Vascular Access

Arterial Stenoses in Patients with Arteriovenous Dialysis Access

A l e x a n d e r S Ye v z l i n , M D 1 a n d A r i f A s i f, M D 2
1. Assistant Professor of Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health; 2. Professor of Medicine, Department of Internal Medicine, University of Miami Miller School of Medicine

Abstract
Interventional nephrologists have traditionally focused their efforts on the venous side of the access circuit. Several recent studies have evaluated the presence of stenoses within the arteries of the arm bearing a vascular access. The biology, techniques, and outcomes differ greatly between those of arterial and venous disease of the hemodialysis access circuit. This article serves to highlight recent contributions to the practice of arterial intervention for hemodialysis access. The epidemiology, limitations of traditional angiography, medical management, and advanced arterial techniques are discussed.

Keywords
Arteriovenous fistula, vascular access, artery
Disclosure: The authors have no conflicts of interest to declare. Received: October 8, 2009 Accepted: November 27, 2009 Correspondence: Alexander S Yevzlin, MD, 9209 Bear Claw Way, Madison, WI 53717. E: asy@medicine.wisc.edu

Neointimal hyperplasia of the venous system leading to stenosis and access dysfunction has been a major problem in hemodialysis patients with arteriovenous access. 13 Interventional nephrologists have historically focused their efforts on the venous side of the access circuit.38 Stenotic lesions can occur anywhere within this system and, when present, can limit access function and hemodialysis delivery. Several recent studies have evaluated the presence of stenoses within the arteries of the arm bearing a vascular access.914 Collectively, these studies have highlighted the impact of arterial stenosis on vascular access outcomes. The biology, techniques, and medical treatment differ greatly between those of arterial and venous disease of the hemodialysis access circuit. This article therefore endeavors to highlight recent contributions to the practice of arterial intervention for hemodialysis access.

arteriovenous grafts and arteriovenous fistulas undergoing either percutaneous balloon angioplasty or thrombectomy procedures utilizing standardized definitions for stenosis.21 In this seminal study, patients were referred to interventional nephrology for either percutaneous balloon angioplasty or thrombectomy procedures. Angiography to evaluate access inflow was performed in all cases. This was accomplished by retrograde occlusive angiography (ROA) or direct diagnostic catheter insertion across the arterial anastomosis, or both. Inflow stenosis was defined as: stenosis within the arterial system, arterygraft anastomosis (in arteriovenous grafts); arteryvein anastomosis (in arteriovenous fistulas); and juxta-anastomotic region if there was a >50% reduction in luminal diameter judged by comparison with either the adjacent vessel or graft. Two hundred and twenty-three consecutive procedures were performed in 158 patients. Inflow stenosis occurred in 29% of the arteriovenous graft cases. All had a co-existing stenosis on the venous side. In fistula cases, 40% had inflow stenosis. Of these, 54% had a co-existing lesion on the venous side. Overall, inflow stenosis occurred in 77 of 223 procedures (35%), suggesting the importance of arterial evaluation in all cases of access dysfunction.21 Outcomes of arterial intervention have generally been very good. A large series was reported in which the primary success rate approached 100% in patients with stenotic lesions of the subclavian artery.22 Earlier small studies had reported similarly excellent short- and long-term

Epidemiology of Arterial Intervention in Hemodialysis Access

Stenosis on the arterial side of the access circuit has traditionally been regarded as an infrequent phenomenon, with reports of occurrence in 04% of hemodialysis patients.1519 Recent data have suggested a significantly higher incidence of inflow stenosis (1442%) in this patient population.9,20 The studies evaluating the incidence of inflow stenosis have, however, suffered from limitations such as retrospective study design and small sample size. A recent multicenter study was undertaken to prospectively examine the incidence of inflow stenosis separately in patients with

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Arterial Stenoses in Patients with Arteriovenous Dialysis Access

patency rates.23 Complete occlusions have a lower likelihood of successful revascularization than do stenotic lesions (see Figure 1). Amor et al. described a patency rate of 53% for stenting of total occlusions.22 Long-term results may also differ with the severity of the steal physiology caused by the culprit lesion. A recent study of 42 patients concluded that the presence of a complete steal syndrome may portend a higher risk of symptomatic subclavian restenosis over five years compared with those with lesser degrees of steal.24

Figure 1: Complete Occlusion of Left Subclavian Vein in a Hemodialysis Patient

Limitations of Traditional Techniques

Imaging of the inflow segment has traditionally been performed by interventional nephrologists via ROA. ROA is a technique by which contrast is injected into an arteriovenous access and made to flow retrograde due to the application of occlusive pressure on the outflow tract by the operator. Salman et al. recently highlighted a potential limitation of the ROA technique.25 The authors presented six cases of fistulae that suffered vascular rupture during ROA. In three cases, vascular damage occurred prior to the application of angioplasty. The remaining cases suffered perforation after angioplasty. Another recent case also emphasized a potential limitation of the retrograde arteriogram as the definitive study to assess arterial disease.26 ROA was initially performed in a patient whose antecedent physical exam findings made the diagnosis of an arterial inflow stenosis very likely. The ROA revealed no inflow lesion, but given the high pre-test probability of an inflow lesion, a wire and catheter were advanced into the arterial system to perform a direct arteriogram. The operators discovered the presence of several peri-anastomotic lesions that did not appear on the initial ROA (see Figure 2). The authors concluded that by relying solely on ROA, interventional nephrologists may be failing to detect a subset of hemodynamically significant inflow lesions. Thus, if the operator has a high suspicion of an inflow lesion, one can argue that a catheter should be manipulated retrograde into the feeding artery and a direct angiogram should be performed.

Figure 2: Diagram of Inflammatory Cascade After Acute Kidney Injury/Chronic Kidney Disease A B

A: Retrograde occlusive arteriogram revealing no inflow lesion; B: Direct arteriogram revealing inflow lesion in the same patient as shown in A.

Medical Management of Arterial Intervention

The ideal medical treatment of arterial disease in the hemodialysis population is yet to be rigorously defined. Nevertheless, patients typically receive 325mg of aspirin and 300mg of clopidogrel prior to intervention. A bolus of intravenous unfractionated heparin (UFH) at 70100U/kg is typically administered at the time of intervention to obtain an activated clotting time of 200300 seconds. All patients who receive an arterial stent should be treated for an extended period of time with the dual antiplatelet regimen consisting of lifelong daily aspirin 81325mg and daily clopidogrel 75mg for three to six months.27 pressures are typically required to achieve adequate radiographic results,29 balloon inflation to greater than 10 atmospheres is neither required nor recommended. If the balloon expands as predicted and postexpansion angiography demonstrates reasonable patency of the target lesion, an appropriately sized stent can be deployed. A residual stenosis may occur despite maximal inflation of the balloon-expandable stent. In cases of uncertain hemodynamic effect, a post-stent deployment gradient will be measured if adequate stent expansion is in question. If the gradient is significantly reduced (>50%), the residual stenosis is often treated with post-stent balloon dilation. Alternatively, a suboptimal angiographic result may be preferable to repeated post-stent deployment balloon dilatations, as the latter approach may increase the risk of complications. The restenosis rate for stents placed in previously stenotic lesions is generally low (311% at 1760 months) if angiographic and hemodynamic success is confirmed.23,26 Major complications resulting from this technique are uncommon, but could include death, stroke, transient ischemic attacks, and stent thrombosis. The seminal paper on subclavian intervention, as a

Advanced Techniques
Percutaneous intervention can be performed over 0.014-, 0.018-, or 0.035-inch wires. An 0.035-inch wire to assist advancement of the guide sheath into the general area of the target artery, followed by exchange to an 0.014-inch wire system, is generally accepted. Balloon angioplasty with an undersized balloon followed by placement of a balloonexpandable stent is the standard methodology for arterial intervention.23,28 Pre-dilatation balloons can be inflated to a nominal pressure in the area of stenosis or occlusion. Unlike the venous system, where ultra-high

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Vascular Access
representative of all arterial intervention in hemodialysis access patients, reported a 0% event rate for any of these potential complications.23 The patients in the aforementioned study, however, were not on hemodialysis, which is known to promote a proinflammatory milieu that has been associated with aggressive vascular disease. Minor complications are also rare (up to 5%) and include access-site hematoma or pseudoaneurysm, peripheral emboli and stent embolization. 23,26 Very little is known about the impact on the hemodialysis (HD) access of arterial intervention on the ipsilateral side. This represents an important avenue of future research. Hemostasis after percutaneous intervention can be achieved using manual pressure or an approved vascular closure device. If the manual approach is used, the sheath is left in place until theactivated clotting time is <170 seconds. After the sheath is removed, manual pressure is held for 15 minutes. If bleeding continues a FemoStop HD femoral compression system can be employed. Typically, the authors use an appropriately sized Angioseal or Perclose device in the laboratory followed by two hours of bed rest if the groin anatomy is amenable (i.e. no evidence of ipsilateral peripheral vascular disease and sheath placement in the common femoral artery above its bifurcation). If the radial artery is chosen for initial cannulation, closure can be achieved with the digital pressure described above or with a TR Band, a radial pressure device that allows gradual reduction of pressure with syringe suction of air out of the occlusive balloon over the span of 60 minutes to achieve hemostasis.

Conclusion and Future Directions

The role of interventional nephrology in the care of chronic kidney disease and hemodialysis patients is expanding.30 Arterial intervention per se is coming into the scope of routine interventional nephrology practice. To facilitate this development, formal educational programs in advanced techniques may need to be implemented in both private and academic training programs. n

Alexander S Yevzlin, MD, is Director of Interventional Nephrology and an Assistant Professor of Medicine at the University of Wisconsin School of Medicine and Public Health. He also is a council member of the American Society of Diagnostic and Interventional Nephrology (ASDIN) and Associate Editor of the the ASDIN section of Seminars in Dialysis. He has published and presented more than 100 articles, abstracts and invited lectures. Dr Yevzlins main focus is advanced techniques for and epidemiology of vascular access for hemodialysis. Arif Asif, MD, is Director of Interventional Nephrology and a Professor of Medicine at the University of Miami Miller School of Medicine. He is also President of the American Society of Diagnostic and Interventional Nephrology (ASDIN). Dr Asif has published more than 80 articles in peer-reviewed journals and written several book chapters. His main focus is vascular access for hemodialysis.

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