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Outcomes Of Intervention For Cephalic Arch Stenosis In Brachiocephalic Arterio-Venous Fistulas
Mark G. Davies, MD PhD MBA1, Georges M. Haider, MD1, Hosam E. ElSayad, MD PhD2.
1University of Texas Health Science Center, San Antonio, TX, USA, 2University of Ohio, Columbus, OH, USA.

Background: Development of recalcitrant stenotic lesions of the cephalic arch is a significant cause of dysfunction of brachiocephalic accesses arterio-venous fistulae (AVF). Endovascular and surgical therapy can be used for cephalic arch stenosis. The aim of this study is to evaluate the outcomes of endovascular and surgical interventions for cephalic arch stenosis.
Methods: A retrospective review of all patients over a 6-year period with a compromised but not occluded brachiocephalic AVF due to cephalic arch stenosis was undertaken. Patency, re-intervention, and functional dialysis rates were examined.
Results: From January 2000 to December 2015, 219 patients, (67% female, mean age of 58 + 20) with failing brachiocephalic AVF underwent intervention at the cephalic arch. This represented 37% of patients with malfunctioning brachiocephalic AVF presenting to the facilities. The average time to intervention for cephalic arch stenosis was 1.7 years after primary access placement. The average number of percutaneous interventions prior to the decision to intervene surgically on the cephalic arch was three (range 2 to 6). Technical success was superior in the surgical groups (Table). MACE was overall quite low but significantly higher in the surgical groups (Table). Both surgical options carried significantly superior patency rates and a lower secondary intervention rate (Table). Functional dialysis durations were equivalent between angioplasty and Stenting groups and between transposition and bypass surgical groups. However, both surgical groups were significantly superior to the percutaneous groups.

Bypass (n=31)
Technical Success70%80%96%100%
30-day MACE0.3%0.5%1%*1%*
Primary Patency @ 24 months30%46%61%*67%*
Assisted Primary Patency@ 24 months55%54%74%*84%*
Secondary Patency@ 24 months63%59%90%*92%*
Secondary Interventions per year3.

Conclusion: Cephalic arch stenosis is a significant cause of brachiocephalic AVF malfunction. Surgical options offer superior long term patency and functional results and should be considered earlier in the treatment of this disease.
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