|Year : 2016 | Volume
| Issue : 3 | Page : 94-101
Role of interventional radiology in maintaining the vascular access for hemodialysis patients
Amany Elkharboutly1, Mohamed Raslan2
1 Department of Radiology, Benha University, Banha, Egypt
2 Department of Radiology, Ministry of Health, Banha, Egypt
|Date of Submission||01-Feb-2016|
|Date of Acceptance||04-Feb-2016|
|Date of Web Publication||19-Jan-2017|
Villa 183, Street 4, Benha El Gedida, Benha, Egypt Postal Code: 13111
Background and aim Vascular access dysfunction is serious for hemodialysis patients. Interventional radiologist is able to salvage hemodialysis access fistulas with excellent clinical success.
Patients and methods The procedures were carried out in the Interventional Radiology Unit of National Guard Hospital, Riyadh, Saudi Arabia, between January 2010 and March 2012. In total, 60 patients of vascular access dysfunction were included, who underwent diagnostic interventional angiographic procedures.
Results A total of 60 patients included in study were divided into three groups: group I, which included six patients (10%) with synthetic grafts; group II, which included 15 patients (25%) with tunneled dialysis catheter; and group III, which included 39 patients (65%) with native fistulas. The angiographic success rate was lower for fistulas than for grafts (74.36 vs. 83.33%).
Conclusion The catheter-based treatment of thrombosed and failing hemodialysis accesses achieves technical and clinical success in the majority of cases and allows patients to undergo immediate hemodialysis without the need for the placement of temporary dialysis catheters or surgical consumption of additional venous conduits.
Keywords: Hemodialysis, interventional, radiology
|How to cite this article:|
Elkharboutly A, Raslan M. Role of interventional radiology in maintaining the vascular access for hemodialysis patients. Tanta Med J 2016;44:94-101
|How to cite this URL:|
Elkharboutly A, Raslan M. Role of interventional radiology in maintaining the vascular access for hemodialysis patients. Tanta Med J [serial online] 2016 [cited 2018 Jul 17];44:94-101. Available from: http://www.tdj.eg.net/text.asp?2016/44/3/94/198481
| Introduction|| |
End-stage renal disease is one of the medical problems whose prevalence continues to rise . Hemodialysis is the most commonly used modality for the management, with three well-known vascular accesses: construction of a native arteriovenous fistula (AVF); the placement of a synthetic arteriovenous graft (AVG) in a loop configuration between an artery and a vein; or through a central venous catheter (tunneled or nontunneled) .
The main problems affecting vascular access in patients are infection, thrombosis, steal syndrome, pseudoaneurysms, and central vein stenosis. Complications of vascular access account for 20% of the hospitalizations among hemodialysis patients and can result in loss of access and significant morbidity and mortality .
Maintenance of hemodialysis vascular access is challenging for monitoring and surveillance of the access. Over the past decade, surgical intervention was the ‘gold standard’ for maintaining vascular accesses; however, image-guided endovascular interventional procedures, mainly percutaneous transluminal angioplasty (PTA), have evolved as major techniques and are slowly restoring patency to native accesses, but now referral to an interventional radiologist before any surgical interference leads to a decrease in the incidence of thrombosis and results in a longer access life .
An interventional radiologist is able to salvage nonmaturing hemodialysis access fistulas with excellent clinical success and secondary patency rates .
| Aim of the work|| |
The aim of the present study was to evaluate the role of interventional radiology in maintaining the vascular access for end-stage renal failure patients dependent on hemodialysis, by using the multiple interventional radiological procedure.
| Patients and methods|| |
The present study included 60 end-stage renal failure patients dependant on hemodialysis, with failed or malfunctioning vascular access. All patients were written a consent as they know the maneuver and compete agree with passable risks. The procedures were carried out in the Interventional Radiology Unit of the National Guard Hospital, Riyadh, Saudi Arabia, between January 2010 and March 2012. The patients were divided into three groups according to the type vascular access: the first group included patients with synthetic AVG; the second group included patients with a tunneled dialysis catheter; and the third group included patients with a native AVF.
Siemens Artis zeego angiography machine (Siemens AG, Muenchen, Germany) and Philips Allura Xper FD20 X-ray machine (Philips Medical, Amsterdam, The Netherlands) were used in the present study. The angiographic devices used were as follows: initial puncture needle 18-G, 5-Fr angiographic catheter ordinary J-tip, Teflon guide wires with a diameter of 0.035 inch, hydrophilic wire with angled tip, Fogarty catheters, and standard PTA balloon.
Patient demographic characteristics and dialysis access history data were collected.
Procedural data collected for analysis included number and degree of stenosis; type of intervention performed; and the degree of residual stenosis after treatment.
Asprin 325 mg was given orally before the procedure. For nonthrombosed accesses, lower doses of heparin (2000–3000 U) were given. For thrombosed accesses, direct instillation of 60 000–180 000 U of urokinase as pulse was carried out, followed by administering a dose of heparin 5000 U intravenously.
Exclusion criteria for the current study were inability to obtain informed consent, suspected acute infection of the arteriovenous access, and patients with contraindications to thrombolysis.
Specific indications for radiological intervention of hemodialysis accesses
- Early failure of hypoplastic native AVFs.
- Late failure of chronic fistulas and grafts.
- Arm edema (central vein or double-outlet stenosis).
Diagnostic angiographic procedure
With the patient in the supine position, the arm of interest is abducted and the access region is exposed while the rest of body covered with sterile wraps. Then, initial puncture is introduced by using a needle 18 G in an antegrade manner. An injection of 5 ml diluted contrast 1 : 1 by saline contrast is enough for each imaging series to reveal the outflow up to the heart – that is, the venous limb of the access, superficial vein, and the deep veins. Arterial reflux is carried out either by manual compression to the upper limb proximal to the access or by inflating the occluding balloon within the venous outflow while injecting the contrast via a sheath.
At this point any pathology present should be revealed. Radiologically, the thrombus as a filling defect or as stenosis appears as circumferential diminishment of the calibre of the lumen of the vessel in comparison with the vessel proximal to it. The degree of stenosis is visually assessed and images are saved to be compared by using postangioplasty images.
Interventional angiographic procedures
A guide wire is passed through a needle directed into the venous side, and then the needle is removed after placing a 6- or 7-Fr sheath into the access. Then, another needle is inserted into the access directed down towards the arterial side; a wire is passed through the needle into the feeding artery distal or proximal to the anastomosis; then, the needle is removed and a sheath is placed.
Revision of the arterial side: A Fogarty catheter is passed via the retrograde sheath and passed through the arterial anastomosis into the arterial side, and is used to aspirate clots and pick up flow from the arterial anastomosis. A guiding catheter and a wire are then manipulated across the arterial anastomosis, and selective brachial artery catheterization and arteriogram are performed. In cases of venous stenosis, a guide wire and a guiding catheter are passed through the antegrade catheter and manipulated extensively to pass the stenosis, after which angioplasty is carried out by passing a balloon over the wire till the stenotic site is at the middle of the balloon. Careful inflation of the balloon is done till the stenosis waist disappears. The balloon is kept inflated for about 30 s to 2 min according to the degree of the stenosis.
In some cases, stenting is carried out to overcome the recoil of the stenotic lesion and to control venous rupture. In cases of stenosis in the arterial side of the access, a guide wire is passed through the retrograde sheath into the feeding artery proximal, and then a balloon is passed over the guide wire and angioplasty is performed.
Angioplasty is considered as successful when the residual stenosis is less than 30%. At the end of the procedure, the sheaths are removed and the patients kept under supervision for the vital signs for at least 1 h after the procedure.
Quantitative data were statistically analyzed using the SPSS software statistical computer package version 17 (SPSS, Chicago, IL, USA). The difference between the two means was statistically analyzed using the Student t-test. The Mann–Whitney test was carried out to test the mean values when the observations were found not to follow normal distribution. For qualitative data, the number and percent distribution was calculated. The χ2-test was used as a test of significance, and when found inappropriate, Fisher’s exact test was used. Significance was set at a P-value of less than 0.05. Statistical presentation and analysis of the present study was conducted using the mean, SE, unpaired Student t-test, the Wilcoxon tests, linear correlation coefficient, analysis of variance tests, paired t-test, and the χ2-test.
| Result|| |
A total of 60 patients were included in the study, and were classified into three groups: group I, which included six patients (10%) with synthetic grafts; group II, which included 15 patients (25%) with tunneled dialysis catheter; and group III, which included 39 patients (65%) with native fistulas. Patients’ ages ranged from 23 to 88 years, with a mean of 63.6 years for group I, 50.8 years for group II, and 58.1 years for group III. There was an insignificant difference between the three studied groups as regards renal failure. Diabetes mellitus was common for the total number of patients and group III; however, hypertension was common for groups I and II, and the second common for the total number of patients. Other causes included polycystic kidney disease (PCKD) vesicoureteric reflux (VUR), glomerulonepheritis (GN), and obstruction by stone.
As regards the presence or absence of thrombosis at dialysis access, we compared the three studied groups and find no significant difference between the ([Table 1]) revealed insignificant difference between them [group I, 83.33% (n = 5); group II, 80% (n = 3); group III, 92.31% (n = 9); P = 0.437], but there was significant absence of thrombosis in three studied group as only seven cases (11.67%) had thrombi.
|Table 1: Comparison between three studied groups as regard presence and absence of thrombosis|
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Comparison between the three studied groups as regards the number of venous stenosis revealed a significant presence of multiple venous stenoses in group I [(n = 4), 66.67%] and group III [(n = 21), 53.85%], and the data were not applicable for group II [(n = 4) 26.67%]. As regards arterial anastomosis stenosis, comparison between the studied groups revealed a significant absence of arterial stenosis in group I [(n = 5), 83.33%] and group III [(n = 26), 66.67%], and the data were not applicable for group II (n = 0) (P ≤ 0.001) ([Table 2]).
|Table 2: Comparison between three studied groups as regards indication for intervention|
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Comparison between the three studied groups as regards the type of intervention revealed that balloon angioplasty was the most commonly used procedure, especially alone [(n = 34), 56.67%] ([Figure 1] and [Figure 2]). Balloon angioplasty was significantly used as a type of intervention in group I (n = 3) and in group III (n = 31), whereas balloon angioplasty and catheter changes were used as the types of intervention in group II [(n = 7) 46.67%]. The rombolysis done at only two cases, one case at group 1 (as a single intervention technique) and the other combined with balloon angioplasty done at group III ([Table 3]).
|Figure 1: A 69-year-old female patient on regular dialysis through left arm arteriovenous (AV) graft; she was complaining of left-arm swelling, and on examination a weak thrill was found. (a) Retrograde fistulogram revealing greater than 90% stenosis (arrow) at the arterial anastomosis. (b) 5-mm balloon inflated (arrows) within the stenotic lesion. (c) Postangioplasty with less than 30% residual stenosis.|
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|Figure 2: A 73-year-old male patient, on regular dialysis through right leg arteriovenous (AV) graft, complaining of right lower limb swelling; on examination, weak thrill over the graft was found. (a) Balloon inflated at the venous limb of right leg arteriovenous graft (AVG) and contrast injected through the sheath to show the graft and arterial anastomosis; no graft thrombosis or anastomotic stenosis. (b, c) High-grade stenosis seen in the right common iliac vein, which was persistent after balloon dilatation. (d) Poststenting revealing good result. Poststenting examination revealed normal thrill over the graft.|
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|Table 3: Comparison between three studied groups as regards type of intervention|
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Comparison between the three studied groups as regards prestenosis venography stenosis, revealed a significant presence of more than 30% stenosis in group I [(n = 4), 66.65%] and group III [(n = 32), 82%]; more than 30% stenosis and occlusion was present in three cases in group III. Overall, 30% thrombosis was present in one case in group II, and another in group III ([Table 4]). Comparison between the three studied groups as regards postvenography showed a significant presence of less than 30% stenosis in group I and III; only seven cases has stenosis more than 30% ([Table 5]).
|Table 4: Comparison between three studied groups as regards prevenography|
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|Table 5: Comparison between three studied groups as regards post-venography|
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There was a negative correlation between the overall result of the intervention and age and sex of the patients and the presence or absence of diabetes mellitus.
There was a negative correlation between the overall result of the intervention and the number of venous stenosis (P = 0.064). There was a negative correlation between the overall result of the intervention and the presence of arterial anastomosis stenosis([Table 4] and [Table 5]).
Among the 60 cases, 54 cases (90%) passed without complications, whereas two cases (3.33%) had extravasation, two (3.33%) had hematoma grade I, one had (1.67%) hematoma grade II, and one more (1.67%) had vascular spasm.
In this study, the angiographic success rate was lower for fistulas than for grafts (74.36 vs. 83.33%) ([Table 6]).
|Table 6: Comparison between three studied groups as regards overall result of intervention|
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| Discussion|| |
Vascular access dysfunction is a serious issue for hemodialysis patients. It is crucial to extend the functional life of each dialysis access for as long as possible, because the sites available for dialysis fistulas are limited and patients are dependent on dialysis for survival .
It was noted in this study that the majority of dysfunctional or failed permanent accesses are primarily related to venous stenosis, which was usually multiple and more than 30% in the present study.
The pathophysiology of this venous stenosis is based on the premise that turbulent nonlaminar flow promotes vessel vibration in a thin-walled vein with different wall compliance than the feeding artery (AVF) or graft (AVG). The turbulence promotes thickening of the vein wall by intimal and smooth muscle hyperplasia, thus compromising the lumen caliber .
Tunneled dialysis catheter, which is often a transitional stage before renal transplant or maturation of surgically created AVF and AVG, is also prone to dysfunction. Various interventional radiological techniques can prolong the functional life of a failing catheter because of fibrin sheath formation or malposition of the line, thus preventing unnecessary line replacement ([Figure 3]) .
|Figure 3: A 50-year-old female patient on regular dialysis through left common femoral venous dialysis catheter; she was referred to the angiographic unit because of a poor catheter flow. (a) Catheterogram revealed malpositioned catheter tip with stenosis of lower IVC. (b) 14-mm balloon inflated within the stenotic lesion. (c, d) Postpercutaneous transluminal angioplasty (post-PTA) showed good result; then, the tunneled dialysis catheter was inserted with its tip in the lower IVC. Good flow in both lumens of the catheter.|
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Catheter-based interventions were successful in restoring function of the hemodialysis access in more than 78% of the cases.
In agreement with the findings of Bittl (2010) , we found that fistula failure is more common in diabetic and elderly patients, but, in our study, it was not affected by the presence or absence of diabetes.
Grafts are prone to recurrent stenosis and thrombosis, and require multiple radiologic or surgical interventions to ensure patency but fistulas have a much lower incidence of stenosis and thrombosis than do grafts; however, tunneled dialysis catheters have the highest frequency of infection and thrombosis .
Mechanical thrombectomy of thrombosed hemodialysis fistulas is more difficult than that of grafts because of the more complex anatomical arrangement of native fistulas, as reflected by longer procedure time .
Zaleski et al. (2001)  reported on 17 patients with complete thrombosis of their Brescia-Cimino fistulas, which were treated through angioplasty and urokinase infusion. Procedural success was 82%. In their study, Poulain et al. (1991)  combined a local low-dose infusion of urokinase with PTA and thromboaspiration to achieve a 12-month overall patency in 14 native fistulas of ~90%. Out of 24 patients with occluded fistulas, 20 (83%) were successfully declotted. In their study, Turmel-Rodrigues et al. (2002)  described an 81% initial success rate using thromboaspiration and PTA in 16 patients. An 81% secondary patency at 1 year was reported. Mickley et al. (2003)  reported a success rate of 100% in patients with thrombosis of a newly created dialysis access. Comparable results, however, with fewer patients, have been reported in various studies.
The findings of our study were in agreement with those reported in the studies by Turmel-Rodrigues et al. (2002), Mickley et al. (2003), and Trerotola et al. (2005). Declotting of the thrombosed access was achieved by using local infusion of thrombolytics, pulse spray fluid injection through catheters, and manual catheter-directed thromboaspiration.
Catheter-based interventions have a more than 80% success rate in restoring the flow during thrombosis, and have gradually replaced surgical revision as the treatment of choice for failing or thrombosed fistulas and grafts ([Figure 4] and [Figure 5]) .
|Figure 4: A 74-year-old male patient was on regular dialysis through left arm arteriovenous (AV) fistula, and was referred to the angiographic unit due to neck and both upper-limb swelling; on examination, the graft was found to be pulsatile with weak thrills over it. (a) Central venogram was done through bilateral upper-limb injection, which showed occluded brachiocephalic veins (BCVs) with multiple collaterals. (b, c) Bilateral upper limb access with balloon expansion of 14 mm stent of left BCV and upper IVC. (d) Post-left stent venogram showed good flow with no stenosis.|
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|Figure 5: A 73-year-old male patient on hemodialysis through right brachiobasilic arteriovenous fistula (AVF) presented with thrombosed fistula. On examination, no flow could be detected over the fistula. (a) Venogram was done while catheter passed central to the thrombosed part. (b) After thrombolysis and clot aspiration, balloon was used to dilate the stenosis in the venous outflow. (c) Final fistulogram showed good flow with no gross remaining clots and no stenosis.|
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In this study, the angiographic success rate was lower for fistulas than for grafts (74.36 vs. 83.33%).
The reported technical success rates are comparable to our own, which was close to 80%. We believe that ideal clinical management of the hemodialysis patient encompasses physical examination, clinical knowledge of each individual patient, contiguous patient follow-up, and permanent access imaging surveillance, as well as close interdisciplinary collaboration and consultations between primary care, surgery, interventional radiology, and nephrology services.
Using this approach, we were able to detect impending access failure in time, which resulted in higher success rates, as well as technically easier hemodialysis access salvage interventional procedures. This was clearly seen in the low number of thrombosed accesses due to regular surveillance.
Treatment results of thrombosis and associated stenosis in synthetic grafts have been summarized in a study by Aruny (1996) . Clinical success rates for thrombolysis or mechanical thrombectomy range from 75 to 94%.
Bittl (2009)  reported that, in a series of 1242 cases, only 11 patients had complications in the form of venous rupture or perforation; none of them died.
Major complications resulting from interventional techniques are uncommon, but could include death, stroke, and stent thrombosis. Minor complications are also rare (up to 5%) and include access-site hematoma or pseudoaneurysm, peripheral emboli, and stent embolization.
Our complication rates (six cases, 10%) are also comparable to that in the previously published studies. This study reported a 0% event rate for any of the major complications. The complications encountered were hematoma, vascular spasm, and extravasation due to vascular tear during angioplasty. These are attributed to the extensive manipulation of the guide wire or overinflation of the angioplasty balloon. Overall, these complications were self-limiting; two patients were followed up in the postoperative room for 2 h, and then were released.
| Conclusion|| |
The catheter-based treatment of thrombosed and failing hemodialysis accesses achieves technical and clinical success in the majority of the cases, and allows patients to undergo immediate hemodialysis without the need for placement of temporary dialysis catheters or surgical consumption of additional venous conduits.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]