Interventions for AVF and AVG Stenosis
Both surgery and interventional procedures are established treatments for stenosis in patent and thrombosed AVF1. The 2019 KDOQI hemodialysis access working group recommends that a hemodynamically significant stenosis requiring intervention should display a ≥50 percent stenosis (as determined radiographically) plus evidence of a clinical or physiologic abnormality such as elevated venous pressure or decreased blood flow2. In recent years, endovascular techniques have tended to supplant traditional surgery at many centers1. Percutaneous therapies including angioplasty, percutaneous thrombectomy, the use of stents, and thrombolytics have made access repair easier, more successful, less invasive and readily available on an outpatient basis3. Although there have been few recent direct comparisons between percutaneous transluminal angioplasty (PTA) and surgical revision, uncontrolled studies have reported that PTA has a greater than 95% success rate4. This success rate combined with superior convenience and less morbidity compared with surgery has resulted in increasing usage of PTA therapy for stenotic lesions4.
Percutaneous angioplasty and surgical revision each have advantages and disadvantages. The major advantages of surgery for venous stenosis are the elimination of the lesion and potentially lower recurrence rates. The major disadvantages are the loss of potential venous access sites and the significant burden logistically and physically imposed by surgery. Even a patch angioplasty, for example, results in the loss of a small portion of vein. Since venous stenosis is a recurrent problem, this may result in a progressive loss of venous anatomy available for access creation2. Percutaneous angioplasty has the principal advantage of preserving potential venous access sites; however, severe lesions (>80% of lumen) may require surgical revision2. See table below.
Characteristics of AVF stenosis intervention modality
|Percutaneous angioplasty||Surgical revision|
|Access immediately available for dialysis once the lesion is corrected||x|
|Lesions in all locations, even those centrally located, can be easily, effectively, and safely treated||x|
|Preserves potential venous access sites||x|
|Elimination of the lesion||x|
|Effective for severe lesions (>80% of lumen)||x|
|Loss of potential venous access sites||x|
|Minimal post procedure discomfort||x|
|Occasional need for a temporary access||x|
|Inaccessibility of central veins to the surgeon||x|
|Lesions tend to be recurrent||x||x|
Although PTA corrects over 80% of stenoses in both native fistulae and synthetic grafts and in both venous and arterial outflow tracts2, several studies have suggested that angioplasty outcomes may be inferior to surgical therapy3. The rationale for this view is that underlying pseudointimal hyperplasia causing stenosis may rapidly recur post angioplasty3. Though some studies have lauded the efficacy of surgical treatment, others question it. In a 2002 surgical study conducted over a two-year period, 101 operative procedures were performed on failed grafts in which all cases had previously been treated with percutaneous dilatation5. Primary patency rates of grafts following surgical revision were 43, 24, and 12 percent at 30, 60, and 90 days, respectively5. These surgical investigators concluded that surgical intervention did not significantly prolong the patency of grafts that had previously failed percutaneous interventions5. However, a 2008 study by Crikis found that surgery achieves superior patency rates compared to repeated radiological interventions and should be considered if reocclusion occurs within a month following radiological thrombolysis6.
The rapid development and widespread use of new technologies (thrombolytics, specialized guide wires, angioplasty catheters and balloons, stents, covered stents, digital imagining, ultrasound, etc.) has made interpreting the literature more difficult3. In this changing environment, outcome and trials data may quickly become outdated and result in the use of therapies based primarily on experience, expedience and practice patterns3.
- Lipari G, Tessitore N, Poli A, et al. Outcomes of surgical revision of stenosed and thrombosed forearm arteriovenous fistulae for haemodialysis. Nephrol Dial Transplant. 2007;22(9):2605-2612. Available from: https://pubmed.ncbi.nlm.nih.gov/17517799/.
- Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4):S1-S164. Available from: https://pubmed.ncbi.nlm.nih.gov/32778223/.
- Sands J. Vascular access 2007. Minerva Urol e Nefrol. 2007;59((3)):237-249.
- Aktas A, Bozkurt A, Aktas B, Kirbas I. Percutaneous transluminal balloon angioplasty in stenosis of native hemodialysis arteriovenous fistulas: Technical success and analysis of factors affecting postprocedural fistula patency. Diagnostic Interv Radiol. 2015;21(2):160-166. Available from: /pmc/articles/PMC4463311/.
- Alexander J, Hood D, Rowe V, Kohl R, Weaver F, Katz S. Does surgical intervention significantly prolong the patency of failed angioaccess grafts previously treated with percutaneous techniques? In: Annals of Vascular Surgery. Vol 16. Springer New York; 2002:197-200. Available from: https://pubmed.ncbi.nlm.nih.gov/11972252/.
- Crikis S, Lee D, Brooks M, Power DA, Ierino FL, Levidiotis V. Predictors of Early Dialysis Vascular-Access Failure after Thrombolysis. Am J Nephrol. 2008;28(2):181-189. Available from: https://www.karger.com/Article/FullText/110086.
P/N 101049-01 Rev A 03/2021