Salvage of Suboptimal or Occluded Arteriovenous Fistulas Using a 4 French System from the Radial Artery for Initial Balloon Angioplasty Maturations
Christian Voto1, Jacqueline Nikakis2, Thomas Panetta, MD1, Sharon Pochron, PhD2, Rafik Moufid, MD1.
1Thomas Panetta Vascular Surgery, Great Neck, NY, USA, 2Stony Brook University, Stony Brook, NY, USA.
Objective: To determine assisted patency rates, salvage rates, and patient survival rates of small diameter, sclerotic, accessory or recanalized veins used to create arteriovenous fistulas (AVFs).
Methods: From May 2008 until March 2017, 2154 balloon angioplasty maturations (BAMs) were performed in 885 patients who had primary balloon angioplasty during AVF creation. Of these, 188 BAMs in 152 patients were preformed utilizing the radial artery for access to the fistula. Micro-puncture access, a 4 Fr sheath and a low profile 0.018” system for angioplasty were utilized. All salvaged fistulas had diameters less than 2 mm and 87 (46.3%) were occluded precluding micro-access through the proximal or distal fistula and required recanalization of the vein. The type of AVFs treated were radial-cepahlic (48%), brachial-cephalic (26%), mid-forearm radial-cephalic (19%) and radial-accessory vein (7%). Kaplan- Meier analysis of survival and patency rates were calculated utilizing data from a prospective database and medical records. Technical success was defined as the ability to successfully utilize the AVF for dialysis.
Results: The mean time for follow-up was 31.9 months (range 1-131 months). Out of the 152 patients receiving the treatment in the study, 107 remained alive (86.3% survival). 17 patients were deceased and 28 patients were lost to follow-up. Among the 188 BAMs utilizing a 4 Fr sheath and low profile system, technical success of fistula salvage was achieved in 134 procedures (71.3%). Initially, in the remainder of patients, 16 had renal insufficiency and were not dialysis dependent, 23 continued to use their catheters and 9 underwent placement of a graft. The average assisted patency for these suboptimal AVFs was 27.5 months. Assisted patency rates at one, two and three years were 64.1%, 51.5%, 34.1% respectively with ongoing surveillance and interventions.
Conclusion: Utilizing radial artery access with low profile systems for initial BAMs of AVFs allows for salvage of small diameter, sclerotic and/or occluded fistulas. Although primary assisted patency in this subset of patients was lower than the overall group, patient survival was comparable. This new approach further enhances to ability to create and salvage AVFs in a group of patients who would otherwise not be amenable to a fistula and may contribute to their overall survival.
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