The role of stents in hemodialysis vascular access

Abstract

Vascular access is the Achilles' heel of dialysis therapy among patient with end stage kidney disease. The development of neointimal hyperplasia and subsequent stenosis is common in vascular access and is associated with significant morbidity. Percutaneous transluminal angioplasty using balloon inflation was the standard therapy of these lesions. However, the balloon-based approaches were associated with poor vascular access patency rate necessitating new inventions. It is within this context that different types of stents were developed in order to improve the overall dialysis vascular access functionality. In this article, we review the available literature regarding the use of stents in treating dialysis vascular access stenotic lesions. Further, we review the major clinical trials of stent use in different anatomic locations and in different clinical scenarios.

Keywords: Stents; arteriovenous access; hemodialysis; hemodialysis Vascular access; vascular stenosis.

Figure 1.

Stent placement to control extravasation following angioplasty: (a) stenosis (arrow) involving the venous anastomosis of a brachial-brachial arteriovenous graft, (b) an extravasation (arrow) into the axilla immediately after angioplasty to 8 mm is noted, and (c) there is complete cessation of extravasation after the placement of a bare metal stent (arrow).

Figure 2.

Stent migration: (a) venous stenosis (arrow) at the innominate vein and superior vena cava junction resistant to balloon angioplasty so decision was made to deploy a stent at the site of stenosis and (b) during stent deployment, the stent migrated into the inferior vena cava (arrow).

Figure 3.

Stent fracture. A fractured stent in the outflow vein of a brachiocephalic arteriovenous fistula. The arrow points to the location of the fracture.

Figure 4.

Stent protrusion. Stent material (struts) was cut by the repetitive cannulation from hemodialysis needle. The injured struts may protrude through the skin, which will carry risks to the dialysis patient’s healthcare providers. The arrow points at the damaged stent struts.