacerbated by external compression, are bypassed and that typical venous outflow stenosis and neointimal hyperplasia concerns are not to be expected? Intuitively, this makes sense. Future studies, including a potential head-to-head comparison of HeRO graft to costoclavicular bypass are anticipated with interest.

Post authorZagum Bhatti, MD
Assistant Professor
Department of Radiology, Interventional Radiology Division
University of Texas Health Science Center at Houston, Houston, TX
@ZagumBhatti

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