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Nephrology Dialysis Transplantation 2005 20(1):241-242; doi:10.1093/ndt/gfh600
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Nephrol Dial Transplant Vol. 20 No. 1 © ERA-EDTA 2005; all rights reserved

Can blood flow surveillance and pre-emptive repair of subclinical stenosis prolong the useful life of arteriovenous fistulae? A randomized controlled study

Sir,

In the September 2004 issue of Nephrology Dialysis Transplantaion, Tessitore et al. [1] provide further evidence that arteriovenous (AV) access blood flow surveillance and pre-emptive repair of subclinical stenosis reduce the thrombosis rate and prolong the life of AV fistulae. In this report, 12 of the 43 patients with dysfunction of AV fistulae proposed for treatment with percutaneous transluminal angioplasty (PTA) were considered not to be amenable to PTA by radiologists, and thus were surgical candidates for the following reasons: stenosis segment >2.5 cm, multiple perianastomotic stenoses and critical (>90%) isolated perianastomotic stenosis.

It has been documented that 2–6% of the cases referred for PTA are not amenable to angioplasty [2–4]. In contrast, in the present study [1], the 12 patients (28%) deemed ineligible for PTA by radiology represent an exceptionally high referral rate requiring surgical intervention. Of particular concern, seven out of the 43 patients (16%) received an AV interposition graft, rendering them susceptible to recurrent stenosis [5].

Multiple reports [2–4,6] have demonstrated that all of the above-mentioned complex stenoses of the AVF have routinely been treated successfully with PTA by interventional nephrologists and do not require referral to a vascular surgeon (Figures 1 and 2). We consider that referral of such cases for surgical revision is rarely needed, and actually can be deleterious, leading to unnecessary conversion of fistulae to grafts as well as surgical complications.



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  		Fig. 1. Successful angioplasty of multiple perianastomotic lesions.

 


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  		Fig. 2. Successful angioplasty of a >90% perianastomotic lesion.

 
Conflict of interest statement. None declared.

Cristian D. Cipleu, Gautam V. Cherla, Donna Merrill and Arif Asif

Division of Nephrology Section of Interventional Nephrology University of Miami School of Medicine 1600 NW 10th Ave (R 7168) Miami, FL 33136 USA Email: Aasif{at}med.miami.edu

References

  1. Tessitore N, Lipari G, Poli A et al. Can blood flow surveillance and pre-emptive repair of subclinical stenosis prolong the useful life of arteriovenous fistulae? A randomized controlled study. Nephrol Dial Transplant 2004; 19: 2325–2333[Abstract/Free Full Text]
  2. Beathard GA. Angioplasty for arteriovenous grafts and fistulae. Semin Nephrol 2002; 22: 202–210[CrossRef][Medline]
  3. Beathard GA. Percutaneous transvenous angioplasty in the treatment of vascular access stenosis. Kidney Int 1992; 42: 1390–1397[Web of Science][Medline]
  4. Beathard GA, Arnold P, Jackson J, Litchfield T. Aggressive treatment of early fistula failure. Physician Operators Forum of RMS Lifeline. Kidney Int 2003; 64: 1487–1494[CrossRef][Web of Science][Medline]
  5. NKF-K/DOQI Clinical Practice Guidelines for Vascular Access: Update 2000. Am J Kidney Dis 2001; 37 [Suppl 1]: S137–S181
  6. Asif A, Merrill D, Briones P, Roth D. Hemodialysis vascular access: percutaneous interventions by nephrologist. Semin Dial 2004; 17: 528–534[Medline]

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This Article
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