Stent-Graft placement after angioplasty demonstrates improved patency rates compared to angioplasty alone in cephalic arch stenosis

Cephalic arch stenosis is a common cause of fistula dysfunction that has poor patency rates with traditional angioplasty. Stenting has been suggested to improve patency rates; however, to date this is the first prospective study examining the outcomes of stent graft placement for cephalic arch stenosis. This was a randomized, prospective, single blinded study of 14 patients over a four year period, five of whom had PTA alone, and 9 of whom had PTA with placement of a Viabahn stent. The lesions studied showed greater than 50% stenosis, were treated with angioplasty to achieve less than 30% stenosis, and then if randomized to the stent arm, a Viabahn stent was placed and post dilated. Anatomic success (residual stenosis of less than 30%) and clinical success (at least one normal dialysis session post treatment) were achieved in all patients. The mean patency of angioplasty alone was 100 days (range 56-154 days) versus 300 days (range 201-504) in the angioplasty plus stent group. Circuit patency rates (time from intervention to next access thrombosis or intervention) were 0% at 6 months for PTA alone versus 67% at 6 months with PTA and stent (p<0.01).

Comment:

As compared to angioplasty alone, angioplasty plus stent shows improved patency rates in the setting of cephalic arch stenosis greater than 50%. While this study was limited by a small sample size, with enrollment failing to meet the calculated sample size, the results are compelling. Repeat studies are warranted to confirm the authors’ findings.


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(a) Initial fistulogram demonstrates focal stenosis 4 50% near the junction of the cephalic vein with the axillary vein in a 65- year-old woman with right brachiocephalic fistula who presented with decreased access blood flow. (b) After placement of an 8-mm 60-mm stent graft in this patient, a fistulogram demonstrates preservation of flow in the axillary vein. Arrows mark the end point of the stent graft. (c) In another patient, fistulography 8 months after stent-graft placement demonstrates focal stenosis adjacent to the edge (arrow) of the stent graft.


Citation: Rajan, D. K. & Falk, A. A Randomized Prospective Study Comparing Outcomes of Angioplasty versus VIABAHN Stent-Graft Placement for Cephalic Arch Stenosis in Dysfunctional Hemodialysis Accesses. Journal of Vascular and Interventional Radiology (2015). doi:10.1016/j.jvir.2015.05.001


Post Author: Tim Huber, MD. VIR Pathway Resident at University of Virginia