Strategies for Managing Resistant Stenosis · Qiantai HONG, Enming YONG, Sadhana CHANDRASEKAR, Glenn TAN Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital

Zhiwen Joseph LO

MBBS, B Med Sci, MRCS, MMed, FRCSEd, FAMS, AFACS, FICS

Qiantai HONG, Enming YONG, Sadhana CHANDRASEKAR, Glenn TAN

Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital

Singapore

Strategies for Managing Resistant Stenosis

Conflicts of Interest

• Research grants:

• NMRC, A*STAR, Konica-Minolta, Tetsuyu

• Travel honorarium:

• Acelity, BD, Smith & Nephew, Ziehm Imaging

• Speaker's honorarium:

• Acelity, Granulox, Ziehm Imaging

United States Renal Data System Annual Data Report 2014

Singapore Renal Registry Annual Registry Report 1999-2016National Registry of Diseases Office. Health Promotion Board Singapore.

Tan Tock Seng Hospital (Singapore)

• 1,500-bed university tertiary hospital

• 2000 Vascular in-patient admissions per year

• 400 AV access creation per year

• 400 endovascular AV procedures per year

2017 Annual Data ReportVolume 2, Chapter 1 ZJ Lo et al. JVA 2016

29%10%

2017 Annual Data ReportVolume 2, Chapter 1

(n=103, 2008-2015)

Ann Vasc Dis 2018; 11(3): 318-323

10-24%

8%

Ann Vasc Surg 2018; 46:331-336

(n=47, 2009-2014) (n=1259)

13%0%

Endovascular Treatment of AV Access

AVF

Assisted Primary Patency

•Balloon-assisted maturation

•Access Maintenance (stenosis)

Secondary Patency (Thrombosis)

AVG


(Outflow stenosis)



National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) Practice Guidelines

• AVF intervention when:

• 5.2.1 Inadequate dialysis flow (B)

• 5.2.2 Haemodynamically significant venous stenosis (B)

• 5.3 Pre-emptive PTA in:

• AVF with >50% stenosis with clinical / physiological abnormalities (B)

• 8.4 Successful angioplasty as treatment resulting in <30% residual stenosis with clinical / physiological parameters returning to acceptable limits

NKF KDOQI 2006 Vascular Access Guidelines


National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) Practice Guidelines

• Intervention in AVG stenosis without thrombosis when lesion >50% and associated with:

• 6.4.1 Abnormal physical findings (B)

• 6.4.2 Decreased flow (<600mL/min) (B)

• 6.4.3 Elevated static pressure within graft (B)

• Treatment of AVG thrombosis:

• 6.7.1 Done urgently to prevent temporary HD catheter (B)

• 6.7.2 Either percutaneous or surgical techniques (B)

• 6.7.5 Stenoses corrected using angioplasty or surgical revision (B)

NKF KDOQI 2006 Vascular Access Guidelines

Fistuloplasty Workhorses

Strategies for Managing Resistant Stenosis

2017 Annual Data ReportVolume 2, Chapter 1Agarwal SK et al. Journal Interventional Cardiology. 2015

Cutting balloon vs high-pressure balloon

• Similar technical success rates (87% vs 84%)

• 6-month target lesion patency – 67% vs 56%

• NNT: 9


AVF





AVG


(Outflow stenosis)



Zangan & Falk. Seminars in Intervention Radiology 2009

Balloon-Assisted Maturation (BAM)


Right RC-AVF BAM (5 months post-creation)

Mustang 6mm x 40mm


Left BC-AVF BAM (6 months post-creation)

Mustang 6mm x 40mmX2 side branches open ligation

Mustang 6mm x 40mm


Right RC-AVF (4 months post-creation)

Sterling 5mm x 40mm

Cutting 5mm x 20mm

Sterling 5mm x 40mm

Access Maintenance (Stenosis) – Anatomy

Quencer & Arici. AJR 2015

1

2 3

4

5


• >50% luminal diameter reduction within 5cm from AV anastomosis

• Most commonly seen in RC-AVF

• Aetiology hypothesis:

• Loss of vasa venosum during AVF creation dissection

• Low and fluctuating shear stress

• Downstream kinking / increased turbulence

• Torsional stress

• Leading to proinflammatory cytokines and neointimal hyperplasia

• Mortamais et al. JVIR 2013:

• 124-month

• 147 interventions in 75 RC-AVF JAS

• If residual stenosis <50%,1-year primary patency 85% and 3-year 76%

Access Maintenance (Venous) – Juxta-Anastomosis Stenosis



Juxta-Anastomosis Fistuloplasty

Lt RC-AVF (9mo)Mustang 6mm x 40mm

Rt BC-AVF (2yo)Mustang 6mm x 40mm


Juxta-Anastomosis Cutting BalloonLeft BC-AVF (15mo)

Mustang 7mm x 40mmCutting 5mm x 20mm

Mustang 7mm x 40mm


• Seen in up to 77% of dysfunctional BC-AVFs

• Rarely seen in dysfunctional RC-AVFs

• Aetiology hypothesis:

• Extrinsic compression by clavi-pectoral fascia

• Sharp turn of arch causing turbulent flow

• High concentration of valves

• Angioplasty

• 12m primary patency 23%

• 12m assisted primary patency 75%

• 1.6 interventions per patient-year

• Adjuncts:

• High pressure / Cutting balloons

• Stent grafts > bare metal stents

Access Maintenance (Venous) – Cephalic Arch

Quencer & Arici. AJR 2015 ; Sivananthan et al. JVA 2014


Cephalic Arch Fistuloplasty

Left BC-AVF (4yo)

Conquest 8mm x 40mm

Left BC-AVF (3yo)

Mustang 8mm x 40mm

Cutting 7mm x 20mm

Mustang 8mm x 40mm


• Basilic vein transits from surgically created superficial and lateral location to its naturally deep and more medial location

• 70-75% of BBT-AVF stenosis

• Beaulieu et al. JVA 2007

• 93 BBT-AVFs from 2001-2004

• 74% BBT-AVF stenosis at swing segement

• 50% of swing stenosis required >2 interventions

• 1-year primary patency 42%

• 1-year secondary patency 68%

Access Maintenance (Venous) – Basilic Swing Segment



Basilic (swing segment) Fistuloplasty

Lt BBT-AVFMustang 9mm x 40mm

Rt BBT-AVFConquest 8mm x 40mm

Ann Vasc Dis 2018; 11(3): 292-297

• Mean time from AVF creation to first central venoplasty: 24 months

• 74% required two or more central venoplasty

• Mean time to second venoplasty: 7 month


Central Venoplasty

Lt BBT-AVFSVC stenosisConquest 10mm x 40mmAtlas 14mm x 40mm


Right innominate stenting (1-month recurrence)

Rt innominate occlusion(Rt CFV access)

Rt BC-AVF & Rt CFV access

Conquest 12mm x 40mmAtlas 14mm x 40mm

Venovo 14mm x 60mm


AVF





AVG


(Outflow stenosis)



AV Graft Salvage – Stent-graft vs POBA

Haskal et al. NEJM 2010


AVG thrombectomy and venous stent-graft

Post open thrombectomyOf Lt BA-AVG (Propaten 6mm)

Mustang 8x80Fluency 8x80


Left LL loop AVG (1yo)Open thrombectomy and outflow venoplasty with stenting

Conquest 8mm x 40mm

Covera (flared) 8mm x 60mm

Zhiwen Joseph LO

MBBS, B Med Sci, MRCS, MMed, FRCSEd, FAMS, AFACS, FICS

Qiantai HONG, Enming YONG, Sadhana CHANDRASEKAR, Glenn TAN

Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital

Singapore

Strategies for Managing Recurrent Stenosis

DCB in AVF – SR and MA

• JVS 2019

• 17 studies 1113 access

• Superior 6-month and 12-month

primary patency

• Central venous stenosis: significantly

better 6-month and 12-month primary

patency

• JVIR 2018

• 12 studies 908 patients

• Significant in patency at 3-month, 6-

month, 12-month and 24-month

• Central venous stenosis: no significant

difference


DCB in AVF

Rt BC-AVF Recurrent cephalic arch 3 monthsMustang 7mm x 80mmRanger 7mm x 60mm

(Viabahn 8mm x 50mm)Mustang 8mm x 40mm

Ranger 8mm x 80mm


Juxta-Anastomosis Stenting

Swinnen et al. JVS 2015


Juxta-Anastomosis Stenting

Lt BC-AVF (2yo)Failed BAM 6m prior

Sterling 4mm x 100mmMustang 6mm x 120mmSupera 6mm x 100mm

Mustang 6mm x 80mmSupera 6mm x 80mm

Lt RC-AVF (12mo)JA fistuloplasty x2 within 7m

Patient Age Age of fistula

(Months)

No. endovascular intervention

Type of fistula

Indication Stenosis location

Vein size

Stent deployed

1 53 12 2 RC AVF Recurrent stenosis

JAS 4mm 6X80mm


JAS 3mm 6X80mm


JAS 4mm 6X80mm

4 69 8 1 BC AVF FTM JAS and Cephalic

arch

3mm 6x100mm

5 66 26 1 BC AVF FTM JAS 2mm 6x80mm

RC Chong et al. JVA in-press

Juxta-Anastomosis Stenting (Pilot) • Male with mean age of 67 years old

• Mean AVF age 17.6 months

• Mean vein caliber 3mm

• Technical success rate 100%

• Average positive improvement in access flow rate of 209ml/min

• Primary patency rate 100% at 1 year

• Able to cannulate through stent

RC Chong et al. JVA in-press


Conclusion

• Ultra high pressure balloons and cutting balloons are useful adjuncts in resistant AVF/AVG lesions

• Rupture risks are low and usually amenable to balloon tamponade

• AVG outflow may be treated with ultra high pressure balloons followed by stent-graft

• In recurrent lesions, DCB may be considered

• Stenting of AVF should be reserved for final salvage

My Practice – resistant AVF/AVG lesions

AVF

• Balloon-assisted maturation – cutting balloon

• Access maintenance

• Juxta-anastomois – cutting balloon

• Venous – ultra high pressure

• Cephalic arch – ultra high pressure / cutting

• Central veins – ultra high pressure

AVG – ultra high pressure + stent-graft

Recurrent lesions (< 6months) – DCB

Final salvage – stenting

[email protected]

Documents

Strategies for Managing Resistant Stenosis · Qiantai HONG, Enming YONG, Sadhana CHANDRASEKAR, Glenn TAN Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital