Arnolda Marija Baškytė1, Rytis Kijauskas1, Jonas Bernotas2
1Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
2Department of Vascular Surgery, Lithuanian University of Health Sciences, Kaunas
ABSTRACT
Aim: The aim of the study was to evaluate the results of endovascular treatment of arteriovenous fistula dysfunction at the Hospital of Lithuanian University of Health Sciences (LUHS) Kaunas Clinics.
Methods: Data of 125 patients, who underwent endovascular treatment of arteriovenous fistula disfunction at the Hospital of Lithuanian University of Health Sciences (LUHS) Kaunas Clinics between 1st January, 2016 and 31st December, 2018 were analyzed.
Results: The study population consisted from 80 male and 45 female. The average age of the participants was 61,73 ± 14,86 years. 36,1% patient had AVF stenosis, 87,2% of
them had just one stenosis site and 63,9% patient had occlusion. The most frequent localization of the occlusion or stenosis was at the site of AVF anastomosis – 68%.
Conclusions: 1. AVF occlusion was more frequent than stenosis. 2. Mostly AVF stenosis or occlusion were usually on one site. 3. Most often AVF stenosis or occlusion was found on the site of AVF anastomosis and rarely on the other localization.
Keywords: arteriovenous fistula, arteriovenous access, endovascular treatment, percutaneous transluminal angioplasty, stent.
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Medical Sciences 2020 Vol. 8 (16), p. 236-242
Role of PTA and stenting in treatment of arteriovenous access
dysfunction
Arnolda Marija Baškytė
1
, Rytis Kijauskas
1
, Jonas Bernotas
2
1
Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
2
Department of Vascular Surgery, Lithuanian University of Health Sciences, Kaunas
ABSTRACT
Aim: The aim of the study was to evaluate the results of endovascular treatment of arteriovenous fistula dysfunction at the
Hospital of Lithuanian University of Health Sciences (LUHS) Kaunas Clinics.
Methods: Data of 125 patients, who underwent endovascular treatment of arteriovenous fistula disfunction at the Hospital of
Lithuanian University of Health Sciences (LUHS) Kaunas Clinics between 1st January, 2016 and 31st December, 2018
were analyzed.
Results: The study population consisted from 80 male and 45 female. The average age of the participants was 61,73 ± 14,86
years. 36,1% patient had AVF stenosis, 87,2% of
them had just one stenosis site and 63,9% patient had occlusion. The most frequent localization of the occlusion or stenosis
was at the site of AVF anastomosis – 68%.
Conclusions: 1. AVF occlusion was more frequent than stenosis. 2. Mostly AVF stenosis or occlusion were usually on one
site. 3. Most often AVF stenosis or occlusion was found on the site of AVF anastomosis and rarely on the other localization.
Keywords: arteriovenous fistula, arteriovenous access, endovascular treatment, percutaneous transluminal angioplasty,
stent.
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237
1.Introduction
Arteriovenous fistula (AVF) is formed surgically for
patients who need permanent hemodialysis. Over time AVF
can become occluded or stenotic, what causes its failure.
The meaning of this term differs in literature. Mostly it
describes anatomical changes that cause difficulty in
performing qualitative hemodialysis (1). Arteriovenous
access stenosis or occlusion has meaningful negative effect
on quality of hemodialysis. To prevent this, The National
Kidney Foundation Kidney Disease Outcomes Quality
Initiative Practice Guidelines on Vascular Access
recommend that “all dialysis facilities have a program in
place to provide regular assessment of the AV access and
hemodialysis adequacy. The goal of this program is to
prospectively detect the presence of AV access
dysfunction’’ (2 – 3). Unfortunately, sometimes it is hard to
predict early stages AVF disfunction at the time of
inspection, but once it is diagnosed it must be treated.
Nowadays various correction methods can be used:
percutaneous transluminal angioplasty (PTA), surgical
treatment, endovascular stent or stent-graft placement (4).
The first choice for AVF disfunction diagnostic and
treatment is endovascular. Stenotic lesions are commonly
treated with PTA, PTA and stenting or stent-graft
placement. Still, PTA is the gold standard treatment method
because it leaves nothing behind. Unless it is not effective,
then the stents can be used. In case of AVF occlusion
whether to treat endovascular or surgically is still not very
clear.
2. Aim
The aim of the study is to evaluate the results of
endovascular treatment of arteriovenous fistula stenosis or
occlusion at the Hospital of Lithuanian University of Health
Sciences (LUHS) Kaunas Clinics.
3. Methods
This research was approved by Lithuanian University of
Health Sciences Bioethics Centre. Retrospective analysis
was done. Analysis was performed from visual diagnostic
database and treatment procedure protocols. This study
included 125 patients treated and examined in the Hospital
of LUHS Kaunas Clinics between 1st January, 2016 and
31
st
December, 2018. Cases were evaluated in terms of
gender, age, occlusion or stenosis localization of the AVF,
changes before and after treatment, treatment method. To
compare results, we used „Microsoft Office Excel 2013“and
IBM SPSS Statistics 25.0 software package. Statistical
significance is p < 0,05.
4. Results
Of 125 patients there were 80 male and 45 female. The
mean age of the participants was 61,73 ± 14,86 years (60,51
± 15,09 in male group and 63,74 ± 14,1 in female group).
There was no statistically significant difference between
male and female groups in comparison with age (p=0,49).
Totally 125 procedures were performed. 33 procedures were
radiological diagnostic examinations and rest 92 procedures
were diagnostic procedures with endovascular treatment.
The localization of AVF varied: 63,6% of patients had
lower arm AVF, 36,4% - upper arm AVF. In total, 36,1%
patient had AVF stenosis (of those: 87,2% had one and
12,8% had two or more stenosis) and 63,9% patient had
occlusion. After evaluation it was found no statistical
significance between lesion quantity (p=0,184). The most
frequent localization of the occlusion or stenosis was at the
site of AVF anastomosis – 68% (of those: 52% occlusion
and 16% stenosis), while in the outflow veins – 32% (of
those: 15% occlusion and 17% stenosis), but the statistical
significance of treatment results wasn’t found (p=0,09)
between those groups (Figure 1).
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81,8% patient with stenosis were treated with PTA and
18,2% were stented. Patients with occlusion mostly were
treated with PTA – 86,4%, while stented – 13,6% (Figure
2). There was found no statistically significant difference in
treatment success between stenosis and occlusion groups
(p=0,051).
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In comparison, although PTA was the most common
treatment method for upper and lower arm AVF, stent-graft
placement was more frequently required for upper arm AVF
(26,9%), than for the lower arm AVF (13,3%) (Figure 3).
Even so, there was no statistical 77significance between
treatment method and AVF localization (p=0,153).
Puncture sites during treatment were: radial artery – 58,7%,
brachial artery – 19,56%, other – 21,74%. 10 treated
patients’ results (10,87%) were not evaluated due to lack of
information. For 9 patients (10,97%) treatment of stenosis
or occlusion was not effective. Overall 73 patients had
successful procedure. For 7 of these patients were achieved
100% successful recanalization with 0% residual stenosis.
Successful treatment showed better results for women
96,88% compared to 84% treatment success in male group.
There was no statistical significance between treatment
success and gender group (p=0,069).
5. Discussion
Based on previous foreign research, stenosis or occlusion of
the AVF is the most common chronic complication, causing
it’s disfunction (6). In our study, we decided to look through
the results of revascularization and its’ success. Our
research consisted of 125
patients, who had arteriovenous fistula stenosis or
occlusion. Age of patients ranged from 27 to 88 years. The
average age of the population was 61,73 ± 14,86 years. To
our knowledge in the majority of studies the average age
was quite similar (5, 7 – 8) . Previous
researches showed, that male gender is more likely to have
arteriovenous access stenosis or occlusion (5, 8). Relatively,
we obtained similar results: study population consisted of
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80 male and 45 female. Sedat Belli et al. in a study,
conducted in Turkey, estimated that
ordinary patients had brachial – cephalic fistula (9).
However, our survey showed that radial - cephalic fistula is
more common in LUHS Kaunas Clinics as in the Umraniye
Training and Research Hospital (10). Nevertheless, our
study showed that in Kaunas Clinics, as in the whole
Europe, lower arm fistula is more common compared to the
United States, where upper arm fistula is more often (11).
According to our findings it became evident, that the most
common localization of AVF failure was at the site of
anastomosis. Meanwhile, other authors suggest, that most
common localization of stenosis is in the outflow draining
vein (6). In our hospital PTA is the first choice
treatment method for AVF stenosis (3). Endovascular stent
placement was needed only for 15,85% patient, although
Mokdong Hospital researchers used stent even less
frequently (5). Also, the difference may be achieved
because of quite aggressive tactics
of LUHS Kaunas Clinics endovascular specialists in case
where success is not likely to achieve. During the study, we
found that surgical treatment was recommended only for
8,8% patient. However, the practice of other countries
shows that PTA is only a temporary solution of the AVF
stenosis and occlusion, because revascularization surgery
shows better results in AVF survival time (12). In LUHS
Kaunas Clinics overall treatment success was achieved for
89,02% patients (96,88% in female and 84% in male
group). M.Han et al. research shows quite similar results:
technical success was 95,7% and clinical success – 86,5%
(13). In comparison, in Jan H.M. Tordoir et al. Review of
Evidence clinical success rates from 43% to 100% (14). All
in all, our study has drawbacks due to its small sample size,
but the initial results are similar to those of other foreign
studies. Therefore, new researches about new therapies,
reduction of arteriovenous access dysfunction and new AVF
creation methods are underway (15 – 17).
6. Conclusions
1. AVF occlusion was more frequent than stenosis.
2. Mostly AVF stenosis or occlusion had one lesion site.
3. Most often AVF stenosis or occlusion was found on the
site of AVF anastomosis and rarely on the other
localization.
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