Extending the lifeline of renal failure patients by endovascular fistula salvage

Ankita Khurana; Pranay Pawar; Amit Mahajan; Anil Luther; Timothy Rajamanickam

doi:10.4103/cjhr.cjhr_109_20

CASE REPORT

Year : 2021 | Volume : 8 | Issue : 4 | Page : 255-258

Extending the lifeline of renal failure patients by endovascular fistula salvage

Ankita Khurana¹, Pranay Pawar², Amit Mahajan¹, Anil Luther¹, Timothy Rajamanickam³
¹ Vascular and Endovascular Surgery Unit, Department of Surgery, Christian Medical College and Hospital, Ludhiana, Punjab, India<, India
² Division of Vascular Surgery, Christian Medical College and Hospital, Ludhiana, Punjab, India<, India
³ Department of Nephrology, Christian Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission	05-Aug-2020
Date of Decision	22-Oct-2020
Date of Acceptance	29-Jul-2021
Date of Web Publication	27-May-2022

Correspondence Address:
Pranay Pawar
Division of Vascular Surgery, Christian Medical College and Hospital, Ludhiana, Punjab
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/cjhr.cjhr_109_20

Abstract

The establishment and maintenance of durable and functional access are a top priority in end-stage renal disease patients. The traditional method of treatment of failing arteriovenous fistula has been thrombectomy. Over the recent years, percutaneous methods for thrombus dissolution have become alternate treatment modalities. We would like to report a case series of endovascular fistula salvage.

Keywords: Angioplasty, arteriovenous fistula, endovascular, fistula salvage

How to cite this article:
Khurana A, Pawar P, Mahajan A, Luther A, Rajamanickam T. Extending the lifeline of renal failure patients by endovascular fistula salvage. CHRISMED J Health Res 2021;8:255-8

How to cite this URL:
Khurana A, Pawar P, Mahajan A, Luther A, Rajamanickam T. Extending the lifeline of renal failure patients by endovascular fistula salvage. CHRISMED J Health Res [serial online] 2021 [cited 2023 Mar 28];8:255-8. Available from: https://www.cjhr.org/text.asp?2021/8/4/255/346095

Introduction

In patients with end-stage renal failure, vascular access remains the Achilles' heel of maintenance hemodialysis (HD). Successful HD requires repetitive access to large vessels that are capable of providing rapid extracorporeal blood flow. The primary arteriovenous fistula (AVF), was first described by Brescia and Cimino in 1966. The cephalic vein becomes arterialized and will theoretically stay uncollapsed even when blood is drawn from it at high flow rates.^[1],[2]

The flow disturbances and hemodynamic changes associated with an arteriovenous (AV) access can initiate an intimal hyperplasia response that leads to stenoses at various sites of the fistula circuit predisposing to fistula failure. We describe four cases of endovascular salvage of these fistulas.^[3]

Case Reports

Case 1

A 32-year-old female on HD using a left Brachio-cephalic AVF presented with tortuous swelling of the left upper limb veins till the chest for 3 months and increased bleeding from needling sites. On local examination, she had dilated veins in the neck and chest with an aneurysmal brachiocephalic fistula with good palpable thrill. She complained of increased bleeding after removing the needles postdialysis and her venous pressures were consistently high for the previous 2 months. She was taken up for a fistulogram which showed a tight cephalic arch stenosis. The access was taken via a 5 F sheath in the left radial artery. The fistula and the cephalic arch stenosis were crossed by 0.035 hydrophilic guidewire with a guiding catheter. A stiff wire was exchanged and the dilatation of the cephalic arch stenosis was done by an 8 mm × 80 mm balloon. Postdilatation her stenosis was resolved and her dilated veins reduced significantly [Figure 1].

Figure 1: Cephalic arch stenosis angioplasty

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Case 2

A 65-year-old male on HD using a Brachio-cephalic AVF as vascular access for 5 years presented with sudden occlusion of the fistula for 3 days. His Doppler showed minimal flow in the cephalic vein with thrombus. On local examination, the thrill was not palpable. He was taken up for a fistulogram through a 5 F sheath from the radial artery. He had a very tight juxta-anastomotic stricture with thrombosis of a short segment of the cephalic vein. The lesion was crossed with a 0.014 wire. A 6 × 60 high-pressure balloon was used to dilate the lesion and the cephalic vein. Post balloon angioplasty, the lesion resolved and clinically he had good thrill and was able to use the fistula [Figure 2].

Figure 2: Juxta- anastomotic stenosis angioplasty of brachiocephalic fistula

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Case 3

A 68-year-old male on HD using a Brachio-cephalic fistula presented with decreased flow rates in the fistula. On local examination, there was reduced thrill and decreased blood flow rates during dialysis (200 ml/min). He gave a history of stenting of the innominate vein for stenosis. He was taken up for a fistulogram which showed an in stent restenosis (ISR) of previously inserted stent which was undersized. We placed a 6F sheath in the basilic vein and crossed the ISR with a hydrophilic guidewire and support catheter. Since the previously deployed stent was a self-expanding stent of 10 mm × 120 mm, we dilated it sequentially with a 10 mm × 80 mm high-pressure balloon. Postangioplasty the lumen of the stent was restored, and the flow rates improved to 450–500 ml/min. The patient was advised regular follow-up as the chances of restenosis are high [Figure 3].

Figure 3: In stent restenosis angioplasty

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Case 4

A 52-year-old male on HD using a brachiocephalic fistula presented with decreasing flow rates and thrill for 3 months. On local examination, there was an absent thrill in the proximal part of the cephalic vein post 10 cm. He was taken up for a fistulogram which showed a long segment stenosis of the cephalic vein. A 5 F sheath was inserted in the radial artery and the fistula and lesion were crossed with a 0.014 hydrophilic wire and dilated with a 6 mm × 60 mm high-pressure balloon. Postangioplasty, he had good palpable thrill and improved flow rates [Figure 4].

Figure 4: Long segment cephalic vein stenosis angioplasty

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Discussion

In patients with end-stage renal failure, vascular access remains the Achilles' heel of maintenance HD. Successful HD requires repetitive access to large vessels that are capable of providing rapid extracorporeal blood flow. Creation of an AVF, leads to arterialization of the vein and maintains a high flow rate. This is the preferred mode of access for dialysis over the past few decades.^[1]

Maintaining patent vascular access remains a major challenge, especially in an aging HD population. Cumulative data show that vascular access is lost predominantly from an inability to resolve a thrombotic episode. Over 85% of the documented episodes of thrombosis have an anatomical cause, the most common being stenotic lesions at the AV anastomosis or along the proximal venous limb. Prospective detection and preventive treatment of a high-grade venous stenosis are important since they will improve the patency of vascular access and hence decrease the incidence of HD failure due to fistula loss. Percutaneous transluminal angioplasty (PTA) has been gaining favor in recent years as a means of correcting venous stenosis, thereby improving fistula function and prolonging fistula survival.^[2]

There are three main types of AVFs. The radiocephalic fistula is a forearm fistula created by anastomosing the side of a radial artery to the end of a cephalic vein. It is also referred to as the Brescia-Cimino fistula. The brachiocephalic fistula is an upper arm fistula created by connecting the side of a brachial artery to the end of a cephalic vein at or slightly central to the level of the elbow. Finally, the brachial artery–to–transposed basilic vein fistula is another upper arm fistula. This fistula is created by anastomosing the side of a brachial artery to the end of a basilic vein that has been transposed laterally and elevated superficially to make it amenable to dialysis cannulation.^[4]

The NKF-K/DOQI guidelines for vascular access recommend the use of vascular adequacy parameters and physical examination for monitoring AVF and AV grafts. The observation that an experienced nurse of the HD team can predict the ultimate adequacy of a fistula with 80% accuracy simply through physical examination, and that the major causes of AV fistula failure can be identified by physical examination, suggests that this is an easy and cost-effective method of monitoring AV fistula.

The first step of such an examination is to evaluate the anastomosis. The two most important components of an anastomosis examination are the thrill, which is an indicator of flow, and the pulse, which is an indicator of downstream resistance. Another component that can be evaluated is the bruit. Normally, the thrill and the bruit are prominent near the anastomosis and they are both present in systole as well as early diastole (continuous). The presence of stenosis reduces the blood flow and this, in turn, reduces the strength of the thrill.

With regard to the pulse, it must be soft. If it is forceful, like a “water-hammer” pulse, this often suggests the presence of stenosis. The intensity of the hyper-pulsatility is proportional to the severity of the stenosis.

The second step is to examine the entire length of the AV fistula. Moving up the vein away from the anastomosis, the thrill, and bruit gradually diminish. An increase in the strength of the thrill or a new palpable thrill downstream from the anastomotic site suggests the presence of a stenosis. The pulse should be soft and compressible as in the anastomosis. An important maneuver to evaluate the pulse is to elevate the arm above the level of the heart. Normally, the pulse may collapse with arm elevation. If it does not, the intra access pressure must be high and a significant stenosis may be the cause. In this case, only the segment upstream from the stenosis does not collapse, but the downstream segment does collapse.

An important cause of early AV fistula dysfunction is the presence of accessory veins. They must be distinguished from collateral veins, which are pathological and develop in the presence of stenosis. The development of AV fistula depends on the inflow pressure and the resistance of draining veins. This resistance is decreased in the presence of side branch vessels (accessory veins), thus limiting the maturation of the AV fistula. Accessory veins may be single or multiple, but not all apparently decrease blood flow.

The third and last step on physical examination is to check for pulse augmentation. With one hand, the body of the AV fistula is manually occluded proximally and with the other hand, the pulse is palpated next to the anastomosis. With this maneuver, the pulse must become hyper-pulsatile. If the pulse augments poorly, it is an indicator of low inflow. In this case, the arteries, anastomosis, and juxta-anastomotic region should be evaluated.^{[5],[6],[7],[8],[9]}

The NFK-K/DOQI recommends that vascular access with blood flow <600 mL/min or <1000 mL/min that has decreased by more than 25% over 4 months should be referred for a fistulogram.^[6]

Angioplasty for stenosis of AVFs was, for the first time, reported in 1981. Venous stenoses have traditionally been corrected surgically, but this extends the fistula further up the involved extremity, thereby minimizing future vascular access sites. Transcatheter techniques have, in recent years, made it possible to treat these lesions percutaneously, and PTA is an excellent means of correcting venous stenosis in both native and synthetic fistulae. It has the advantages of being a shorter procedure than surgery, inciting less stress and discomfort to patients, obviating the need for prolonged hospitalization, having a lower chance of infection, sparing the patient's veins, and in selected cases, enabling immediate dialysis without the need for a temporary central venous catheter.^[10],[11]

There are several factors, be it clinical, anatomical, and biochemical factors which affect fistula patency. In a meta-analysis by Neuen et al., they found out that fistulas which were <6 months of age, longer lesion lengths >4 cm, patients with diabetes mellitus, residual stenosis >50% and patient age >75 years were all independently associated with shorter primary patency.^[12]

In a study by Malka et al. occluded fistulas as compared to stenosed fistulas, fistulas requiring pharmaco-mechanical thrombectomy and fistulas needing a second re-intervention were associated with poor patency rates. Given the number of interventions necessary to maintain some AVFs and arteriovenous grafts, at some point, it may be prudent to abandon the failing access and to pursue a new HD access in some patients.^[13]

Aktas et al. reported a primary patency rate of 84.7%, 62.2%, and 23.7% for the 1^st, 2^nd, and 3^rd years, respectively. Heye et al. determined primary patency rate as 48.5%, 31.4%, and 22.5% in the 1^st, 2^nd, and 3^rd years. Most studies report 6-month and even 1-year primary patency of 50%. However, there is a need for repeated angioplasty because of the unavoidable hyperplasia of the vessel wall that is caused by the balloon use.^{[14],[15],[16]}

Paclitaxel drug-eluting angioplasty has shown to significantly reduce restenosis after angioplasty in coronary arteries and femoropopliteal arteries, inciting application of drug-coated balloon (DCB) technology in HD vascular access. Many studies have been done recently comparing the outcomes of DCBs versus standard balloon angioplasty and they have found significant difference in primary patency and target lesion restenosis in favor of DCBs and they advocate their use vehemently.^[17]

Conclusion

The native fistula should be maintained as long as possible. This is done by regular follow-up, imaging, and feedback by the dialysis technician and the patient. Teamwork between the treating nephrologist, dialysis technician, and the vascular surgeon will ensure early identification of the dysfunction and its rapid treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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