- Email: [email protected]
Early Results of Duplex-Guided Transradial Artery Fistuloplasties
Early Results of Duplex-Guided Transradial Artery Fistuloplasties Ahmad Alsheekh, Anil Hingorani, Afsha Aurshina, Pavel Kibrik, Jesse Chait, and Enrico Ascher, Brooklyn, New York
Background: Although arteriovenous fistulae (AVFs) are the preferred mode of hemodialysis access because of their high patency rates, they are associated with an appreciable rate of nonmaturation. Balloon-assisted maturation (BAM) has been described to treat this issue. BAM is defined as repeated sequential graduated dilatation of the outflow vein. This study aims to evaluate the short-term complications of using the radial artery as an access for BAM procedures and fisutloplasties. Transradial access was used preferentially with multiple lesions in the AVF that were difficult to access with a single venous puncture. Methods: Data were collected over 3 years on 44 office-based duplex-guided transradial access BAM procedures in 27 patients of whom 19 were men. BAM with ultrasound guidance was performed in 324 cases using a venous puncture during this period. The indication for the procedures was a failure of AVF maturation, and 5 cases were with short segment thrombectomy. All procedures were performed with local anesthesia only. Access site puncture, vessel cannulation, wire placement, and balloon advancement and insufflation were duplex-guided. The radial artery was punctured with ultrasound guidance and a 4e5 French low-profile sheath was placed. After crossing the lesion(s), 5,000 units of heparin was given. The radial artery was used as the access vessel for all procedures except one, in which the brachial artery was used in addition. Vascular injuries were classified based on the postprocedural duplex assessment. All patients had follow-up duplex scans within a week. Results: The average age was 79 years (±14 SD, range 39e99 years). The types of AVF were 35 radio-cephalic, 1 radio-basilic, 2 brachio-brachial, 2 brachio-cephalic, and 4 brachio-basilic. The number of sites of lesions was 17 on the venous outflow, 7 perianastomotic, and 6 in the radial artery. In the remaining 14 failing AVFs, we were not able to identify any lesion. The balloon size ranged from 3e6 mm (28 patients) and 7e12 mm (16 patients). The most common injury was outflow vein wall injury (25), the formation of wall hematoma of the outflow vein (11), localized extravasation or rupture at the balloon site (4), spasm of the AVF (3), the formation of a puncture-site hematoma (2), and intimal flap (3). Extravasation was controlled with duplexguided compression. There were no radial artery thromboses, and all the AVFs were patent on completion duplex and follow-up duplex. Conclusions: These data suggest that the radial artery could be used as a safe access route for BAM procedures with relatively low rates of complication. This approach can be considered as an adjunct in the armamentarium for angioplasty of AVF.
Conflict of interest: None.
INTRODUCTION
Total Vascular CareÒ, Brooklyn, NY. Ò
Correspondence to: Ahmad Alsheekh, MD, Total Vascular Care , 960 50th Street Brooklyn, NY 11221; E-mail: ahmadalshike@ hotmail.com Ann Vasc Surg 2019; 60: 178–181 https://doi.org/10.1016/j.avsg.2019.02.036 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: November 26, 2018; manuscript accepted: February 3, 2019; published online: 7 May 2019
178
Maintaining adequate patent dialysis access remains an established goal in the care of patients with end-stage renal failure on hemodialysis. The native arteriovenous fistula (AVF) is recommended as the best vascular access for hemodialysis by the National Kidney Foundation Kidney
Volume 60, October 2019
Dialysis Outcomes Quality Initiative clinical practice guideline.1 Compared with prosthetic arteriovenous grafts and tunneled catheters, AVFs are the preferred mode of dialysis vascular access because of low long-term rates of infection and stenosis.2 Despite the many advantages of the native AVF, dysfunctional dialysis access is a common cause of morbidity and hospitalization. A number of studies have documented major problems with AVF maturation (failure to increase flow and diameter adequately to support dialysis) as a result of a conduit stenosis, and this lesion can occur at various locations of the access circuit.3,4 Previously, the vascular technology applied to manage dysfunctional native AVF consisted of angioplasty treatment of focal venous stenosis. Advances in balloon catheter technology, along with a comprehensive approach to address all of the arterial and venous pathologies, have been shown to promote fistula maturation and prompt lesions management. The culmination of many authors’ studies has made possible the understanding of fistula maturation we have today. More recently, physicians have championed a more aggressive approach to AVF maturation failure in which repeated long-segment angioplasty procedures are used to sequentially dilate up stenosis to improve fistula flow, which will allow the vein to dilate and grow over time to achieve clinical usefulness. Moreover, the angioplasties have been performed in an office-based setting with duplex guidance, which was found to be safe and feasible and avert nephrotoxic contrast and radiation with a low rate of complications.5e7 The transradial access (TRA) is increasingly being used for percutaneous coronary intervention since its first report in 1989.8 The TRA has proven to shorten recovery and time to ambulation, with higher patient preference and comparable success rates to femoral artery access; a low complication rate has also been noted. Although TRA is currently regarded as one of the default sites of access for cardiac catheterization procedures, we have used TRA preferentially in AVF with multiple lesions that were difficult to access with a single venous puncture.9 This study aims to evaluate the short-term results of using the radial artery as an access for fistuloplasties that were performed in an office-based setting with the ultrasound guidance. There was no need for the use of contrast materials, sedation, channel blockers, amides, or vasodilators.
Early results of duplex-guided transradial artery fistuloplasties
179
MATERIALS AND METHODS Data were collected over 3 years. Fistuloplasty was performed in 324 cases with ultrasound guidance using a venous puncture during this period. We performed 44 office-based duplex-guided TRA fistuloplasties in 27 patients. The indication for the procedures was the failure of AVF maturation, with 5 cases out of them having additional shortsegment thrombectomy. Physical examination and duplex scans were performed before the procedure. All procedures were performed with local anesthesia only. A radial artery that is less than 2 mm in diameter or having a circumferential severe calcification would not be utilized as an access site. We believe that the presences of an abnormal arch would not prevent using a suitable radial artery as an access site for the procedure. There is no evidence that a normal Allen’s test is required for the safe undertaking of a transradial procedure.10 Access site puncture, vessel cannulation, wire placement, and balloon advancement and insufflation were duplex-guided. The radial artery was punctured with ultrasound guidance and a 4e5 French lowprofile sheath was placed. No bare balloons were deployed in this study. After crossing the lesion(s), 5,000 units of heparin was given. The radial artery was used as the access vessel for all procedures except one, in which the brachial artery was used in addition. In cases where vascular injuries were classified based on the postprocedural duplex assessment. Accessing the radial artery for the procedure was performed distal to the anastomosis as a short segment was enough for the access. Compression of the radial artery was performed at the end of the procedure with ultrasound guidance until no local bleeding or oozing was noted. There was no routine recommendation of antiplatelet or anticoagulant therapy after completion of the procedure, and the patients were advised to continue their home medications as usual. All patients had follow-up duplex scans within a week. The protocol for the collection and interpretation of data conformed to the principles set by the Declaration of Helsinki. Institutional Review Board of Total Vascular Care IncorporatedÒ (registered with the U.S. Office for Human Research Protections) approval was obtained and consent was waived as the data are blinded and retrospective. After collecting the data, all patients’ identifiers were removed.
RESULTS The average age was 79 years (±14 SD, range 39e99 years). The types of AVF were 35
180 Alsheekh et al.
radio-cephalic, 1 radio-basilic, 2 brachio-brachial, 2 brachio-cephalic, and 4 brachio-basilic. The sites of lesions were 17 on the venous outflow, 7 perianastomotic, and 6 in the radial artery. In the remaining 14 failing AVFs, we were not able to identify any lesion. Although we were not able to identify any lesion in the remaining 14 failing AVFs, balloon angioplasty was performed to help accelerate the maturation of the fistulae (balloon-assisted maturation). Most AVFs were distal radio-cephalic. The balloon size ranged from 3e6 mm (28 patients) and 7e12 mm (16 patients) with 0.018 wires. The one 12-mm balloon was used in the patient with the additional brachial artery puncture. All remaining procedures were done using balloons up to 10 mm only. The balloons were inflated under ultrasound guidance for duration just enough to efface the lesion. At the end of the procedure, an ultrasound was performed to check for lesion recoil. The most common injury was outflow vein wall injury (25), the formation of wall hematoma of the outflow vein (11), localized extravasation or rupture at the balloon site (4), spasm of the AVF (3), the formation of a puncture-site hematoma(2), and intimal flap (3). Extravasation was controlled with duplex-guided compression. All the complications related to the procedure were transient, self-limiting, and tended to resolve on its own as most of them were localized and minimal. A prior study showed the low incidence of local complications after the procedure with further interventions needed.7 Actually, the exploitation of ultrasound made these complications easier to identify, which would be very hard to detect on fluoroscopy. There was no radial artery thrombosis, and all the AVFs were patent on completion duplex ultrasound and 1-week follow-up duplex ultrasound. There was no development of pseudoaneurysms in our patients during the study period. No stenoses were found at 1-week follow-up duplex scans. We did not use any type of sedation, and all the patients received local anesthesia only. No contrast material or X-rays were used, and the whole procedure was under ultrasound guidance. We did not use calcium channel blockers, amides, or vasodilators in the study patients. Although we did not have any, in the case of frank extravasation, the balloon tamponade would be used and the patient is transferred to the nearest hospital for further management.
DISCUSSION A major complication with AVF is the high frequency of primary failure; ultrasound evaluation
Annals of Vascular Surgery
successfully identifies all the lesions that have contributed to AVF structure and prevented its proper maturation. It is possible to find stenosis at the anastomosis site and venous stenosis in the body of the AVF, or its venous outflow tract. However, a wide spectrum of lesions can be seen, and in many instances, multiple lesions coexist in the same AVF. However, there may be difficulty in clearly evaluating the juxta-anastomotic lesion with a retrograde puncture and fistulogram. When various lesions may be identified including at the anastomosis, proximal, and distal arteries, a second access site may be necessary to treat the lesions. The TRA approach is advantageous in circumstances where a dialysis access has evidence of a juxtaanastomotic stenosis, multiple proximal venous outflow stenosis, or lesions in the inflow part of the AVF.11 In a traditional access for fistulogram, an additional angiography may be required to visualize the anastomosis and the arterial limb, which can add more time and more contrast use. If the lesion happened to be in the central venous system, it could be difficult or impossible to access as the ultrasound cannot precisely identify these lesions. On the other hand, the utilization of duplex guidance eliminates the need and risks of contrast use especially in patients undergoing dialysis, which decreases the chance of worsening renal function or the incidence of contrast allergy. Many of our patients had multiple lesions with various locations that required treatment. These lesions were assumed acquired stenoses that need balloon sizes ranging 3e12 mm with balloon length ranging 20e60 mm according to the location of the lesion. We preferentially chose the balloon angioplasty over the open surgical option as percutaneous transluminal angioplasty (PTA) does not exclude a later surgical correction of the AVF, the similar assisted patency suggests performing a PTA first. The use of the radial artery as an access site for the fistuloplasties gives the ability to reach and treat these lesions easily and effectively.12,13 However, the TRA is an alternative for select patients with a patent radial artery who have multiple lesions along the conduit of AVF. By using basic tools readily available in the endovascular suite, duplex scaneguided ballooning and angioplasty of the arterial and venous part of AVF can both be performed through 1 access sheath. Accessing the radial artery allows for a more direct route to the lesion versus the traditional venous puncture that may require crossing difficult angles and kinks to reach all lesions. The TRA is effective
Volume 60, October 2019
in visualizing and treating both arterial and venous limbs via 1 access. A limitation to the TRA is the inability to accommodate large sheath sizes, although all interventions in this series were performed through a small sheath. Potential disadvantages are related to radial artery complications, such as spasm, occlusion, and hand ischemia and limitations in using larger sheaths and balloons in patients with small radial arteries. One should say that the venous access has advantages as it could accommodate larger sheaths with an easier puncture as they can be easily identified. This could be done through the antegrade approach for more accessibility to treat various lesions. On the other hand, the TRA has the advantage of accessing more complicated lesion locations in both directions of the AVF. One of the main limitations of this study is that of being a retrospective review of prospectively collected data, nonrandomized patients from a single institution. We also did not compare our TRA patients with patients undergoing intervention with access other than the radial artery. In addition, this study looked at only early technical results and access site complications. The date since the fistula was formed to the time of the procedure was not included in this study, which warrants a further analysis. Future studies would be needed to evaluate the efficacy, maturation, and flow data for TRA with a comparison to transvenous access. We believe that the TRA is an effective alternative that offers unique advantages in certain clinical scenarios of dysfunctional dialysis access, including patients with evidence of a juxta-anastomotic stenosis, multiple proximal venous outflow stenosis, or lesions in the arterial system.
Early results of duplex-guided transradial artery fistuloplasties
181
REFERENCES 1. National Kidney Foundation. NKF-K/DOQI clinical practice guidelines for vascular access: update 2006. Am J Kidney Dis 2006;48:S176e276. 2. Allon M. Current management of vascular access. Clin J Am Soc Nephrol 2007;2:786e800. 3. Dixon BS. Why don’t fistulas mature? Kidney Int 2006; 70:1413e22. update 2006. Am J Kidney Dis. 2006; 48: S176eS276. 4. Roy-Chaudhury P, Arend L, Zhang J, et al. Neointimal hyperplasia in early arteriovenous fistula failure. Am J Kidney Dis 2007;50:782e90. 5. Miller GA, Goel N, Khariton A, et al. Aggressive approach to salvage non-maturing arteriovenous fistulae: a retrospective study with follow-up. J Vasc Access 2009;10:183e91. 6. Gallagher JJ, Boniscavage P, Ascher E, et al. Clinical experience with office-based duplex-guided balloon-assisted maturation of arteriovenous fistulas for hemodialysis. Ann Vasc Surg 2012;26:982e4. 7. DerDerian T, Hingorani A, Boniviscage P, et al. Acute complications after balloon-assisted maturation. Ann Vasc Surg 2014;28:1275e9. 8. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16:3e7. 9. Caputo RP, Tremmel JA, Rao S, et al. Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI. Catheter Cardiovasc Interv 2011;78:823e39. 10. Hildick-Smith D. Use of the Allen’s test and Transradial catheterization. J Am Coll Cardiol Volume 2006;48. https://doi. org/10.1016/j.jacc.2006.06.022. 11. Le L, Brooks A, Donovan M, et al. Transradial approach for percutaneous intervention of malfunctioning arteriovenous accesses. J Vasc Surg 2015;61:747e53. 12. Napoli M1, Prudenzano R, Russo F, et al. Juxta-anastomotic stenosis of native arteriovenous fistulas: surgical treatment versus percutaneous transluminal angioplasty. J Vasc Access 2010;11:346e51. 13. McCutcheon B, Weatherford D, Maxwell G, et al. A preliminary investigation of balloon angioplasty versus surgical treatment of thrombosed dialysis access grafts. Am Surg 2003;69:663e7. discussion 668.
Background: Although arteriovenous fistulae (AVFs) are the preferred mode of hemodialysis access because of their high patency rates, they are associated with an appreciable rate of nonmaturation. Balloon-assisted maturation (BAM) has been described to treat this issue. BAM is defined as repeated sequential graduated dilatation of the outflow vein. This study aims to evaluate the short-term complications of using the radial artery as an access for BAM procedures and fisutloplasties. Transradial access was used preferentially with multiple lesions in the AVF that were difficult to access with a single venous puncture. Methods: Data were collected over 3 years on 44 office-based duplex-guided transradial access BAM procedures in 27 patients of whom 19 were men. BAM with ultrasound guidance was performed in 324 cases using a venous puncture during this period. The indication for the procedures was a failure of AVF maturation, and 5 cases were with short segment thrombectomy. All procedures were performed with local anesthesia only. Access site puncture, vessel cannulation, wire placement, and balloon advancement and insufflation were duplex-guided. The radial artery was punctured with ultrasound guidance and a 4e5 French low-profile sheath was placed. After crossing the lesion(s), 5,000 units of heparin was given. The radial artery was used as the access vessel for all procedures except one, in which the brachial artery was used in addition. Vascular injuries were classified based on the postprocedural duplex assessment. All patients had follow-up duplex scans within a week. Results: The average age was 79 years (±14 SD, range 39e99 years). The types of AVF were 35 radio-cephalic, 1 radio-basilic, 2 brachio-brachial, 2 brachio-cephalic, and 4 brachio-basilic. The number of sites of lesions was 17 on the venous outflow, 7 perianastomotic, and 6 in the radial artery. In the remaining 14 failing AVFs, we were not able to identify any lesion. The balloon size ranged from 3e6 mm (28 patients) and 7e12 mm (16 patients). The most common injury was outflow vein wall injury (25), the formation of wall hematoma of the outflow vein (11), localized extravasation or rupture at the balloon site (4), spasm of the AVF (3), the formation of a puncture-site hematoma (2), and intimal flap (3). Extravasation was controlled with duplexguided compression. There were no radial artery thromboses, and all the AVFs were patent on completion duplex and follow-up duplex. Conclusions: These data suggest that the radial artery could be used as a safe access route for BAM procedures with relatively low rates of complication. This approach can be considered as an adjunct in the armamentarium for angioplasty of AVF.
Conflict of interest: None.
INTRODUCTION
Total Vascular CareÒ, Brooklyn, NY. Ò
Correspondence to: Ahmad Alsheekh, MD, Total Vascular Care , 960 50th Street Brooklyn, NY 11221; E-mail: ahmadalshike@ hotmail.com Ann Vasc Surg 2019; 60: 178–181 https://doi.org/10.1016/j.avsg.2019.02.036 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: November 26, 2018; manuscript accepted: February 3, 2019; published online: 7 May 2019
178
Maintaining adequate patent dialysis access remains an established goal in the care of patients with end-stage renal failure on hemodialysis. The native arteriovenous fistula (AVF) is recommended as the best vascular access for hemodialysis by the National Kidney Foundation Kidney
Volume 60, October 2019
Dialysis Outcomes Quality Initiative clinical practice guideline.1 Compared with prosthetic arteriovenous grafts and tunneled catheters, AVFs are the preferred mode of dialysis vascular access because of low long-term rates of infection and stenosis.2 Despite the many advantages of the native AVF, dysfunctional dialysis access is a common cause of morbidity and hospitalization. A number of studies have documented major problems with AVF maturation (failure to increase flow and diameter adequately to support dialysis) as a result of a conduit stenosis, and this lesion can occur at various locations of the access circuit.3,4 Previously, the vascular technology applied to manage dysfunctional native AVF consisted of angioplasty treatment of focal venous stenosis. Advances in balloon catheter technology, along with a comprehensive approach to address all of the arterial and venous pathologies, have been shown to promote fistula maturation and prompt lesions management. The culmination of many authors’ studies has made possible the understanding of fistula maturation we have today. More recently, physicians have championed a more aggressive approach to AVF maturation failure in which repeated long-segment angioplasty procedures are used to sequentially dilate up stenosis to improve fistula flow, which will allow the vein to dilate and grow over time to achieve clinical usefulness. Moreover, the angioplasties have been performed in an office-based setting with duplex guidance, which was found to be safe and feasible and avert nephrotoxic contrast and radiation with a low rate of complications.5e7 The transradial access (TRA) is increasingly being used for percutaneous coronary intervention since its first report in 1989.8 The TRA has proven to shorten recovery and time to ambulation, with higher patient preference and comparable success rates to femoral artery access; a low complication rate has also been noted. Although TRA is currently regarded as one of the default sites of access for cardiac catheterization procedures, we have used TRA preferentially in AVF with multiple lesions that were difficult to access with a single venous puncture.9 This study aims to evaluate the short-term results of using the radial artery as an access for fistuloplasties that were performed in an office-based setting with the ultrasound guidance. There was no need for the use of contrast materials, sedation, channel blockers, amides, or vasodilators.
Early results of duplex-guided transradial artery fistuloplasties
179
MATERIALS AND METHODS Data were collected over 3 years. Fistuloplasty was performed in 324 cases with ultrasound guidance using a venous puncture during this period. We performed 44 office-based duplex-guided TRA fistuloplasties in 27 patients. The indication for the procedures was the failure of AVF maturation, with 5 cases out of them having additional shortsegment thrombectomy. Physical examination and duplex scans were performed before the procedure. All procedures were performed with local anesthesia only. A radial artery that is less than 2 mm in diameter or having a circumferential severe calcification would not be utilized as an access site. We believe that the presences of an abnormal arch would not prevent using a suitable radial artery as an access site for the procedure. There is no evidence that a normal Allen’s test is required for the safe undertaking of a transradial procedure.10 Access site puncture, vessel cannulation, wire placement, and balloon advancement and insufflation were duplex-guided. The radial artery was punctured with ultrasound guidance and a 4e5 French lowprofile sheath was placed. No bare balloons were deployed in this study. After crossing the lesion(s), 5,000 units of heparin was given. The radial artery was used as the access vessel for all procedures except one, in which the brachial artery was used in addition. In cases where vascular injuries were classified based on the postprocedural duplex assessment. Accessing the radial artery for the procedure was performed distal to the anastomosis as a short segment was enough for the access. Compression of the radial artery was performed at the end of the procedure with ultrasound guidance until no local bleeding or oozing was noted. There was no routine recommendation of antiplatelet or anticoagulant therapy after completion of the procedure, and the patients were advised to continue their home medications as usual. All patients had follow-up duplex scans within a week. The protocol for the collection and interpretation of data conformed to the principles set by the Declaration of Helsinki. Institutional Review Board of Total Vascular Care IncorporatedÒ (registered with the U.S. Office for Human Research Protections) approval was obtained and consent was waived as the data are blinded and retrospective. After collecting the data, all patients’ identifiers were removed.
RESULTS The average age was 79 years (±14 SD, range 39e99 years). The types of AVF were 35
180 Alsheekh et al.
radio-cephalic, 1 radio-basilic, 2 brachio-brachial, 2 brachio-cephalic, and 4 brachio-basilic. The sites of lesions were 17 on the venous outflow, 7 perianastomotic, and 6 in the radial artery. In the remaining 14 failing AVFs, we were not able to identify any lesion. Although we were not able to identify any lesion in the remaining 14 failing AVFs, balloon angioplasty was performed to help accelerate the maturation of the fistulae (balloon-assisted maturation). Most AVFs were distal radio-cephalic. The balloon size ranged from 3e6 mm (28 patients) and 7e12 mm (16 patients) with 0.018 wires. The one 12-mm balloon was used in the patient with the additional brachial artery puncture. All remaining procedures were done using balloons up to 10 mm only. The balloons were inflated under ultrasound guidance for duration just enough to efface the lesion. At the end of the procedure, an ultrasound was performed to check for lesion recoil. The most common injury was outflow vein wall injury (25), the formation of wall hematoma of the outflow vein (11), localized extravasation or rupture at the balloon site (4), spasm of the AVF (3), the formation of a puncture-site hematoma(2), and intimal flap (3). Extravasation was controlled with duplex-guided compression. All the complications related to the procedure were transient, self-limiting, and tended to resolve on its own as most of them were localized and minimal. A prior study showed the low incidence of local complications after the procedure with further interventions needed.7 Actually, the exploitation of ultrasound made these complications easier to identify, which would be very hard to detect on fluoroscopy. There was no radial artery thrombosis, and all the AVFs were patent on completion duplex ultrasound and 1-week follow-up duplex ultrasound. There was no development of pseudoaneurysms in our patients during the study period. No stenoses were found at 1-week follow-up duplex scans. We did not use any type of sedation, and all the patients received local anesthesia only. No contrast material or X-rays were used, and the whole procedure was under ultrasound guidance. We did not use calcium channel blockers, amides, or vasodilators in the study patients. Although we did not have any, in the case of frank extravasation, the balloon tamponade would be used and the patient is transferred to the nearest hospital for further management.
DISCUSSION A major complication with AVF is the high frequency of primary failure; ultrasound evaluation
Annals of Vascular Surgery
successfully identifies all the lesions that have contributed to AVF structure and prevented its proper maturation. It is possible to find stenosis at the anastomosis site and venous stenosis in the body of the AVF, or its venous outflow tract. However, a wide spectrum of lesions can be seen, and in many instances, multiple lesions coexist in the same AVF. However, there may be difficulty in clearly evaluating the juxta-anastomotic lesion with a retrograde puncture and fistulogram. When various lesions may be identified including at the anastomosis, proximal, and distal arteries, a second access site may be necessary to treat the lesions. The TRA approach is advantageous in circumstances where a dialysis access has evidence of a juxtaanastomotic stenosis, multiple proximal venous outflow stenosis, or lesions in the inflow part of the AVF.11 In a traditional access for fistulogram, an additional angiography may be required to visualize the anastomosis and the arterial limb, which can add more time and more contrast use. If the lesion happened to be in the central venous system, it could be difficult or impossible to access as the ultrasound cannot precisely identify these lesions. On the other hand, the utilization of duplex guidance eliminates the need and risks of contrast use especially in patients undergoing dialysis, which decreases the chance of worsening renal function or the incidence of contrast allergy. Many of our patients had multiple lesions with various locations that required treatment. These lesions were assumed acquired stenoses that need balloon sizes ranging 3e12 mm with balloon length ranging 20e60 mm according to the location of the lesion. We preferentially chose the balloon angioplasty over the open surgical option as percutaneous transluminal angioplasty (PTA) does not exclude a later surgical correction of the AVF, the similar assisted patency suggests performing a PTA first. The use of the radial artery as an access site for the fistuloplasties gives the ability to reach and treat these lesions easily and effectively.12,13 However, the TRA is an alternative for select patients with a patent radial artery who have multiple lesions along the conduit of AVF. By using basic tools readily available in the endovascular suite, duplex scaneguided ballooning and angioplasty of the arterial and venous part of AVF can both be performed through 1 access sheath. Accessing the radial artery allows for a more direct route to the lesion versus the traditional venous puncture that may require crossing difficult angles and kinks to reach all lesions. The TRA is effective
Volume 60, October 2019
in visualizing and treating both arterial and venous limbs via 1 access. A limitation to the TRA is the inability to accommodate large sheath sizes, although all interventions in this series were performed through a small sheath. Potential disadvantages are related to radial artery complications, such as spasm, occlusion, and hand ischemia and limitations in using larger sheaths and balloons in patients with small radial arteries. One should say that the venous access has advantages as it could accommodate larger sheaths with an easier puncture as they can be easily identified. This could be done through the antegrade approach for more accessibility to treat various lesions. On the other hand, the TRA has the advantage of accessing more complicated lesion locations in both directions of the AVF. One of the main limitations of this study is that of being a retrospective review of prospectively collected data, nonrandomized patients from a single institution. We also did not compare our TRA patients with patients undergoing intervention with access other than the radial artery. In addition, this study looked at only early technical results and access site complications. The date since the fistula was formed to the time of the procedure was not included in this study, which warrants a further analysis. Future studies would be needed to evaluate the efficacy, maturation, and flow data for TRA with a comparison to transvenous access. We believe that the TRA is an effective alternative that offers unique advantages in certain clinical scenarios of dysfunctional dialysis access, including patients with evidence of a juxta-anastomotic stenosis, multiple proximal venous outflow stenosis, or lesions in the arterial system.
Early results of duplex-guided transradial artery fistuloplasties
181
REFERENCES 1. National Kidney Foundation. NKF-K/DOQI clinical practice guidelines for vascular access: update 2006. Am J Kidney Dis 2006;48:S176e276. 2. Allon M. Current management of vascular access. Clin J Am Soc Nephrol 2007;2:786e800. 3. Dixon BS. Why don’t fistulas mature? Kidney Int 2006; 70:1413e22. update 2006. Am J Kidney Dis. 2006; 48: S176eS276. 4. Roy-Chaudhury P, Arend L, Zhang J, et al. Neointimal hyperplasia in early arteriovenous fistula failure. Am J Kidney Dis 2007;50:782e90. 5. Miller GA, Goel N, Khariton A, et al. Aggressive approach to salvage non-maturing arteriovenous fistulae: a retrospective study with follow-up. J Vasc Access 2009;10:183e91. 6. Gallagher JJ, Boniscavage P, Ascher E, et al. Clinical experience with office-based duplex-guided balloon-assisted maturation of arteriovenous fistulas for hemodialysis. Ann Vasc Surg 2012;26:982e4. 7. DerDerian T, Hingorani A, Boniviscage P, et al. Acute complications after balloon-assisted maturation. Ann Vasc Surg 2014;28:1275e9. 8. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16:3e7. 9. Caputo RP, Tremmel JA, Rao S, et al. Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI. Catheter Cardiovasc Interv 2011;78:823e39. 10. Hildick-Smith D. Use of the Allen’s test and Transradial catheterization. J Am Coll Cardiol Volume 2006;48. https://doi. org/10.1016/j.jacc.2006.06.022. 11. Le L, Brooks A, Donovan M, et al. Transradial approach for percutaneous intervention of malfunctioning arteriovenous accesses. J Vasc Surg 2015;61:747e53. 12. Napoli M1, Prudenzano R, Russo F, et al. Juxta-anastomotic stenosis of native arteriovenous fistulas: surgical treatment versus percutaneous transluminal angioplasty. J Vasc Access 2010;11:346e51. 13. McCutcheon B, Weatherford D, Maxwell G, et al. A preliminary investigation of balloon angioplasty versus surgical treatment of thrombosed dialysis access grafts. Am Surg 2003;69:663e7. discussion 668.