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December 23, 2005
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natalie marks, md, Anil Hingorani, M.D., enrico ascher, md, richard schutzer, md, manikyam mutyala, md, alexander shiferson, md, william yorkovich, rpa, theresa jacob, PhD.
Maimonides Medical Center, Brooklyn, NY, USA.
Objective: Patients not yet on dialysis with borderline renal function with non-maturing AV accesses present a therapeutic problem. As the standard treatment with balloon angioplasty is based upon using contrast for diagnosis and treatment, and the contrast is nephrotoxic, we have sought alternative therapies.
Methods: Five patients with chronic renal insufficiency and failing arterio-venous (AV) access (4 autologous and 1 prosthetic) underwent duplex-guided balloon angioplasties at our institution. These were 3 females and 2 males with age ranging from 70 to 85 years (mean 77 ± 7 years). All patients were hypertensive, 4 (80%) were diabetics and 3 (60%) had coronary artery disease). Three patients (60%) had target AV access used for dialysis. Severe stenoses (>70%) as measured by duplex image and confirmed by peak systolic velocity (PSV) step-up were indications for all procedures. Number of stenoses ranged from 1 to 5 per AV access. Preoperative volume flows (VF) measured by duplex ranged from 200 ml/min to 1160 ml/min (mean 755 ± 358 ml/min). PSV obtained at the most significant stenosis preoperatively ranged from 428 cm/sec to 656 cm/sec (mean 555 ± 87 cm/sec).
Technique: All procedures were performed via short sheath (6Fr in 3 cases and 4 Fr in the remaining 2 cases) inserted under duplex guidance. Wire and balloon passage and inflation were performed under duplex surveillance as well. Balloon size (5 mm to 8 mm in diameter) was chosen based on duplex measurements. Cutting balloons (4x20 mm and 5x20 mm) were used for dilatation of recoiling lesions in 2 cases.
Results: None of these procedures required use of fluoroscopy or contrast material. One patient required duplex-guided stent placement for recoiling lesion in the junction of the brachial and axillary veins. Postoperative VF ranged from 520 ml/min to 1750 ml/min (mean 1272 ± 486 ml/min). VF increase ranged from 25% to 160% (mean 89 ± 68%). PSV obtained at the most significant stenosis postoperatively ranged from 142 cm/sec to 321 cm/sec (mean 233 ± 64cm/sec). PSV decrease ranged from 25% to 77% (mean 56 ± 19%).
Conclusion: Angioplasty of failing AV access can be performed under duplex guidance alone. Duplex guidance offers invaluable advantages of hemodynamic evaluation for recoiling lesions and need for stenting. Avoidance of contrast use for repair of non-functioning AV access can be a useful adjunct in these patients with renal failure not yet on dialysis.
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Duplex-guided angioplasty of failing arterio-venous access.Duplex-guided angioplasty of failing arterio-venous access.
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natalie marks, md, Anil Hingorani, M.D., enrico ascher, md, richard schutzer, md, manikyam mutyala, md, alexander shiferson, md, william yorkovich, rpa, theresa jacob, PhD.
Maimonides Medical Center, Brooklyn, NY, USA.
Objective: Patients not yet on dialysis with borderline renal function with non-maturing AV accesses present a therapeutic problem. As the standard treatment with balloon angioplasty is based upon using contrast for diagnosis and treatment, and the contrast is nephrotoxic, we have sought alternative therapies.
Methods: Five patients with chronic renal insufficiency and failing arterio-venous (AV) access (4 autologous and 1 prosthetic) underwent duplex-guided balloon angioplasties at our institution. These were 3 females and 2 males with age ranging from 70 to 85 years (mean 77 ± 7 years). All patients were hypertensive, 4 (80%) were diabetics and 3 (60%) had coronary artery disease). Three patients (60%) had target AV access used for dialysis. Severe stenoses (>70%) as measured by duplex image and confirmed by peak systolic velocity (PSV) step-up were indications for all procedures. Number of stenoses ranged from 1 to 5 per AV access. Preoperative volume flows (VF) measured by duplex ranged from 200 ml/min to 1160 ml/min (mean 755 ± 358 ml/min). PSV obtained at the most significant stenosis preoperatively ranged from 428 cm/sec to 656 cm/sec (mean 555 ± 87 cm/sec).
Technique: All procedures were performed via short sheath (6Fr in 3 cases and 4 Fr in the remaining 2 cases) inserted under duplex guidance. Wire and balloon passage and inflation were performed under duplex surveillance as well. Balloon size (5 mm to 8 mm in diameter) was chosen based on duplex measurements. Cutting balloons (4x20 mm and 5x20 mm) were used for dilatation of recoiling lesions in 2 cases.
Results: None of these procedures required use of fluoroscopy or contrast material. One patient required duplex-guided stent placement for recoiling lesion in the junction of the brachial and axillary veins. Postoperative VF ranged from 520 ml/min to 1750 ml/min (mean 1272 ± 486 ml/min). VF increase ranged from 25% to 160% (mean 89 ± 68%). PSV obtained at the most significant stenosis postoperatively ranged from 142 cm/sec to 321 cm/sec (mean 233 ± 64cm/sec). PSV decrease ranged from 25% to 77% (mean 56 ± 19%).
Conclusion: Angioplasty of failing AV access can be performed under duplex guidance alone. Duplex guidance offers invaluable advantages of hemodynamic evaluation for recoiling lesions and need for stenting. Avoidance of contrast use for repair of non-functioning AV access can be a useful adjunct in these patients with renal failure not yet on dialysis.
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