J Vasc Access 2014 ; 15 ( 2): 76-82 Review

DOI: 10.5301/jva.5000194

Stenosis complicating vascular access for hemodialysis:

indications for treatment

Nicola Pirozzi1, José Garcia-Medina2, Mélanie Hanoy3

Department of Clinical and Molecular Medicine, Sapienza University of Rome, Nephrology Unit, Sant’Andrea
1

Hospital, Rome - Italy

Vascular and Interventional Radiology Department, Reina Sophia Hospital, Murcia - Spain
2

Nephrology Department, Rouen University Hospital, Rouen - France

3

ABSTRACT
The aim of the multidisciplinary team committed to the care of vascular access (VA) for hemodialysis is to prolong as much
as possible the functional patency of the access. Stenosis is definitely the most frequent complication of arteriovenous VA.
Whereas the best surveillance strategy is still a matter of debate, some evidence is now available about treatment indication
and options. The available body of evidence on the best strategy facing this complication of VA is reviewed.

Key words: Hemodialysis, Percutaneous transluminal angioplasty, Stenosis, Treatment, Vascular access

Accepted: September 6, 2013

INTRODUCTION interventional radiologist: [JGM]; and nephrologist:

Vascular access (VA) for hemodialysis (HD) is the
mainstay of adequate dialysis delivery (1, 2). Its complica-
tions account for significant morbidity and mortality (3, 4),
along with increased financial costs (5) in end-stage renal
disease (ESRD) patients.
The aim of the multidisciplinary team committed to
the care of the VA is to prolong as much as possible the
functional patency of the angioaccess (6, 7). To this purpose
the crucial point is the timely recognition of complications
menacing patency of the access and their treatment, but to
date the ideal tool has yet to be found (8, 9).
Stenosis is definitely the most frequent complication
of arteriovenous (AV) VA (both AV fistula and AV graft)
(10). The associated clinical consequences depend on
its location along the VA (Fig. 1). Whereas the best sur-
veillance strategy is still a matter of debate (11), some
evidence is now available about treatment indication
and options.
It is now clear how indications for treatment differ sig-
nificantly, depending on the site of the stenosis and the
hemodynamics of the access conduit (7).
The available body of evidence on the best strategy
facing stenosis of VA for HD is reviewed; the authors’
opinion (interventional nephrologist/VA surgeon: [NP];
[MH]), has been added, when no definite evidence is
available.
INFLOW STENOSIS
The term refers to stenosis occurring in the arteri-
al limb from the origin of the subclavian artery to the
anastomotic and juxta-anastomotic region (12-14), due
to both atherosclerotic lesion and Monckeberg’s medial
calcification.
Arterial stenosis
The clinical picture is generally characterized by a
delayed maturation in both distal and proximal access
(13) (Tab. I).
It could be a rare cause of ischemia induced by VA
(hemodialysis access-induced distal ischemia, HAIDI)
(15, 16). The physical examination (17) reveals a low-
flow (“flat”) fistula. Problems in dialysis are difficult can-
nulation and low delivered dialysis dose (because of low
blood pump flow). At ultrasound examination, reduced
flow is found along with the typical ultrasound findings of
an arterial stenosis (18).

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Pirozzi et al

Fig. 1 - Clinical consequences of different site stenoses.

TABLE I - INFLOW STENOSIS: INDICATION AND THERAPEUTIC Fig. 2 - Inflow stenosis. A) Stenosis of radial artery (arrow) proximally to
OPTIONS the distal left radiocephalic anastomosis (transbrachial contrast injection).
B) Detail of radial artery angioplasty (4 mm x 40 mm, 15 atm) by retro-
grade access through the cephalic vein. C) Final angiogram.
Site of the Clinical Indications Treatment
stenotic picture for option
lesion treatment

Arterial - delayed - Early tre- PTA

Immature fistula
maturation atment failure
("flat fistula") - Ischemia The clinical picture is similar for distal and proxi-
- HAIDI treatment*†, mal AVF: pulsating anastomosis, low flow at ultrasound,
difficult cannulation and reduced dialysis dose (17); thera-
INFLOW Anastomotic - delayed - Early tre- PTA
STENOSIS and juxta- maturation atment failure
peutic options differ, depending on the site of the anasto-
or
anastomotic mosis.
vein - drop of - Restore Surgical
flow normal flow proximalization
- asympto- and dialysis of anastomosis Distal VA
matic dose

HAIDI = hemodialysis access-induced distal ischemia; PTA = percutaneous trans-

luminal angioplasty.
*Stenosis of proximal arteries (above humeral bifurcation).
†
Stenosis of ulnar artery (anastomosis on radial artery).
Treatment options
Percutaneous transluminal angioplasty (PTA) is the
best and easiest treatment (Fig. 2) (1). Even in small and
calcified distal artery at the forearm, excellent results
have been reported (19-21). Functional patency has
been achieved in a high percentage of cases, with 1 year
primary and secondary patency of 65%-83% and 86%-
96%, respectively.
Anastomotic and juxta-anastomotic vein stenosis
This is the most frequent lesion found in AV fistula
(13), caused by the dramatic increase of shear stress
along with surgical traumatism due to anastomosis cre-
ation (22, 23).
Both surgical proximalization of the anastomosis and
PTA are technically feasible. Several reports, however,
clearly indicate an increased number of endovascular
procedures needing to be repeated, to obtain similar
assisted 1 year patency compared to surgical treatment
[restenosis 0.168 vs 0.519/AVF-year for surgery vs PTA
(p=0.009)] (24, 25). Therefore, surgical proximalization
is the treatment of choice except when multiple stenoses
coexist, or whenever the length of the access is a con-
cern.
Proximal VA
There is no available evidence regarding this compli-
cation, probably because it is a rare clinical picture (26,
27). Anecdotically and in the opinion of experts (28),
PTA is the preferred treatment. Surgical proximalization
above the elbow would likely require extended vein dis-
section and transposition to brachial artery or the use
of a bypass graft. Unfortunately, a comparative study is
lacking.

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Indication for treatment of vascular access stenosis

Mature fistula TABLE II - 

MID-VEIN STENOSES: INDICATION AND THERAPEUTIC
OPTION
Distal and proximal
Site of the Clinical Indications Treatment
When anastomotic or juxta-anastomotic vein steno- stenotic lesion picture for treatment option
sis symptomatically affects a distal or proximal AVF by Between the - delayed - Early tre-
decreasing blood flow, indication for treatment is clear “arterial” and maturation atment failure PTA
and procedures and options are the same as indicated for “venous”
immature AVFs. needles
- prolonged - Restore (Surgical
On the other hand, a debate is going on as to whether bleeding time* normal flow bypass)
MID-VEIN
prophylactic treatment should be performed in asymptom- (+/- drop of
STENOSIS
atic case (normal blood flow, no complication during di- flow)
alysis) for both distal and proximal AVFs. Some studies (29) - aneurism - Prevent
seem to show a beneficial effect on access survival after degeneration* aneurism and
treatment, but in all cases the blood flow and its modifi- (+/- drop of skin necrosis
flow)
cation before and after treatment are the most important
parameter (30); indeed, final evidence is still lacking. PTA = percutaneous transluminal angioplasty.
In the authors’ opinion, provided that no low flow *“Arterial” needle.
(<500 mL/min) or significant drop (>20%) in two consecu-
tive assessments are recorded (31), no treatment should
be done. First, because in the absence of low flow, no bleeding after dialysis (37) and low dialysis dose (40).
risk of thrombosis exists, necessitating no correction (32). Blood flow measurement shows a low or decreased
Second, as treatment of the stenosis would lead to an in- flow (41).
crease in flow (33), high flow would likely be caused, with In such a situation thrombosis is the major risk and
the risk of heart failure (34) or HAIDI (35), especially in prompt stenosis resolution is mandatory.
proximal access. PTA is the widely preferred treatment (1, 2), even
if recurrence after treatment is high (38). To date, no
definitive indication for the best surveillance tool
MID-VEIN STENOSIS exists (11).

The clinical picture is similar in both distal and proxi-

mal AVF: pulsatile conduit from the anastomosis to the
stenosis, risk of aneurism degeneration (36), as well as
bleeding after dialysis and skin necrosis (37) (Tab. II). It
rarely affects AVF maturation, in mature VA both cannula-
tion and dialysis dose are usually not affected because the
stenosis generally falls between the arterial and venous
needles. Indications for treatment are low flow and hemo-
static complication (37), whereas coexistence of subclini-
cal/clinical HAIDI contraindicates it.
Treatment option includes surgery or PTA: some stud-
ies, evaluating the results of treatment of stenosis and
thrombosis, failed to demonstrate a better treatment option
(38, 39). Guidelines on VA do not indicate a preferred ap-
proach (1, 2). In the authors’ opinion, when available, PTA
should be preferred because of its mini-invasive approach
and better preservation of the VA length, along with future
options compared to surgery.
OUTFLOW STENOSIS
Graft-to-vein anastomotic stenosis
It is the most common complication of AV graft
(17). The clinical picture is characterized by prolonged
Cephalic arch – end of basilic vein transposition stenosis
The clinical picture is similar for both AVFs (Table III).
The conduit access is entirely pulsatile, prolonged bleed-
ing time is possible, along with accelerated aneurismal
degeneration (42). Indication for treatment depends on
access blood flow.
Low-normal flow
When outflow stenosis leads to low access flow, the
primary indication for treatment is to prevent thrombosis
(43). Moreover, by decreasing high intra-access pressure,
both aneurismal degeneration and skin necrosis risk are
reduced (37).
Treatment options include PTA (Fig. 3) and surgical
correction. As for mid-vein stenosis, even in the absence
of a demonstrated superiority, the former seems the better
choice, when locally available.
Conflicting results exist about the primary use of the
stent, which seems to prolong the primary patency after
treatment, but with a similar secondary patency com-
pared to isolated PTA, along with the risk of axillary vein
obstruction (44).

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Pirozzi et al

TABLE III - OUTFLOW STENOSIS: INDICATION AND THERAPEUTIC

OPTION

Site of the Clinical Indications Treatment

stenotic picture for treatment option
lesion

Graft-to-vein - low dialysis - restore blood

anastomosis dose flow
- prolonged - reduce PTA
bleeding time recirculation (surgical
- prevent skin bypass)
necrosis

Cephalic - low - restore blood - PTA

arch – end of dialysis dose flow (primary
basilica vein - prolonged - reduce stenting still
transposition bleeding time recirculation debated)
(surgical
- aneurismal - Prevent
bypass)
degeneration skin necrosis Fig. 3 - Outflow stenosis. A) Cephalic arch 90% stenosis (arrow), causing
- blood flow
elevated venous pressure during dialysis in a patient with a left brachial-
reduction if
cephalic fistula (blood flow 700 ml/min). B) Dilation with an 8 mm x 40
high-flow
mm high-pressure balloon catheter (30 atm). C) Final angiogram: absence
OUTFLOW AVFs
of residual stenosis (blood flow 1.200 mL/min).
STENOSIS
Central vein - Asym- - no treatment
stenosis ptomatic/ needed ble, depending on the balance between upper arm blood
(subclavian, paucisympto- flow and venous drainage capacity.
brachio- matic (mild
cephalic edema, chest
trunk, su- collateral “Asymptomatic”
perior vena vein)
cava) This is the picture of a documented central vein ste-
- painful Symptoms PTA
swelling of relief (surgical nosis on the same side of a VA, in the absence of major
the upper bypass) symptoms. The residual lumen and collateral veins devel-
arm oped are sufficient to ensure adequate upper arm venous
- skin
drainage. Collateral vein on the chest and a slight edema
ulceration
- intracranial of the hand and forearm could be evident.
hypertension Some evidences (50, 51) suggest that no intervention
should be performed in these cases. Indeed no clinical
AVF = arteriovenous fistula; PTA = percutaneous transluminal angio- beneficial effect would be obtained, whereas worsening
plasty. of the lesion may be induced. Renaud et al (51) recently
showed that just 40% of untreated patients, followed
Normal-high flow up for an asymptomatic/paucisymptomatic mean 80%
stenosis, became severely symptomatic at 4 years. They
When a high flow exists, treatment of the stenosis is even observed a better secondary overall access and
risky because of the potential of both heart failure (34) and central vein patency at 3 years in untreated asymp-
HAIDI (35) induction. Nevertheless, those accesses could tomatic patients compared to treated symptomatic
present serious hemostatic concern (37), which could be patients.
resolved just by treatment of the stenosis. A combined ap-
proach has recently been proposed, consisting of PTA as- Symptomatic
sociated with surgical reduction of blood flow (45).
When upper arm blood flow drainage becomes in-
sufficient, major symptoms may ensue. Painful swell-
Central vein stenosis ing of the whole upper arm, breast and head (52), skin
ulceration and intracranial hypertension (53) could be
Subclavian, brachiocephalic and superior vena cava present.
stenosis, mainly induced by central venous catheter or In such cases, relief from the debilitating symptoms is
pacemaker wire (46-49), can become symptomatic if an requested. Treatment options include angioaccess ligation
ipsilateral angioaccess is created. Two pictures are possi- or stenosis treatment by surgical or endovascular means.

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Indication for treatment of vascular access stenosis
Fig. 4 - Outflow stenosis. A) Right brachiocephalic vein occlusion (ar-
rows), causing painful arm swelling in a 65-year-old man on hemodialysis
with a brachial-cephalic fistula. B) Balloon dilatation by antegrade access
through the arteriovenous fistula (14 mm x 40 mm, 17 atm). C) Success-
ful percutaneous transluminal angioplasty resulted in immediate relief of
symptoms (note disappearance of collaterals).
Surgical procedures (54, 55) are not recommended as
the first choice, because of significant morbidity and mor-
tality (2).
Conversely, PTA is the treatment of choice (Fig. 4)
as it allows preservation of VA function along with
the resolution of symptomatic venous hypertension.
Unfortunately, high tendency to early restenosis leads to
an average 1 year primary patency of about 40%. It still
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Stenosis is the most frequent complication of VA, sig-
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Financial support: None.
Conflict of interest: None.
Address for correspondence:
Nicola Pirozzi
Department of Clinical and Molecular Medicine
Sapienza University of Rome, Nephrology Unit
Sant’Andrea Hospital
Via di Grottarossa 1035
Rome, Italy
nicola.pirozzi@uniroma1.it
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