Nephrol Dial Transplant Vol. 20 No. 1 © ERA-EDTA 2005; all rights reserved
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Sir,We read with interest the comments made on our paper [1] by Cipleu et al., who raise the issue of the elegibility of stenoses for surgical or endovascular treatment (PTA) in arteriovenous fistulae (AVFs).
Cipleu et al. were concerned by the very high rate of referral to the vascular surgeon (28%) in our study and especially by the use of an arteriovenous interposition graft (that they consider tantamount to ‘conversion of fistulae to grafts’) because of its susceptibility to recurrent stenosis. They also conclude that ‘surgical revision is rarely needed and actually can be deleterious, leading to unnecessary conversion of fistulae to grafts as well as surgical complications’, though they fail to cite literature in support of this statement.
Regarding the treatment of stenosis by PTA, Beathard et al. [2] reported that PTA was performed in 72% of AVFs with largely juxta-anastomotic venous stenoses (a population of AVFs and a rate of PTA similar to our study), but they did not report on the fate of the remaining 28% of AVFs (whether they were abandoned or treated differently).
In our study [1], we did not ‘propose all AVFs for treatment with PTA’ and treat by surgery those ‘considered not to be amenable to PTA’, as Cipleu et al. suggest, but our ‘indications for surgery were lesions that the radiologist considered unlikely to be amenable to PTA’. In other words, we had both surgical and endovascular treatment options equally available, and surgery was performed not only for stenoses deemed technically ineligible for PTA, but also for those expected to have a significant residual stenosis after PTA in the light of our experience, and occasionally for those considered eligible for both treatments—based on the report by Schwab et al. of a higher restenosis rate after PTA than after surgery [3].
We are aware that our criteria for choosing the type of treatment were largely subjective, but this approach enabled us to conduct a prospective controlled trial comparing surgery (either neoanastomosis or jump graft interposition) vs PTA in the pre-emptive treatment of perianastomotic stenoses in lower forearm AVFs, the results of which have been presented at the 2004 American Society of Nephrology meeting in St Louis [4]. This study showed a higher restenosis rate after PTA (n = 40) than after surgery (n = 22) (0.476 vs 0.159 stenoses per AVF-year, P = 0.02), while the rate was similar in the two surgically treated subgroups, i.e. 0.179 events per AVF-year after neoanastomosis (n = 10) and 0.147 after jump graft (n = 12) (P = NS). Neither surgery nor PTA caused major complications in our series, and the survival of the technique was similar between the two. These findings fail to support any of the concerns raised by Cipleu et al. as regards any higher complication rates being associated with surgery.
Conflict of interest statement. None declared.
1 Divisione di Nefrologia2 Dipartimento di Scienze Chirurgiche3 Dipartimento di Medicina e Sanità Pubblica4 Istituto di Radiologia Servizio Emodialisi Ospedale Policlinico Piazzale L. A. Scuro 10 Verona 37126 Italy Email: nicola.tessitore{at}azosp.vr.it
References
- 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: 2325–23332
[Abstract/Free Full Text] - Beathard GA, Arnold P, Jackson J, Litchfield T. Aggressive treatment of early fistula failure. Physician Operators Forum of RMS Lifeline. Kidney Int 2003; 64: 1487–14943[CrossRef][Web of Science][Medline]
- Schwab SJ, Raymond JR, Saeed M et al. Prevention of hemodialysis fistula thrombosis. Early detection of venous stenosis. Kidney Int 1989; 36: 707–7114[Web of Science][Medline]
- Tessitore N, Lipari G, Poli A et al. A prospective controlled trial on surgical vs endovascular treatment of stenosis in forearm arteriovenous fistulae. J Am Soc Nephrol 2004; in press [abstract SU-FC082]
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