Percutaneous intervention in axillary loop-configured arteriovenous grafts for chronic hemodialysis patients

Abstract

Objective: The purpose of this study was to evaluate the fistulographic features of malfunctioning axillary loop-configured arteriovenous grafts and the efficacy of percutaneous interventions in failed axillary loop-configured arteriovenous grafts.

Materials and methods: Ten patients with axillary loop-configured arteriovenous grafts were referred for evaluation of graft patency or upper arm swelling. Fistulography and percutaneous intervention, including thrombolysis, percutaneous transluminal angioplasty and stent placement, were performed. Statistical analysis of the procedure success rate and the primary and secondary patency rates was done.

Results: Four patients had graft related and subclavian venous stenosis, two patients had graft related stenosis and another four patients had subclavian venous stenosis only. Sixteen sessions of interventional procedures were performed in eight patients (average: 2 sessions / patient) until the end of follow-up. An interventional procedure was not done in two patients with central venous stenosis. The overall procedure success rate was 69% (11 of 16 sessions). The post-intervention primary and secondary patency rates were 50% and 63% at three months, 38% and 63% at six months and 25% and 63% at one year, respectively.

Conclusion: Dysfunctional axillary loop-configured arteriovenous grafts almost always had subclavian venous and graft-related stenosis. Interventional treatments are helpful to overcome this and these treatments are expected to play a major role in restoring and maintaining the axillary loop-configured arteriovenous loop grafts.

Keywords: Dialysis; interventional procedure Veins; shunt Graft; transluminal angioplasty.

Fig. 1

43-year-old female patient (case no. 1) was referred for evaluation of graft patency due to clot aspiration. Initial fistulogram showed stenosis at arterial and venous anastomoses (A). Percutaneous transluminal angioplasty was performed with 7 mm × 4 cm sized balloon catheter (B, C). Final fistulogram showed improvement of stenoses and no flow disturbance (D). Hemodialysis has been performed with this axillary to axillary autogenous arteriovenous fistula graft for 262 days after percutaneous intervention.

Fig. 2

54-year-old female patient (case no. 10) was referred for evaluation of upper arm swelling. Venography and fistulography showed stenosis in subclavian vein with multiple collateral veins and normal fistulogram (A). After conventional balloon angioplasty, waist of stenosis did not disappear. We used 8 mm × 2 cm sized cutting balloon (B) and we performed repeated percutaneous transluminal angioplasty with 14 mm × 4 cm balloon catheter. Waist then disappeared (C). Immediate elastic recoil was found on post-procedural venography (D). Three days after percutaneous transluminal angioplasty, 14 mm by 6 cm sized Hercules stent was placed (E), and venogram showed no flow disturbance in arteriovenous graft and subclavian vein.

Fig. 3

67-year-old female patient (case no. 6) visited our interventional radiology practice for evaluation of graft dysfunction. Initial fistulogram showed thrombus in graft, and 'lyse and wait' technique was performed. Residual thrombus and stenosis at venous arm of graft were noted on repeated fistulogram (A). Aspiration thrombectomy and percutaneous transluminal angioplasty were done, but elastic recoil occurred (B). On next day, thrombosis relapsed (C) and 6 mm by 4 cm Zilver stent was placed in stenotic venous arm after removal of thrombus (D). Eleven days after stent placement, repeated thrombosis was noted on fistulogram, and graft was bent at distal end of stent (E). Additional 8 mm by 4 cm Zilver stent was placed distally (F). After 21 days, patient was referred for graft dysfunction. Fistulogram with position change (G, H) showed kinking of venous anastomosis of graft in standing position. Graft moved downward in standing position, and proximal end of stent folded graft up (arrow). Patient refused additional interventions and tunneled hemodialysis catheter was placed through right internal jugular vein.

Fig. 4

Post-intervention cumulative primary and secondary patency rates.