Cutting Balloon Angioplasty for the Treatment of Stenosis in Hemodialysis Arteriovenous Fistulas
- Volume 2 - Issue 3 - May/June 2005
- Posted on: 9/5/08
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Gianpaolo Carrafiello, MD, Domenico Laganá, MD, Monica Mangini, MD, Chiara Recaldini, MD, Domenico Lumia, MD, Andrea Giorgianni, MD, Carlo Fugazzola, MD
Hemodialysis fistulas (AVFs) are an element of fundamental importance in the treatment of patients undergoing dialysis. Their correct functioning is an indispensable condition for the success of the dialysis procedure.
Interventional radiology has taken on an increasingly important role in the percutaneous management of failing grafts and fistulas.1,2 In some patients, the fistula stenosis can be resistant to dilation with conventional angioplasty balloons3,4 and even high-pressure balloons.5
The cutting balloon (Boston Scientific, Maple Grove, MN), utilized for the first time by Barath in 1991, is a device that combines the principles of conventional angioplasty with the techniques of microsurgery.6 Over the last decade, numerous series regarding this device have been published, most concerning the use of the device in the fields of cardiology7 and endo-urology.8 The cutting balloon has also been considered for other applications in the extra-cardiac vessel9–16 and, in particular, for the treatment of stenosis in hemodialyisis AVFs.3,17–19
Material and Methods
Of the 21 patients with tight focal stenosis of hemodialysis AVFs that were selected for cutting balloon angioplasty, 20 of 21 patients had radio-cephalic fistulas and 1 patient had a femoral fistula.
All patients presented a with “failing fistula” with a flow capacity < 300ml/min. Prior to the treatment, all patients were assessed with CDU (Philips ATL® 5000) to study the feeding artery, arterial anastomosis, graft, venous anastomosis and venous outflow to the subclavian artery. Stenosis greater than 50% was considered present if the maximum systolic velocity was more than 4 m/sec, the maximum velocity ratio was more than 3:1, or both. The velocity ratio was calculated by comparing the velocity of the area of suspected stenosis with the velocity next to the area of suspected stenosis.
On the basis of the abnormal findings of a preliminary angiography, a decision was made to carry out angioplasty of the venous stenosis. Informed consent was obtained from all patients. Focal tight stenoses due to intimal hyperplasia were considered suitable for treatment with a cutting balloon, either as a first treatment or after failure of high-pressure balloon angioplasty.
After opacifying the ipsilateral brachial artery (n = 20) and common femoral artery (n = 1) with Terumo® 4F glide catheters and crossing the anastomosis with a 0.035” Terumo hydrophilic guidewire, a 6-7Fr sheath was inserted and angioplasty with a high-pressure balloon (Blue Max®20™ Balloon Catheter, Boston Scientific) was performed.
Ten patients who underwent incomplete dilation with a high-pressure balloon were treated with a cutting balloon (Boston Scientific). The guidewire was exchanged for a 0.014” Terumo guidewire with a 5F catheter for advancing the cutting balloon. The dilatation was carried out with a syringe equipped with a manometer (Medflator II, Medex Medical, Carlsbad, CA) with a gradual inflation of the balloon until it reached a pressure of 20 atm if a high-pressure balloon was utilized, and 6 atm with the use of a cutting balloon. During the procedure, 2000 UI of heparin was administered. Cutting balloons with the following diameters were used: 8 mm (n = 2), 6 mm (n = 10), 5 mm (n = 8) and 4 mm (n = 1). Results were assessed by means of an angiographic study at the end of the procedure.
A follow-up was carried out using CDU after 1, 3, 6, 12, 18 and 24 months and by clinical assessment of the flow capacity of the fistula during the dialysis procedure.
Of the 21 patients, preliminary angiography demonstrated the presence of stenosis at the level of the efferent vein in 17 patients (Figures 1a, 2a) and at the level of the anastomoses in the remaining 4 patients (Figures 1a, 3a). After incomplete dilation with a high-pressure balloon (Figures 3b-c), 10 patients were treated with a cutting balloon. In the other cases (9 focal stenosis and 2 cases of restenosis, respectively, at 6 and 9 months from a prior angioplasty), a “primary cutting balloon angioplasty” was carried out (Figures 1b, 2b). In 13 cases, complete resolution of the stenosis was achieved (Figures 1c, 3d). In 7 cases, the angiography carried out at the end of the procedure demonstrated a residual stenosis of < 10%, and in one case, a residual stenosis of 30% was detected. In this latter case, the elimination of collateral circles confirmed the hemodynamic success of the procedure (Figures 3c).
The device was inserted easily in 20 patients, resulting from the use of a 0.014” stiff guidewire. In the remaining case, the balloon advanced with difficulty due to the rigidity of the device and to the small caliber of the supporting guidewire. Eventually the sheath was advanced beyond the stenosis with the help of a stiff guidewire (Amplatz Super Stiff®, Boston Scientific) and the balloon was pushed inside the sheath, which was then removed before inflation.
cious thrombosis. In 3 cases, the cutting balloon ruptured when inflated at a pressure of 7 and 8 atm, but in all 3 cases, it was removed in one piece without any difficulty or complications. During the dilatation with the cutting balloon, none of the patients reported any pain.
Constant monitoring of the fistula flow and the prompt treatment of a hemodynamically significant stenosis (> 50%) is necessary in order to increase the life of the fistula and to reduce the percentage of thrombosis.20
Endovascular treatment has taken on a fundamental role in the follow-up of AVF accesses and today it represents the most appropriate therapeutic approach,20 as it has a lower risk of complications compared to surgical treatment.5
1. Mc Cutcheon B, Weatherford D, Maxwell G, et al. A preliminary investigation of balloon angioplasty versus surgical treatment of thrombosed dialysis grafts. Am Surg 2003;69:663–667.
2. Marston WA, Criado E, Jaques PF, et al. Prospective randomized comparison of surgical versus endovascular management of thrombosed dialysis access grafts. J Vasc Surg 1997;26:373–380.
3. Vorwerk D, Adam G, Muller-Leisse C, et al. Hemodialysis fistulas and grafts: use of cutting balloons to dilate venous stenoses. Radiology 1996;201:864–886.
4. Bittl JA. Percutaneous therapy of dialysis access failure. Catheter Cardiovasc Interv 2002;56:157–161.
5. Treortola SO, Stavropoulos SW, Shlansky-Goldberg R, et al. Hemodialysis-related venous stenosis: Treatment with ultrahigh-pressure angioplasty balloons. Radiology 2004;231:259–282.
6. Barath P, Fishbein MC, Vari S et al. Cutting balloon: A novel approach to percutaneous angioplasty. Am J Cardiol 1991;68:1249–1252.
7. Takebayashi H, Haruta S, Kohno H, et al. Immediate and 3-month follow-up outcome after cutting balloon angioplasty for bifurcation lesions. J Interv Cardiol 2004;17:1–7.
8. Varkarakis IM, Bhayani SB, Allaf ME, et al. Management of secondary ureteropelvic junction obstruction after failed primary laparoscopic pyeloplasty. J Urol 2004;172:180–182.
9. Bergersen LJ, Perry SB, Lock JE. Effect of cutting balloon angioplasty on resistant pulmonary artery stenosis. Am J Cardiol 2003;15:185–189.
10. Rhodes JF, Lane GK, Mesia CI, et al. Cutting balloon angioplasty for children with small-vessel pulmonary artery stenoses. Catheter Cardiovasc Interv 2002;55:73–77.
11. Ansel GM, Sample NS, Botti III CF Jr, et al. Cutting balloon angioplasty of the popliteal and infrapopliteal vessels for symptomatic limb ischemia. Catheter Cardiovasc Interv 2004;61:1-4.
12. Engelke C, Sandhu C, Morgan RA, et al. Using 6-mm Cutting Balloon angioplasty in patients with resistant peripheral artery stenosis: Preliminary results. AJR 2002;179:619–623.
13. Kasirajan K, Schneider PA. Early outcome of “cutting” balloon angioplasty for infrainguinal vein graft stenosis. J Vasc Surg 2004;39:702–708.
14. Engelke C, Morgan RA, Belli AM. Cutting balloon percutaneous transluminal angioplasty for salvage of lower limb arterial bypass grafts: Feasibility. Radiology 2002;223:106–114.
15. Munneke GJ, Engelke C, Morgan RA, et al. Cutting balloon angioplasty for resistant renal artery in-stent restenosis. J Vasc Interv Radiol 2002;13:327–331.
16. Rath PC, Lakshmi G, Henry M. Percutaneous transluminal angioplasty using a cutting balloon for stenosis of the arch vessels in aortoarteritis. Indian Heart J 2004;56:54–57.
17. Bittl JA, Feldman RL. Cutting balloon angioplasty for undilatable venous stenoses causing dialysis graft failure. Catheter Cardiovasc Interv 2003;58:524–526.
18. Ryan JM, Dumbleton SA, Smith TP. Using a cutting balloon to treat resistant high-grade dialysis graft stenosis. AJR 2002;180:1072–1074.
19. Vorwerk D, Guenther RW, Schurmann K et al. Use of a cutting balloon for dilatation of a resistant venous stenosis of a hemodialysis fistula. Cardiovasc Intervent Radiol 1995;18:62–64.
20. NFK-K/DOQI. Clinical practice guidelines for vascular access: Update 2000. Am J Kidney Dis 2001;37:137–181.
21. Beathard G. Percutaneous transvenous angioplasty in the treatment of vascular access stenosis. Kidney Inter 1992;42:1390–1397.
22. Vorwerk D, Guenther RW, Mann H, et al. Venous stenosis and occlusion in hemodialysis shunts: Follow-up results of stent placement in 65 patients. Radiology 1995;195:140–146.
23. Inoue T, Sakai Y, Hoshi K. Lower expression of neutrophile adhesion molecule indicates less vessel wall injury and might explain lower restenosis rate after cutting balloon angioplasty. Circulation 1998;97:2511–2518.