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Shunt stenosis and occlusion: The pattern of reobstruction and how to
approach?
Michael Moche, Tobias Paulus
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Disclosure
Speaker name:
Michael Moche
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest X
LINC 2016
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Facts
• Vascular access essential for survival of patients with chronic renal failure
• Arteriovenous fistulae (AVF) best and most durable vascular access for hemodialysis
• Relevant stenosis (>50%) already 3 months after formation in > 54% (Grogan J Vasc Surg 2005, Sivanesan
Nephrol 1999)
• Median problem-free patency period: AVF 3y, arteriovenous grafts (AVG) 1-2y
LINC 2016
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Criteria for dysfunction/failure • no pulse, no thrill palpable
• difficult puncture
• reduced flow < 200-300ml/min
• high recirculation (> 15% with 300ml/min)
• increasing retention parameters - incomplete dialysis
stenosis or thrombosis in- or outflow
• elevated venous pressure
• increased pulsation, prolonged bleeding after puncture
• arm swelling, varicosis, collateral veins
central ven. stenosis
• hand ischemia – steal syndrome
• aneurysm
LINC 2016
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Diagnosis and pattern of failure
Course of failure
• Early – inflow stenosis (e.g. intima hyperplasia) failure to mature
• Late – venous outflow stasis (e.g. stress triggered focal fibromuscular hyperplasia) thrombosis
Assessment • Clinical examination • Doppler ultrasound • CE-MRI • Direct angiography
Stenosis location • 5% - arterial inflow • 34% - juxa-anastomotic • 43% - venous outflow Grogan et al. J Vasc Surg 2005
Sayed et al. Vascular 2005
CO2 6mm Cutting Balloon
LINC 2016
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Endovascular approach
Indications
• Non-mature fistulas
– Distant inflow stenosis
– Distant early outflow stenosis
• Mature fistulas
– Access thrombosis (urgent)
– Isolated venous or outflow
anastomotic stenosis
• Arm edema
– Central vein or double outlet stenosis
Bittl Am Coll Cardiol Interv. 2010
Technical success
LINC 2016
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Acute failure - thrombosis
Tordoir et al. J Vasc Surg 2009
Endovascular vs. surgery
LINC 2016
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Declotting Thrombolysis
Thrombectomy • Aspiration
• Mechnical / hydrodynamic (Arrow-Trerotola, AngioJet, Aspirex etc. )
Wen Act Cardiol Sin 2011 – n=135
Angiojet
LINC 2016
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Which balloons? Advanced force!
“Buddy wire technique” – High pressure ballon
• Precision
• Safety – less dissections
• Larger luminal gain
RCT
n = 516
2. patency after 3m
CBA 96%
HPBA 80%
Aftab et al. J Vasc Interv Radiol 2014
p = 0.03
LINC 2016
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AVF & AVG: PTA vs. Stent
Fu, Sem Dialysis, 2015 Metaanalysis: 10 studies, n = 860
6mm PTFE AVG 6mm Cutting Balloon
Nitinol
Bare metal
LINC 2016
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AVG: PTA vs. Stentgraft/PTA
Procedural success: 94% graft vs. 74% PTA
2010
Haskal NEJM 2010
LINC 2016
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Central venous stenosis (CVS)
Asif et al. Seminars in Dialysis 2009
9% at 12m
86% at 12m
2.1 procedures per year
Bakken et al. J Vasc Surg 2007
No evidence to treat asymptomatic CVS!
Renaud at al. Nephrol Dial Transplant 2012
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Take home
• Able to increase mean survival
AVF from 3 up to 7y
AVG from 1-2 up to 3y
• Thrombosis – urgent treatment!
• Peripheral stenosis PTA and bailout stent
• Evidence for “advanced focused forces” PTA
• AVG evidence for covered Stents
• Treat only symptomatic central venous stenosis
LINC 2016
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Shunt stenosis and occlusion: The pattern of reobstruction and how to
approach?
Michael Moche, Tobias Paulus