- Email: [email protected]
Bidirectional Angioplasty with Single Vascular Access in Autogenous Arteriovenous Fistula
Bidirectional Angioplasty with Single Vascular Access in Autogenous Arteriovenous Fistula Byung Moon Kim, MD, Dong Erk Goo, MD, and Sung Il Park, MD
PURPOSE: In autogenous arteriovenous (AV) fistulas with multiple stenoses at extreme ends, one option for treatment of the stenoses with angioplasty is dual access directed toward both ends of the fistula. The present study is a retrospective evaluation of experiences with an alternative access technique, bidirectional angioplasty with a single vascular access. MATERIALS AND METHODS: A total of 124 bidirectional angioplasty procedures with a single vascular access performed in 96 autogenous AV fistulas (48 men and 48 women; mean age, 58 years) were evaluated. After fistulography, a dilated segment of the draining vein located between the proximal and distal stenoses, with its course straight or convex toward the interventional radiologist, was punctured with an 18-gauge needle. The needle was directed antegrade and an introducer sheath was inserted for angioplasty of the proximal or central venous stenoses. Then, with a safety guide wire in place, the introducer sheath was withdrawn and redirected retrograde for angioplasty of the distal stenoses. RESULTS: Technical success rates of redirection of the introducer sheath and angioplasty were 100% and 96.8%, respectively. The failures of angioplasty were related to elastic recoil (n ⴝ 3) and inability to pass the guide wire through an occluded distal vein (n ⴝ 1). Overall procedure times were 7–70 minutes (mean, 31 min). One pseudoaneurysm was the only access-related complication. CONCLUSIONS: Bidirectional angioplasty with a single vascular access is a feasible method of access in angioplasty of autogenous AV fistulas with stenoses at extreme ends. J Vasc Interv Radiol 2007; 18:868 – 874 Abbreviation:
AV ⫽ arteriovenous
MAINTENANCE of vascular access is a great concern in patients who undergo long-term hemodialysis. The most common cause of vascular access failure is progressive stenosis from intimal hyperplasia. In arteriovenous From the Department of Diagnostic Radiology (B.M.K.), Kangbuk Samsung Hospital, Sungkyunkwan University; Department of Diagnostic Radiology (D.E.G.), Soonchunhyang University Hospital, Seoul; and Department of Diagnostic Radiology (S.I.P.), Myongji Hospital, Kwandong University, #697-24 Hwajung-dong, Dukyang-ku, Koyang-si, Gyeonggi-do, 412-270, Republic of Korea. Received September 24, 2006; final revision received April 10, 2007; accepted April 16, 2007. From the 2004 SIR Annual Meeting. Address correspondence to S.I.P.; E-mail: [email protected] None of the authors have identified a conflict of interest. © SIR, 2007 DOI: 10.1016/j.jvir.2007.04.029
868
(AV) grafts, the stenosis is found most commonly at the venous anastomosis (1,2). In autogenous AV fistulas, the stenosis is found most commonly at the juxtaanastomotic vein, followed by venous outflow stenosis (3). In autogenous AV fistulas, percutaneous transluminal angioplasty is generally used for management of these stenoses, but multiple stenoses are frequently encountered (4,5). When the stenoses are located at extreme ends, without accessible segment of the vein proximal to the most proximal stenosis and distal to the most distal stenosis, one option for treatment of the stenoses with angioplasty is dual access directed toward each end of the fistula (6 – 8). In this study, our experience with an alternative method of single vascular access for bidirectional angioplasty in autogenous AV fistulas is evaluated.
MATERIALS AND METHODS Patient Population During the period from August 2001 to August 2006, 2037 percutaneous angioplasty procedures were performed in 1802 patients with autogenous AV fistulas. Among them, 124 bidirectional angioplasty procedures with a single vascular access were performed consecutively in 96 patients with concomitant proximal and distal stenoses without an accessible segment of the vein proximal to the most proximal stenosis and distal to the most distal stenosis. Our experience in these 124 bidirectional angioplasty procedures was retrospectively evaluated. Informed consent was obtained from all patients before the procedure, but, because the procedures were performed for management of failing au-
Volume 18
Number 7
togenous AV fistulas and this is a retrospective study, approval by the institutional review board was not required. The report was prepared to meet the standards recommended in reporting percutaneous interventions for hemodialysis access (9). The patients were all Asian and included 48 men and 48 women whose ages ranged from 29 to 84 years (mean age, 58 y). All patients had autogenous AV fistulas: radiocephalic in 60 patients, brachiocephalic in 26, radiobasilic in one, brachiobasilic in two, ulnar– basilic in three, and brachiobrachial in one; brachiobasilic fistulas with basilic transposition were seen in a further three patients. Seventeen patients had interposition of graft in the proximal draining vein. The fistulas were in the left upper extremity in 69 patients and the right upper extremity in 27 patients. The duration of fistula implantation was 1–164 months (mean, 47.6 months ⫾ 34.9). The patients were referred for AV fistulography and angioplasty as a result of progressive worsening of dialysis flow rate, progressive increase in static venous pressure, or clinical findings of palpable pulsation, poor hemostasis after dialysis, and/or extremity swelling. Fistulography Procedure After thorough physical examination (10 –12) of the AV fistula and the draining vein, fistulography was performed with digital subtraction angiography technique and iodinated contrast materials (iodixanol; Visipaque 320; Amersham, Cork, Ireland; or ioversol; Optiray 320; Tyco, Montreal, QC, Canada). In 112 bidirectional angioplasty procedures performed in 86 patients, fistulography was performed after puncture of the juxtaanastomotic segment of the vein with a 21-gauge butterfly needle (Becton Dickinson Korea, Gumi, Korea). The fistulograms were reviewed and the entry site between the stenoses was selected to access for the bidirectional angioplasty. In the later period of the study in one institution, the method of fistulography was modified and 12 bidirectional angioplasty procedures were performed in 10 patients. When an anastomotic or juxtaanastomotic stenosis was suspected based on physical examination, the entry site was deter-
Kim et al
mined solely by physical examination. The entry site was punctured perpendicular to the course of the vein with an 18-gauge Angiocath (Dukwoo Medical, Suwon, Korea) and fistulography of the proximal draining vein was performed. In 10 procedures in eight patients, fistulography of the distal vein was performed by redirecting the introducer sheath toward the anastomosis after angioplasty of the proximal stenosis. In two procedures in two patients, fistulography of the distal vein was performed by redirecting the Angiocath (Dukwoo Medical; Fig 1). In the two patients with the Angiocath directed toward the anastomosis, the Angiocath was again redirected toward the proximal stenosis before bidirectional angioplasty. Angioplasty Procedure A stenosis was considered significant for treatment when the diameter reduction was 50% or greater relative to the normal segment of the outflow vein. When a stenosis was located at a confluence without a proximal venous segment, the diameter reduction was measured relative to the inflow vein. Bidirectional angioplasty with a single vascular access was performed when (i) the AV fistula was sufficiently dilated to be cannulated easily for hemodialysis, (ii) the most proximal and most distal stenoses were angiographically significant, and (iii) the inflow vein distal to the most distal stenosis and the outflow vein proximal to the most proximal stenosis were inadequate for access. The inflow vein was considered inadequate for access when the distal stenosis was less than 2 cm away from the anastomosis and access through the inflow vein would be too close to the stenosis to perform angioplasty. Depending on venous anatomy, the outflow vein was considered inadequate for access when (i) the proximal stenosis involved the central vein, (ii) the proximal stenosis was proximal to or involved the upper third of the upper-arm cephalic vein, (iii) the main outflow was through the basilic vein and stenosis involved the upper-arm basilic vein, or (iv) the outflow vein proximal to the most proximal stenosis was not palpable. In regard to the ease of performing the angioplasty procedure, redirecting the introducer sheath, gain-
•
869
ing sufficient distance from the stenoses to the access, and positioning the operator’s hands during the procedure, a suitable entry site for the bidirectional angioplasty was determined on the basis of fistulography or physical examination according to the following provisions: (i) the entry site is close to the AV anastomosis so the thrill, pulsation, or vein itself could be palpated from the anastomosis to the entry site; (ii) the entry site is at least 1 cm away from any suspected nearby stenosis; (iii) the course of the segment of the draining vein containing the entry site is straight or convex toward the operator; and (iv) the entry site, when present, is a dilated segment of the vein with a bulging contour on the skin surface. Patients were prepared and draped in standard sterile fashion. A spot radiograph of the arm was obtained immediately before administration of local anesthesia to mark the time of initiation of the procedure. The lateral wall of the vein selected for the entry site was anesthetized with 1% lidocaine hydrochloride (Daihan, Seoul, Korea) and was punctured vertical to the course of the vein with an 18gauge Angiocath (Dukwoo Medical). After entry into the vein, the Angiocath was rotated toward the antegrade direction. A guide wire was advanced and a 5– 8-F introducer sheath (13 cm length; Cook, Bloomington, Ind; or 10 cm length; Terumo, Tokyo, Japan) was inserted. The size of the introducer sheath was selected according to the diameter required to insert the balloon for proximal angioplasty. In two patients with thrombosed fistulas, 8-F Desilets-Hoffman introducer sheaths (Cook) were inserted for bidirectional aspiration thrombectomy and angioplasty. Heparin sulfate (3000 –5000 U; Choongwae, Hwaseong, Korea) was routinely administered through the side port of the introducer sheath. Angioplasty was performed with use of various angioplasty balloons (UltraThin Diamond and XXL; Boston Scientific, Watertown, Mass; ATB Advance; Cook) 6 –14 mm in diameter. As needed, stents (Smart Control; Cordis, Miami, Fla; Zilver 635; Cook; Express LD; Boston Scientific) 8 –14 mm in diameter were inserted. After completion of angioplasty of the proximal stenosis, the introducer
870
•
Bidirectional Angioplasty with Single Vascular Access in AV Fistulas
July 2007
JVIR
Figure 1. Images from a 77-year-old female patient with an autogenous radiocephalic fistula in the left upper extremity. The patient was referred for fistulographic evaluation for swelling of the upper extremity. (a) With an 18-gauge Angiocath, the lateral wall of the dilated segment of the draining vein was punctured vertical to the course of the vein. (b) Upon entry of the needle into the vein, the needle was rotated toward the antegrade direction and advanced for fistulography of the proximal draining vein and central vein. (c) The Angiocath is carefully withdrawn and redirected distally, in this case, without aid of the inner metal needle. Spot radiography reveals the AV anastomosis.
sheath was redirected toward the anastomosis (Fig 2). A 0.035-inch curved hydrophilic guide wire (Radifocus; Terumo) and the introducer dilator were inserted into the introducer sheath so the tip of the guide wire was approximately 2–5 cm beyond the tip of the introducer sheath and the tip of the introducer dilator overlapped the tip of the introducer sheath. The guide wire, the dilator, and the introducer sheath as a whole were withdrawn to the level immediately before the skin entry site and rotated horizontally to be directed toward the distal stenosis. When the tip of the guide wire was still pointing toward the proximal vein, the guide wire was pulled back into the introducer dilator and then reinserted distally. The introducer sheath was
advanced distally to add stability during angioplasty. The guide wire was then negotiated through the distal stenosis and distal angioplasty was performed. In the two patients with thrombosed fistulas, bidirectional aspiration thrombectomy was performed with use of the 8-F DesiletsHoffman introducer sheath (Cook) before the bidirectional angioplasty procedure. When the punctured vein was less than 1 cm in diameter, the entry site was marked with the tip of a needle holder to avoid loss of access during redirection. One to four bidirectional angioplasty procedures were performed in each patient. One procedure was performed in 77, two procedures were performed in 13, three procedures were performed in three, and four pro-
cedures were performed in three. All distal stenoses were treated with angioplasty only. In the proximal stenoses, 114 angioplasty procedures were performed in 87 patients and 10 stent insertion procedures were performed in nine patients. The stents were inserted in the brachiocephalic vein in seven procedures, subclavian vein in two procedures, and proximal basilic vein in one procedure. After completion of the procedures, hemostasis was achieved by digital manual compression or with the use of purse-string stitches around the skin entry site (13,14). Follow-up was performed by physical examination on an outpatient basis during regular follow up at 3-month intervals or by fistulography when restenosis of the fistula was suspected on physical examina-
Volume 18
Number 7
Kim et al
•
871
Figure 2. Images from a 70-year-old female patient with autogenous radiocephalic fistula in the left upper extremity. The patient was referred for fistulographic evaluation of swelling of the upper extremity and progressive decrease in dialysis flow rate. (a) Fistulography with a 21-gauge butterfly needle revealed occlusion of the left brachiocephalic vein (not shown) and diffuse stenosis of the distal vein. (b) An 8-F introducer sheath was inserted in antegrade direction and a 14-mm ⫻ 6-cm stent was inserted in the occluded left brachiocephalic vein. (c) A curved hydrophilic guide wire and the introducer dilator were inserted into the introducer sheath. The entry site (white arrow) was marked with the tip of a needle holder to avoid loss of access. Then the guide wire, dilator, and vascular sheath were withdrawn as a whole to a level immediately below the skin entry site. (d) The guide wire, dilator, and vascular sheath were rotated toward the distal direction. (e) The guide wire was negotiated through the distal stenosis into the radial artery and angioplasty of the distal stenosis was performed. (f) Final angiography revealed good flow through the fistula. (g) Four-month follow-up fistulography was performed because of progressive worsening of the dialysis flow rate. Physical examination revealed a segment of distal vein without stenosis and was punctured for fistulography. Recurrent stenosis was noted, but the entry site of previous bidirectional angioplasty with a single vascular access showed no complications.
872
•
Bidirectional Angioplasty with Single Vascular Access in AV Fistulas
tion or during hemodialysis. Among the 96 patients, 18 patients were lost to follow-up. Technical success of the procedure was defined by (i) more than 70% recanalization of all angiographically significant stenoses treated with use of a single vascular access and (ii) the ability of the patient to undergo at least one subsequent hemodialysis procedure. The procedure time was calculated from the time displayed on the spot radiograph obtained immediately before administration of local anesthesia to the time displayed on the final angiogram. The time of redirecting the introducer sheath was not measured separately. Complications were investigated and classified into major and minor complications according to the definitions of the Society of Interventional Radiology (9,15). Stenoses The stenoses were multiple in all patients, and two to four stenoses were found in each patient. The most proximal stenoses were located at the brachiocephalic vein (n ⫽ 18), subclavian vein (n ⫽ 6), brachial vein (n ⫽ 3), basilic vein (n ⫽ 16), upper-arm cephalic vein (n ⫽ 41), forearm cephalic vein (n ⫽ 20), vein-to-vein anastomosis (n ⫽ 4), intragraft stenosis (n ⫽ 2), and graft-to-vein anastomosis (n ⫽ 14). The degree of the proximal stenosis was 50%–100% (mean, 80.0% ⫾ 11.2%) with lengths of 1– 8 cm (mean, 2.1 cm ⫾ 1.3). The most distal stenoses were located at the artery (n ⫽ 2), AV anastomosis (n ⫽ 4), juxtaanastomotic vein (n ⫽ 28), forearm cephalic vein (n ⫽ 50), upper-arm cephalic vein (n ⫽ 30), basilic vein (n ⫽ 9), and brachial vein (n ⫽ 1). The degree of distal stenosis was 50%–100% (mean, 75.2% ⫾ 12.6%) with lengths of 1– 8 cm (mean, 2.7 cm ⫾ 1.7). Statistical Analysis The Kaplan-Meier method was used to calculate the cumulative patency rate according to the time of follow-up.
RESULTS The technical success rate in redirecting the introducer sheath without a second access was 100%. Technical
success of the overall procedure was achieved in 120 procedures (96.8%). The failures were caused by elastic recoil in the proximal cephalic vein combined with a weblike stenosis in the brachiocephalic vein (n ⫽ 1), elastic recoil in the proximal cephalic vein with pseudoaneurysm at the entry site (n ⫽ 1), elastic recoil in the proximal cephalic vein (n ⫽ 1), and failure to pass the guide wire through an occluded segment of the distal cephalic vein (n ⫽ 1). Procedure times ranged from 7 to 70 minutes (mean, 31 min), excluding the time required for fistulography. One major complication occurred in the form of a pseudoaneurysm at the entry site in one patient who eventually underwent graft interposition. Minor complications were rupture of the stenotic vein in three patients in which hemostasis was achieved by balloon tamponade. Among the 18 patients followed up by physical examination and the 60 patients followed up by fistulography, there were no entry site complications except the pseudoaneurysm. Primary patency rates were 75.9%, 53.1%, 28.1%, and 16.4% at 3, 6, 12, and 24 months, respectively, with a mean patency duration of 10.0 months and a median patency duration of 6.4 months.
DISCUSSION Percutaneous transluminal angioplasty is generally used for management of stenoses of AV fistulas, but multiple stenoses are frequently encountered (4,5). The Kidney Disease Outcomes Quality Initiative guidelines for vascular access (16) recommend increased use of autogenous AV fistulas rather than AV grafts for permanent vascular access for hemodialysis. Consequently, the performance of angioplasty for multiple stenoses in autogenous AV fistulas is likely to increase. To perform angioplasty of multiple stenoses with one vascular access, the access has to be proximal to the most proximal stenosis or distal to the most distal stenosis. When there is no accessible vein proximal to the most proximal stenosis and distal to the most distal stenosis, dual access in a crisscross configuration can be made between the stenoses for angioplasty (6 – 8). Other ac-
July 2007
JVIR
cess options for angioplasty of these stenoses include access through the brachial artery, radial artery, jugular vein, or a side branch of the draining vein. However, complications related to brachial artery access have been reported in as many as 12% of cases (17,18), and the transbrachial approach has not been recommended (19). Although no access-related complications were reported, use of the radial artery for access (20,21) requires normal findings on the Allen test, and there are limitations to the use of a large balloon because of the limitations in inserting a large introducer sheath. Use of the jugular vein for angioplasty has also been reported (22,23), but without mention of complications in the jugular access. Although it may be uncommon, thrombosis of the jugular vein after intervention by jugular access has been reported (24 –27). Use of a side branch of the draining vein may complicate the procedure because ultrasonographic guidance may be required for the puncture. Use of these sites for access for angioplasty will pose unnecessary risk of accessrelated complications. Because we redirected the vascular sheath, a second vascular access was not necessary and the entire stenoses from the artery to the central vein could be treated with a single vascular access. The cephalic vein and basilic vein are located subcutaneously in the superficial fascia, outside the antebrachial fascia in the forearm and the brachial fascia in the upper arm (28). Unless the patient is extremely obese, the draining vein will engorge and the wall of the vein will lie immediately below the skin. As a result of their elasticity, the skin and the wall of the vein will move together and allow the vascular sheath to be redirected to the opposite direction. The entry site of the vascular sheath was selected to be at the convex side of the draining vein, preferably at a segment where there was dilation when present. By selecting the convex side of the draining vein, the angle of redirecting the vascular sheath could be decreased. By selecting the dilated segment, the angle of redirecting the vascular sheath could be further decreased as the angular point is moved further away from the axis of the punctured vein. In addition, by selecting the dilated vein,
Volume 18
Number 7
sufficient space to redirect the vascular sheath and acceptable distance from any nearby stenosis can be obtained. There seems to be no definite lower limit of the diameter of the vein to allow redirection of the vascular sheath as long as the fistula is sufficiently dilated to be cannulated for hemodialysis. Redirecting the sheath could be performed in veins as small as approximately 6 –7 mm in diameter compared with the diameter of the angioplasty balloon during angioplasty. When all these conditions are met, the Angiocath can also be redirected toward the opposite direction with or without aid of the metal needle to enhance visualization of the AV anastomosis (Fig 1). Aspiration thrombectomy could also be performed in both directions with use of the DesiletsHoffman introducer sheath (Cook). The technique of redirecting the vascular sheath for bidirectional angioplasty is in some way an extension to autogenous AV fistulas of the concept of the apex puncture technique for thrombolysis of a hemodialysis graft (29). Several advantages can be obtained when the technique of bidirectional angioplasty with a single vascular access is used rather than the dual-access technique. First, the entry site can be selected so there is adequate distance from the stenoses to perform angioplasty. At times, passing a guide wire through a stenosis and performing angioplasty can be difficult when the stenosis is too far from or too close to the entry site. In addition, when the draining vein is located at the medial side of the arm, the operator’s hands may have to be extended over the patient, between the arm and the body of the patient, to gain access or perform the angioplasty. In our technique, the lateral wall of the draining vein is punctured and the hands of the operator can remain in much more comfortable position for the procedures, lateral to the patient’s arm. Second, the hands of the operator can remain outside the radiation field during the entire procedure of redirecting the vascular sheath and performing angioplasty. Finally, the cost of a second vascular sheath can be decreased. Compared with the proximal or central vein, the diameter of the distal vein will be smaller, and the size of the balloon required for angioplasty will also be smaller. When using the
Kim et al
dual-access technique, few interventional radiologists will use the same large introducer sheath when performing angioplasty of the distal stenosis. In our technique, the same introducer sheath used for angioplasty of the proximal or central venous stenosis is used for angioplasty of the distal stenosis, and use of a second vascular sheath is not necessary. Modification of the technique was made during the study period, and the entry site for bidirectional angioplasty was determined solely by physical examination. After omitting the step of fistulography with a 21-gauge butterfly needle, fistulography of the distal stenosis and the anastomosis were done by redirecting the Angiocath during fistulography or after angioplasty of the proximal stenosis and redirecting the vascular sheath. In all these cases, a sufficiently dilated segment of the vein was selected as the entry site and no site was found to be unsuitable in which to reverse the sheath. Major complications after the procedure included a pseudoaneurysm at the entry site in one patient. The pseudoaneurysm occurred in a patient with an extremely well developed brachiocephalic fistula in which angioplasty failed as a result of recoil at the cephalic arch. Persistent high pressure within the vein without relief because of failure of the angioplasty may have resulted in the pseudoaneurysm. When the fistula is extremely well developed with high venous pressure, hemostasis of the entry site may need to be obtained with extra caution. Limitations of the study are that it is a retrospective study, not all patients underwent follow-up fistulography for evaluation of the entry site, and bidirectional angioplasty with a single vascular access was performed only in sufficiently dilated autogenous AV fistulas. Although there are some limitations of the study, bidirectional angioplasty with a single vascular access is a feasible alternative method of access that can be used in autogenous AV fistulas with concomitant stenoses at extreme ends. References 1. Borgis KJ, Gmelin E, Weiss HD. Utility of DSA in the evaluation of hae-
2. 3.
4.
5.
6.
7.
8.
9.
10.
11. 12.
13.
14.
•
873
modialysis access fistulas. Eur J Radiol 1986; 6:215–217. Weiner SN. Complications of vascular access devices for hemodialysis. Angiology 1985; 36:275–284. Glanz S, Bashist B, Gordon DH, Butt K, Adamson R. Angiography of upper extremity access fistulas for dialysis. Radiology 1982; 143:45–52. Kanterman RY, Vesely TM, Pilgram TK, Guy BW, Windus DW, Picus D. Dialysis access grafts: anatomic location of venous stenosis and results of angioplasty. Radiology 1995; 195:135– 139. Safa AA, Valji K, Roberts AC, Ziegler TW, Hye RJ, Oglevie SB. Detection and treatment of dysfunctional hemodialysis access grafts: effect of a surveillance program on graft patency and the incidence of thrombosis. Radiology 1996; 199:653– 657. Valji K, Bookstein JJ, Roberts AC, Oglevie SB, Pittman C, O’Neill MP. Pulse-spray pharmacomechanical thrombolysis of thrombosed hemodialysis access grafts: Long-term experience and comparison of original and current techniques. AJR Am J Roentgenol 1995; 164:1495–1500. Turmel-Rodrigues L, Raynaud A, Louail B, Beyssen B, Sapoval M. Manual catheter-directed aspiration and other thrombectomy techniques for declotting native fistulas for hemodialysis. J Vasc Interv Radiol 2001; 12: 1365–1371. Clark TW, Hirsch DA, Jindal KJ, Veugelers PJ, LeBlanc J. Outcome and prognostic factors of restenosis after percutaneous treatment of native hemodialysis fistulas. J Vasc Interv Radiol 2002; 13:51–59. Gray RJ, Sacks D, Martin LG, et al Reporting standards for percutaneous interventions in dialysis access. J Vasc Interv Radiol 2003; 14(suppl):S433–S442. Trerotola SO. Interventional radiologic approach to hemodialysis access management. In: Savader SJ, Trerotola SO, eds. Venous interventional radiology with clinical perspectives. New York: Thieme, 1996;178 –212. Beathard GA. Physical examination of the dialysis vascular access. Semin Dial 1998; 11:231–236. Trerotola SO, Scheel PJ Jr, Powe NR, et al. Screening for dialysis access graft malfunction: comparison of physical examination with US. J Vasc Interv Radiol 1996; 7:15–20. Vorwerk D, Konnor K, Schurman K, Gunther RW. A simple trick to facilitate bleeding control after percutaneous hemodialysis fistula and graft intervention. Cardiovasc Intervent Radiol 1997; 20:159 –160. Vesely TM. Use of a purse string suture to close a percutaneous access site
874
15.
16.
17.
18.
19.
•
Bidirectional Angioplasty with Single Vascular Access in AV Fistulas
after hemodialysis graft interventions. J Vasc Interv Radiol 1998; 9:447– 450. Sacks D, Marinelli DL, Martin LG, et al. Reporting standards for clinical evaluation of new peripheral arterial revascularization devices. J Vasc Interv Radiol 1997; 8:137–149. National Kidney Foundation. Clinical Practice Guidelines for Hemodialysis Adequacy, update 2006. Am J Kidney Dis 2006; 48(suppl 1):S2–S90. Manninen HI, Kaukanen ET, Ikaheimo R, et al. Brachial arterial access: Endovascular treatment of failing BresciaCimino hemodialysis fistulas—initial success and long-term results. Radiology 2001; 218:711–718. Miyayama S, Matsui O, Taki K, et al. Occluded Brescia-Cimino hemodialysis fistulas: endovascular treatment with both brachial arterial and venous access using the pull-through technique. Cardiovasc Intervent Radiol 2005; 28:806 – 812. Trerotola SO, Turmel-Rodrigues L. Off the beaten path: transbrachial ap-
20.
21.
22.
23.
24.
proach for native fistula interventions. Radiology 2001; 208:617– 619. Wang HJ, Yang YF. Percutaneous treatment of dysfunctional BresciaCimino fistulae through a radial arterial approach. Am J Kidney Dis 2006; 48:652– 658. Kawarada O, Yokoi Y, Nakata S, Morioka N, Takemoto K. Transradial intervention for native fistula failure. Cathet Cardiovasc Intervent 2006; 68: 513–520. Zaetta JM, Baum RA, Haskal ZJ, Shlansky-Goldberg RD, Soulen MC. Thrombosed dialysis grafts: Percutaneous mechanical declotting using a central venous approach. J Vasc Interv Radiol 1998; 9:833– 836. Basile A, Medina JG, Lupattelli T, Medina VG, Leal R. Internal jugular vein access for the interventional management of nonfunctioning arterio-venous haemodialysis fistulas. Eur J Radiol 2004; 52:288 –292. Terhaar OA, Lyon SM, Given MF, Foster AE, Grath FM, Lee MJ. Extended
25.
26.
27. 28.
29.
July 2007
JVIR
interval for retrieval of Gunther tulip filters. J Vasc Interv Radiol 2004; 15:1257–1262. Turmel-Rodrigues L. Percutaneous mechanical declotting of dialysis grafts using a central approach: a summation of risks not acceptable in 1998. J Vasc Interv Radiol 1999; 10:375–376. Aswad MA, Sandager GP, Pais SO, et al. Early duplex scan evaluation of four vena caval interruption devices. J Vasc Surg 1996; 24:809 – 818. Stegmayr B, Wikdahl AM. Access in therapeutic apheresis. Ther Apher Dial 2003; 7:209 –214. Cardiovascular: venous systems. In: Williams PL, Bannister LH, Berry MM, et al, eds. Gray’s anatomy: the anatomical basis of medicine & surgery, 38th edition. Edinburgh, UK: Churchill Livingstone, 1995;1589 –1590. Hathaway PB, Vesely TM. The apexpuncture technique for mechanical thrombolysis of loop hemodialysis grafts. J Vasc Interv Radiol 1999; 10: 775–779.
PURPOSE: In autogenous arteriovenous (AV) fistulas with multiple stenoses at extreme ends, one option for treatment of the stenoses with angioplasty is dual access directed toward both ends of the fistula. The present study is a retrospective evaluation of experiences with an alternative access technique, bidirectional angioplasty with a single vascular access. MATERIALS AND METHODS: A total of 124 bidirectional angioplasty procedures with a single vascular access performed in 96 autogenous AV fistulas (48 men and 48 women; mean age, 58 years) were evaluated. After fistulography, a dilated segment of the draining vein located between the proximal and distal stenoses, with its course straight or convex toward the interventional radiologist, was punctured with an 18-gauge needle. The needle was directed antegrade and an introducer sheath was inserted for angioplasty of the proximal or central venous stenoses. Then, with a safety guide wire in place, the introducer sheath was withdrawn and redirected retrograde for angioplasty of the distal stenoses. RESULTS: Technical success rates of redirection of the introducer sheath and angioplasty were 100% and 96.8%, respectively. The failures of angioplasty were related to elastic recoil (n ⴝ 3) and inability to pass the guide wire through an occluded distal vein (n ⴝ 1). Overall procedure times were 7–70 minutes (mean, 31 min). One pseudoaneurysm was the only access-related complication. CONCLUSIONS: Bidirectional angioplasty with a single vascular access is a feasible method of access in angioplasty of autogenous AV fistulas with stenoses at extreme ends. J Vasc Interv Radiol 2007; 18:868 – 874 Abbreviation:
AV ⫽ arteriovenous
MAINTENANCE of vascular access is a great concern in patients who undergo long-term hemodialysis. The most common cause of vascular access failure is progressive stenosis from intimal hyperplasia. In arteriovenous From the Department of Diagnostic Radiology (B.M.K.), Kangbuk Samsung Hospital, Sungkyunkwan University; Department of Diagnostic Radiology (D.E.G.), Soonchunhyang University Hospital, Seoul; and Department of Diagnostic Radiology (S.I.P.), Myongji Hospital, Kwandong University, #697-24 Hwajung-dong, Dukyang-ku, Koyang-si, Gyeonggi-do, 412-270, Republic of Korea. Received September 24, 2006; final revision received April 10, 2007; accepted April 16, 2007. From the 2004 SIR Annual Meeting. Address correspondence to S.I.P.; E-mail: [email protected] None of the authors have identified a conflict of interest. © SIR, 2007 DOI: 10.1016/j.jvir.2007.04.029
868
(AV) grafts, the stenosis is found most commonly at the venous anastomosis (1,2). In autogenous AV fistulas, the stenosis is found most commonly at the juxtaanastomotic vein, followed by venous outflow stenosis (3). In autogenous AV fistulas, percutaneous transluminal angioplasty is generally used for management of these stenoses, but multiple stenoses are frequently encountered (4,5). When the stenoses are located at extreme ends, without accessible segment of the vein proximal to the most proximal stenosis and distal to the most distal stenosis, one option for treatment of the stenoses with angioplasty is dual access directed toward each end of the fistula (6 – 8). In this study, our experience with an alternative method of single vascular access for bidirectional angioplasty in autogenous AV fistulas is evaluated.
MATERIALS AND METHODS Patient Population During the period from August 2001 to August 2006, 2037 percutaneous angioplasty procedures were performed in 1802 patients with autogenous AV fistulas. Among them, 124 bidirectional angioplasty procedures with a single vascular access were performed consecutively in 96 patients with concomitant proximal and distal stenoses without an accessible segment of the vein proximal to the most proximal stenosis and distal to the most distal stenosis. Our experience in these 124 bidirectional angioplasty procedures was retrospectively evaluated. Informed consent was obtained from all patients before the procedure, but, because the procedures were performed for management of failing au-
Volume 18
Number 7
togenous AV fistulas and this is a retrospective study, approval by the institutional review board was not required. The report was prepared to meet the standards recommended in reporting percutaneous interventions for hemodialysis access (9). The patients were all Asian and included 48 men and 48 women whose ages ranged from 29 to 84 years (mean age, 58 y). All patients had autogenous AV fistulas: radiocephalic in 60 patients, brachiocephalic in 26, radiobasilic in one, brachiobasilic in two, ulnar– basilic in three, and brachiobrachial in one; brachiobasilic fistulas with basilic transposition were seen in a further three patients. Seventeen patients had interposition of graft in the proximal draining vein. The fistulas were in the left upper extremity in 69 patients and the right upper extremity in 27 patients. The duration of fistula implantation was 1–164 months (mean, 47.6 months ⫾ 34.9). The patients were referred for AV fistulography and angioplasty as a result of progressive worsening of dialysis flow rate, progressive increase in static venous pressure, or clinical findings of palpable pulsation, poor hemostasis after dialysis, and/or extremity swelling. Fistulography Procedure After thorough physical examination (10 –12) of the AV fistula and the draining vein, fistulography was performed with digital subtraction angiography technique and iodinated contrast materials (iodixanol; Visipaque 320; Amersham, Cork, Ireland; or ioversol; Optiray 320; Tyco, Montreal, QC, Canada). In 112 bidirectional angioplasty procedures performed in 86 patients, fistulography was performed after puncture of the juxtaanastomotic segment of the vein with a 21-gauge butterfly needle (Becton Dickinson Korea, Gumi, Korea). The fistulograms were reviewed and the entry site between the stenoses was selected to access for the bidirectional angioplasty. In the later period of the study in one institution, the method of fistulography was modified and 12 bidirectional angioplasty procedures were performed in 10 patients. When an anastomotic or juxtaanastomotic stenosis was suspected based on physical examination, the entry site was deter-
Kim et al
mined solely by physical examination. The entry site was punctured perpendicular to the course of the vein with an 18-gauge Angiocath (Dukwoo Medical, Suwon, Korea) and fistulography of the proximal draining vein was performed. In 10 procedures in eight patients, fistulography of the distal vein was performed by redirecting the introducer sheath toward the anastomosis after angioplasty of the proximal stenosis. In two procedures in two patients, fistulography of the distal vein was performed by redirecting the Angiocath (Dukwoo Medical; Fig 1). In the two patients with the Angiocath directed toward the anastomosis, the Angiocath was again redirected toward the proximal stenosis before bidirectional angioplasty. Angioplasty Procedure A stenosis was considered significant for treatment when the diameter reduction was 50% or greater relative to the normal segment of the outflow vein. When a stenosis was located at a confluence without a proximal venous segment, the diameter reduction was measured relative to the inflow vein. Bidirectional angioplasty with a single vascular access was performed when (i) the AV fistula was sufficiently dilated to be cannulated easily for hemodialysis, (ii) the most proximal and most distal stenoses were angiographically significant, and (iii) the inflow vein distal to the most distal stenosis and the outflow vein proximal to the most proximal stenosis were inadequate for access. The inflow vein was considered inadequate for access when the distal stenosis was less than 2 cm away from the anastomosis and access through the inflow vein would be too close to the stenosis to perform angioplasty. Depending on venous anatomy, the outflow vein was considered inadequate for access when (i) the proximal stenosis involved the central vein, (ii) the proximal stenosis was proximal to or involved the upper third of the upper-arm cephalic vein, (iii) the main outflow was through the basilic vein and stenosis involved the upper-arm basilic vein, or (iv) the outflow vein proximal to the most proximal stenosis was not palpable. In regard to the ease of performing the angioplasty procedure, redirecting the introducer sheath, gain-
•
869
ing sufficient distance from the stenoses to the access, and positioning the operator’s hands during the procedure, a suitable entry site for the bidirectional angioplasty was determined on the basis of fistulography or physical examination according to the following provisions: (i) the entry site is close to the AV anastomosis so the thrill, pulsation, or vein itself could be palpated from the anastomosis to the entry site; (ii) the entry site is at least 1 cm away from any suspected nearby stenosis; (iii) the course of the segment of the draining vein containing the entry site is straight or convex toward the operator; and (iv) the entry site, when present, is a dilated segment of the vein with a bulging contour on the skin surface. Patients were prepared and draped in standard sterile fashion. A spot radiograph of the arm was obtained immediately before administration of local anesthesia to mark the time of initiation of the procedure. The lateral wall of the vein selected for the entry site was anesthetized with 1% lidocaine hydrochloride (Daihan, Seoul, Korea) and was punctured vertical to the course of the vein with an 18gauge Angiocath (Dukwoo Medical). After entry into the vein, the Angiocath was rotated toward the antegrade direction. A guide wire was advanced and a 5– 8-F introducer sheath (13 cm length; Cook, Bloomington, Ind; or 10 cm length; Terumo, Tokyo, Japan) was inserted. The size of the introducer sheath was selected according to the diameter required to insert the balloon for proximal angioplasty. In two patients with thrombosed fistulas, 8-F Desilets-Hoffman introducer sheaths (Cook) were inserted for bidirectional aspiration thrombectomy and angioplasty. Heparin sulfate (3000 –5000 U; Choongwae, Hwaseong, Korea) was routinely administered through the side port of the introducer sheath. Angioplasty was performed with use of various angioplasty balloons (UltraThin Diamond and XXL; Boston Scientific, Watertown, Mass; ATB Advance; Cook) 6 –14 mm in diameter. As needed, stents (Smart Control; Cordis, Miami, Fla; Zilver 635; Cook; Express LD; Boston Scientific) 8 –14 mm in diameter were inserted. After completion of angioplasty of the proximal stenosis, the introducer
870
•
Bidirectional Angioplasty with Single Vascular Access in AV Fistulas
July 2007
JVIR
Figure 1. Images from a 77-year-old female patient with an autogenous radiocephalic fistula in the left upper extremity. The patient was referred for fistulographic evaluation for swelling of the upper extremity. (a) With an 18-gauge Angiocath, the lateral wall of the dilated segment of the draining vein was punctured vertical to the course of the vein. (b) Upon entry of the needle into the vein, the needle was rotated toward the antegrade direction and advanced for fistulography of the proximal draining vein and central vein. (c) The Angiocath is carefully withdrawn and redirected distally, in this case, without aid of the inner metal needle. Spot radiography reveals the AV anastomosis.
sheath was redirected toward the anastomosis (Fig 2). A 0.035-inch curved hydrophilic guide wire (Radifocus; Terumo) and the introducer dilator were inserted into the introducer sheath so the tip of the guide wire was approximately 2–5 cm beyond the tip of the introducer sheath and the tip of the introducer dilator overlapped the tip of the introducer sheath. The guide wire, the dilator, and the introducer sheath as a whole were withdrawn to the level immediately before the skin entry site and rotated horizontally to be directed toward the distal stenosis. When the tip of the guide wire was still pointing toward the proximal vein, the guide wire was pulled back into the introducer dilator and then reinserted distally. The introducer sheath was
advanced distally to add stability during angioplasty. The guide wire was then negotiated through the distal stenosis and distal angioplasty was performed. In the two patients with thrombosed fistulas, bidirectional aspiration thrombectomy was performed with use of the 8-F DesiletsHoffman introducer sheath (Cook) before the bidirectional angioplasty procedure. When the punctured vein was less than 1 cm in diameter, the entry site was marked with the tip of a needle holder to avoid loss of access during redirection. One to four bidirectional angioplasty procedures were performed in each patient. One procedure was performed in 77, two procedures were performed in 13, three procedures were performed in three, and four pro-
cedures were performed in three. All distal stenoses were treated with angioplasty only. In the proximal stenoses, 114 angioplasty procedures were performed in 87 patients and 10 stent insertion procedures were performed in nine patients. The stents were inserted in the brachiocephalic vein in seven procedures, subclavian vein in two procedures, and proximal basilic vein in one procedure. After completion of the procedures, hemostasis was achieved by digital manual compression or with the use of purse-string stitches around the skin entry site (13,14). Follow-up was performed by physical examination on an outpatient basis during regular follow up at 3-month intervals or by fistulography when restenosis of the fistula was suspected on physical examina-
Volume 18
Number 7
Kim et al
•
871
Figure 2. Images from a 70-year-old female patient with autogenous radiocephalic fistula in the left upper extremity. The patient was referred for fistulographic evaluation of swelling of the upper extremity and progressive decrease in dialysis flow rate. (a) Fistulography with a 21-gauge butterfly needle revealed occlusion of the left brachiocephalic vein (not shown) and diffuse stenosis of the distal vein. (b) An 8-F introducer sheath was inserted in antegrade direction and a 14-mm ⫻ 6-cm stent was inserted in the occluded left brachiocephalic vein. (c) A curved hydrophilic guide wire and the introducer dilator were inserted into the introducer sheath. The entry site (white arrow) was marked with the tip of a needle holder to avoid loss of access. Then the guide wire, dilator, and vascular sheath were withdrawn as a whole to a level immediately below the skin entry site. (d) The guide wire, dilator, and vascular sheath were rotated toward the distal direction. (e) The guide wire was negotiated through the distal stenosis into the radial artery and angioplasty of the distal stenosis was performed. (f) Final angiography revealed good flow through the fistula. (g) Four-month follow-up fistulography was performed because of progressive worsening of the dialysis flow rate. Physical examination revealed a segment of distal vein without stenosis and was punctured for fistulography. Recurrent stenosis was noted, but the entry site of previous bidirectional angioplasty with a single vascular access showed no complications.
872
•
Bidirectional Angioplasty with Single Vascular Access in AV Fistulas
tion or during hemodialysis. Among the 96 patients, 18 patients were lost to follow-up. Technical success of the procedure was defined by (i) more than 70% recanalization of all angiographically significant stenoses treated with use of a single vascular access and (ii) the ability of the patient to undergo at least one subsequent hemodialysis procedure. The procedure time was calculated from the time displayed on the spot radiograph obtained immediately before administration of local anesthesia to the time displayed on the final angiogram. The time of redirecting the introducer sheath was not measured separately. Complications were investigated and classified into major and minor complications according to the definitions of the Society of Interventional Radiology (9,15). Stenoses The stenoses were multiple in all patients, and two to four stenoses were found in each patient. The most proximal stenoses were located at the brachiocephalic vein (n ⫽ 18), subclavian vein (n ⫽ 6), brachial vein (n ⫽ 3), basilic vein (n ⫽ 16), upper-arm cephalic vein (n ⫽ 41), forearm cephalic vein (n ⫽ 20), vein-to-vein anastomosis (n ⫽ 4), intragraft stenosis (n ⫽ 2), and graft-to-vein anastomosis (n ⫽ 14). The degree of the proximal stenosis was 50%–100% (mean, 80.0% ⫾ 11.2%) with lengths of 1– 8 cm (mean, 2.1 cm ⫾ 1.3). The most distal stenoses were located at the artery (n ⫽ 2), AV anastomosis (n ⫽ 4), juxtaanastomotic vein (n ⫽ 28), forearm cephalic vein (n ⫽ 50), upper-arm cephalic vein (n ⫽ 30), basilic vein (n ⫽ 9), and brachial vein (n ⫽ 1). The degree of distal stenosis was 50%–100% (mean, 75.2% ⫾ 12.6%) with lengths of 1– 8 cm (mean, 2.7 cm ⫾ 1.7). Statistical Analysis The Kaplan-Meier method was used to calculate the cumulative patency rate according to the time of follow-up.
RESULTS The technical success rate in redirecting the introducer sheath without a second access was 100%. Technical
success of the overall procedure was achieved in 120 procedures (96.8%). The failures were caused by elastic recoil in the proximal cephalic vein combined with a weblike stenosis in the brachiocephalic vein (n ⫽ 1), elastic recoil in the proximal cephalic vein with pseudoaneurysm at the entry site (n ⫽ 1), elastic recoil in the proximal cephalic vein (n ⫽ 1), and failure to pass the guide wire through an occluded segment of the distal cephalic vein (n ⫽ 1). Procedure times ranged from 7 to 70 minutes (mean, 31 min), excluding the time required for fistulography. One major complication occurred in the form of a pseudoaneurysm at the entry site in one patient who eventually underwent graft interposition. Minor complications were rupture of the stenotic vein in three patients in which hemostasis was achieved by balloon tamponade. Among the 18 patients followed up by physical examination and the 60 patients followed up by fistulography, there were no entry site complications except the pseudoaneurysm. Primary patency rates were 75.9%, 53.1%, 28.1%, and 16.4% at 3, 6, 12, and 24 months, respectively, with a mean patency duration of 10.0 months and a median patency duration of 6.4 months.
DISCUSSION Percutaneous transluminal angioplasty is generally used for management of stenoses of AV fistulas, but multiple stenoses are frequently encountered (4,5). The Kidney Disease Outcomes Quality Initiative guidelines for vascular access (16) recommend increased use of autogenous AV fistulas rather than AV grafts for permanent vascular access for hemodialysis. Consequently, the performance of angioplasty for multiple stenoses in autogenous AV fistulas is likely to increase. To perform angioplasty of multiple stenoses with one vascular access, the access has to be proximal to the most proximal stenosis or distal to the most distal stenosis. When there is no accessible vein proximal to the most proximal stenosis and distal to the most distal stenosis, dual access in a crisscross configuration can be made between the stenoses for angioplasty (6 – 8). Other ac-
July 2007
JVIR
cess options for angioplasty of these stenoses include access through the brachial artery, radial artery, jugular vein, or a side branch of the draining vein. However, complications related to brachial artery access have been reported in as many as 12% of cases (17,18), and the transbrachial approach has not been recommended (19). Although no access-related complications were reported, use of the radial artery for access (20,21) requires normal findings on the Allen test, and there are limitations to the use of a large balloon because of the limitations in inserting a large introducer sheath. Use of the jugular vein for angioplasty has also been reported (22,23), but without mention of complications in the jugular access. Although it may be uncommon, thrombosis of the jugular vein after intervention by jugular access has been reported (24 –27). Use of a side branch of the draining vein may complicate the procedure because ultrasonographic guidance may be required for the puncture. Use of these sites for access for angioplasty will pose unnecessary risk of accessrelated complications. Because we redirected the vascular sheath, a second vascular access was not necessary and the entire stenoses from the artery to the central vein could be treated with a single vascular access. The cephalic vein and basilic vein are located subcutaneously in the superficial fascia, outside the antebrachial fascia in the forearm and the brachial fascia in the upper arm (28). Unless the patient is extremely obese, the draining vein will engorge and the wall of the vein will lie immediately below the skin. As a result of their elasticity, the skin and the wall of the vein will move together and allow the vascular sheath to be redirected to the opposite direction. The entry site of the vascular sheath was selected to be at the convex side of the draining vein, preferably at a segment where there was dilation when present. By selecting the convex side of the draining vein, the angle of redirecting the vascular sheath could be decreased. By selecting the dilated segment, the angle of redirecting the vascular sheath could be further decreased as the angular point is moved further away from the axis of the punctured vein. In addition, by selecting the dilated vein,
Volume 18
Number 7
sufficient space to redirect the vascular sheath and acceptable distance from any nearby stenosis can be obtained. There seems to be no definite lower limit of the diameter of the vein to allow redirection of the vascular sheath as long as the fistula is sufficiently dilated to be cannulated for hemodialysis. Redirecting the sheath could be performed in veins as small as approximately 6 –7 mm in diameter compared with the diameter of the angioplasty balloon during angioplasty. When all these conditions are met, the Angiocath can also be redirected toward the opposite direction with or without aid of the metal needle to enhance visualization of the AV anastomosis (Fig 1). Aspiration thrombectomy could also be performed in both directions with use of the DesiletsHoffman introducer sheath (Cook). The technique of redirecting the vascular sheath for bidirectional angioplasty is in some way an extension to autogenous AV fistulas of the concept of the apex puncture technique for thrombolysis of a hemodialysis graft (29). Several advantages can be obtained when the technique of bidirectional angioplasty with a single vascular access is used rather than the dual-access technique. First, the entry site can be selected so there is adequate distance from the stenoses to perform angioplasty. At times, passing a guide wire through a stenosis and performing angioplasty can be difficult when the stenosis is too far from or too close to the entry site. In addition, when the draining vein is located at the medial side of the arm, the operator’s hands may have to be extended over the patient, between the arm and the body of the patient, to gain access or perform the angioplasty. In our technique, the lateral wall of the draining vein is punctured and the hands of the operator can remain in much more comfortable position for the procedures, lateral to the patient’s arm. Second, the hands of the operator can remain outside the radiation field during the entire procedure of redirecting the vascular sheath and performing angioplasty. Finally, the cost of a second vascular sheath can be decreased. Compared with the proximal or central vein, the diameter of the distal vein will be smaller, and the size of the balloon required for angioplasty will also be smaller. When using the
Kim et al
dual-access technique, few interventional radiologists will use the same large introducer sheath when performing angioplasty of the distal stenosis. In our technique, the same introducer sheath used for angioplasty of the proximal or central venous stenosis is used for angioplasty of the distal stenosis, and use of a second vascular sheath is not necessary. Modification of the technique was made during the study period, and the entry site for bidirectional angioplasty was determined solely by physical examination. After omitting the step of fistulography with a 21-gauge butterfly needle, fistulography of the distal stenosis and the anastomosis were done by redirecting the Angiocath during fistulography or after angioplasty of the proximal stenosis and redirecting the vascular sheath. In all these cases, a sufficiently dilated segment of the vein was selected as the entry site and no site was found to be unsuitable in which to reverse the sheath. Major complications after the procedure included a pseudoaneurysm at the entry site in one patient. The pseudoaneurysm occurred in a patient with an extremely well developed brachiocephalic fistula in which angioplasty failed as a result of recoil at the cephalic arch. Persistent high pressure within the vein without relief because of failure of the angioplasty may have resulted in the pseudoaneurysm. When the fistula is extremely well developed with high venous pressure, hemostasis of the entry site may need to be obtained with extra caution. Limitations of the study are that it is a retrospective study, not all patients underwent follow-up fistulography for evaluation of the entry site, and bidirectional angioplasty with a single vascular access was performed only in sufficiently dilated autogenous AV fistulas. Although there are some limitations of the study, bidirectional angioplasty with a single vascular access is a feasible alternative method of access that can be used in autogenous AV fistulas with concomitant stenoses at extreme ends. References 1. Borgis KJ, Gmelin E, Weiss HD. Utility of DSA in the evaluation of hae-
2. 3.
4.
5.
6.
7.
8.
9.
10.
11. 12.
13.
14.
•
873
modialysis access fistulas. Eur J Radiol 1986; 6:215–217. Weiner SN. Complications of vascular access devices for hemodialysis. Angiology 1985; 36:275–284. Glanz S, Bashist B, Gordon DH, Butt K, Adamson R. Angiography of upper extremity access fistulas for dialysis. Radiology 1982; 143:45–52. Kanterman RY, Vesely TM, Pilgram TK, Guy BW, Windus DW, Picus D. Dialysis access grafts: anatomic location of venous stenosis and results of angioplasty. Radiology 1995; 195:135– 139. Safa AA, Valji K, Roberts AC, Ziegler TW, Hye RJ, Oglevie SB. Detection and treatment of dysfunctional hemodialysis access grafts: effect of a surveillance program on graft patency and the incidence of thrombosis. Radiology 1996; 199:653– 657. Valji K, Bookstein JJ, Roberts AC, Oglevie SB, Pittman C, O’Neill MP. Pulse-spray pharmacomechanical thrombolysis of thrombosed hemodialysis access grafts: Long-term experience and comparison of original and current techniques. AJR Am J Roentgenol 1995; 164:1495–1500. Turmel-Rodrigues L, Raynaud A, Louail B, Beyssen B, Sapoval M. Manual catheter-directed aspiration and other thrombectomy techniques for declotting native fistulas for hemodialysis. J Vasc Interv Radiol 2001; 12: 1365–1371. Clark TW, Hirsch DA, Jindal KJ, Veugelers PJ, LeBlanc J. Outcome and prognostic factors of restenosis after percutaneous treatment of native hemodialysis fistulas. J Vasc Interv Radiol 2002; 13:51–59. Gray RJ, Sacks D, Martin LG, et al Reporting standards for percutaneous interventions in dialysis access. J Vasc Interv Radiol 2003; 14(suppl):S433–S442. Trerotola SO. Interventional radiologic approach to hemodialysis access management. In: Savader SJ, Trerotola SO, eds. Venous interventional radiology with clinical perspectives. New York: Thieme, 1996;178 –212. Beathard GA. Physical examination of the dialysis vascular access. Semin Dial 1998; 11:231–236. Trerotola SO, Scheel PJ Jr, Powe NR, et al. Screening for dialysis access graft malfunction: comparison of physical examination with US. J Vasc Interv Radiol 1996; 7:15–20. Vorwerk D, Konnor K, Schurman K, Gunther RW. A simple trick to facilitate bleeding control after percutaneous hemodialysis fistula and graft intervention. Cardiovasc Intervent Radiol 1997; 20:159 –160. Vesely TM. Use of a purse string suture to close a percutaneous access site
874
15.
16.
17.
18.
19.
•
Bidirectional Angioplasty with Single Vascular Access in AV Fistulas
after hemodialysis graft interventions. J Vasc Interv Radiol 1998; 9:447– 450. Sacks D, Marinelli DL, Martin LG, et al. Reporting standards for clinical evaluation of new peripheral arterial revascularization devices. J Vasc Interv Radiol 1997; 8:137–149. National Kidney Foundation. Clinical Practice Guidelines for Hemodialysis Adequacy, update 2006. Am J Kidney Dis 2006; 48(suppl 1):S2–S90. Manninen HI, Kaukanen ET, Ikaheimo R, et al. Brachial arterial access: Endovascular treatment of failing BresciaCimino hemodialysis fistulas—initial success and long-term results. Radiology 2001; 218:711–718. Miyayama S, Matsui O, Taki K, et al. Occluded Brescia-Cimino hemodialysis fistulas: endovascular treatment with both brachial arterial and venous access using the pull-through technique. Cardiovasc Intervent Radiol 2005; 28:806 – 812. Trerotola SO, Turmel-Rodrigues L. Off the beaten path: transbrachial ap-
20.
21.
22.
23.
24.
proach for native fistula interventions. Radiology 2001; 208:617– 619. Wang HJ, Yang YF. Percutaneous treatment of dysfunctional BresciaCimino fistulae through a radial arterial approach. Am J Kidney Dis 2006; 48:652– 658. Kawarada O, Yokoi Y, Nakata S, Morioka N, Takemoto K. Transradial intervention for native fistula failure. Cathet Cardiovasc Intervent 2006; 68: 513–520. Zaetta JM, Baum RA, Haskal ZJ, Shlansky-Goldberg RD, Soulen MC. Thrombosed dialysis grafts: Percutaneous mechanical declotting using a central venous approach. J Vasc Interv Radiol 1998; 9:833– 836. Basile A, Medina JG, Lupattelli T, Medina VG, Leal R. Internal jugular vein access for the interventional management of nonfunctioning arterio-venous haemodialysis fistulas. Eur J Radiol 2004; 52:288 –292. Terhaar OA, Lyon SM, Given MF, Foster AE, Grath FM, Lee MJ. Extended
25.
26.
27. 28.
29.
July 2007
JVIR
interval for retrieval of Gunther tulip filters. J Vasc Interv Radiol 2004; 15:1257–1262. Turmel-Rodrigues L. Percutaneous mechanical declotting of dialysis grafts using a central approach: a summation of risks not acceptable in 1998. J Vasc Interv Radiol 1999; 10:375–376. Aswad MA, Sandager GP, Pais SO, et al. Early duplex scan evaluation of four vena caval interruption devices. J Vasc Surg 1996; 24:809 – 818. Stegmayr B, Wikdahl AM. Access in therapeutic apheresis. Ther Apher Dial 2003; 7:209 –214. Cardiovascular: venous systems. In: Williams PL, Bannister LH, Berry MM, et al, eds. Gray’s anatomy: the anatomical basis of medicine & surgery, 38th edition. Edinburgh, UK: Churchill Livingstone, 1995;1589 –1590. Hathaway PB, Vesely TM. The apexpuncture technique for mechanical thrombolysis of loop hemodialysis grafts. J Vasc Interv Radiol 1999; 10: 775–779.