Nephrol Dial Transplant (2001) 16: 2365-2371
© 2001 European Renal Association-European Dialysis and Transplant Association
Salvage of immature forearm fistulas for haemodialysis by interventional radiology
1 Department of Cardio-Vascular Radiology, Clinique St-Gatien, 2 Department of Surgery, Clinique de l'Archette, Olivet, 3 Department of Nephrology-Hemodialysis, Centre Hospitalier Universitaire, Tours cedex, 4 Department of Hemodialysis, Clinique St-Côme, Blois, 5 Hemodialysis Center, Châteauroux, 6 Department of Nephrology-Hemodialysis, Hôpital de La Source, Orléans and 7 Department of Hemodialysis, Clinique de l'Archette, Olivet, France
Background. The goal of this article is to assess the value of endovascular techniques for the salvage of fistulas that fail to mature.
Methods. Over a 6-year period, 52 dysfunctional and 17 thrombosed immature forearm fistulas (mean age 10 weeks) were treated by interventional radiology. Angiography was performed by puncture of the brachial artery but dilation of underlying stenoses was performed after cannulation of the fistula itself, whenever possible, with a balloon never smaller than 5 mm. Embolization or ligation of any type of vein was never indicated and never performed. For thrombosed fistulas, significant clots were removed by manual catheter-directed aspiration. A covered stent (Passager®) was used in cases of dilation-induced rupture not controlled by balloon tamponade.
Results. An underlying stenosis was diagnosed in 100% of cases. Half of them were located in the anastomotic area. The initial success rate of interventional radiology was 97%. Dilation-induced rupture occurred in nine cases (13%) but stents were necessary in only two cases. The rate of significant clinical complications was 2.8% (bacteraemia, pseudoaneurysm). Primary and secondary patency rates at 1 year were 39 and 79%, respectively.
Conclusions. Delayed maturation of native fistulas should lead systematically to imaging as an underlying stenosis is diagnosed in all cases. Interventional radiology can treat the majority of cases and achieve a 97% success rate but early recurrence of stenoses can occur. Multidisciplinary re-evaluation of the patient must, therefore, be performed after radiological salvage of the fistula.
Keywords: arteriovenous fistula; declotting (thrombolysis, thromboaspiration, thrombectomy); percutaneous transluminal angioplasty; stents and prostheses
Correspondence and offprint requests to: L. A. E. Turmel-Rodrigues, Radiologie Vasculaire Diagnostique et Interventionelle, Clinique Saint-Gatien, 8 Place de la Cathédrale, F-37000 Tours, France. Email: luc.turmel{at}wanadoo.fr
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