Korean J Radiol.  2006 Jun;7(2):118-124. 10.3348/kjr.2006.7.2.118.

Metallic Stent Placement in Hemodialysis Graft Patients after Insufficient Balloon Dilation

• Liang HL
• Pan HB
• Lin YH
• Chen CY
• Chung HM
• Wu TH
• Chou KJ
• Lai PH
• Yang CF

• KMID: 1782184
• DOI: http://doi.org/10.3348/kjr.2006.7.2.118

Abstract

OBJECTIVE
We wanted to report our experience of metallic stent placement after insufficient balloon dilation in graft hemodialysis patients. MATERIALS AND METHODS: Twenty-three patients (13 loop grafts in the forearm and 10 straight grafts in the upper arm) underwent metallic stent placement due to insufficient flow after urokinase thrombolysis and balloon dilation. The indications for metallic stent deployment included 1) recoil and/or kinked venous stenosis in 21 patients (venous anastomosis: 17 patients, peripheral outflow vein: four patients); and 2) major vascular rupture in two patients. Metallic stents 8-10mm in diameter and 40-80 mm in length were used. Of them, eight stents were deployed across the elbow crease. Access patency was determined by clinical follow-up and the overall rates were calculated by Kaplan-Meier survival analysis. RESULTS: No procedure-related complications (stent fracture or central migration) were encountered except for a delayed Wallstent shortening/migration at the venous anastomosis, which resulted in early access failure. The overall primary and secondary patency rates (+/- standard error) of all the vascular accesses in our 23 patients at 3, 6, 12 and 24 months were 69% +/- 9 and 88% +/- 6, 41% +/- 10 and 88% +/- 6, 30% +/- 10 and 77% +/- 10, and 12% +/- 8 and 61% +/- 13, respectively. For the forearm and upper-arm grafts, the primary and secondary patency rates were 51% +/- 16 and 86% +/- 13 vs 45% +/- 15 and 73%+/-13 at 6 months, and 25% +/- 15 and 71% +/- 17 vs 23% +/- 17 and 73% +/- 13 at 12 months (p = .346 and .224), respectively. CONCLUSION: Metallic stent placement is a safe and effective means for treating peripheral venous lesions in dialysis graft patients after insufficient balloon dilation. No statistically difference in the patency rates between the forearm and upper-arm patient groups was seen.

Keyword

Dialysis, shunts; Stents and prostheses; Veins; Transluminal angioplasty

MeSH Terms

Vascular Patency
Treatment Failure
Stents
Renal Dialysis
Polytetrafluoroethylene
Middle Aged
Metals
Male
Humans
Graft Occlusion, Vascular/*therapy
Forearm
Female
*Arteriovenous Shunt, Surgical
*Angioplasty, Balloon
Aged, 80 and over
Aged

Figure

• 

  Fig. 1 A 74-year male patient with a thrombosed loop graft in the left forearm. A. The road-map image shows that both the brachial vein (arrow) and basilic vein (arrowhead) were opacified via the downward collateral veins. B. After balloon dilation (6 & 8 mm in diameter), a persistent narrowing (arrow) of the outflow brachial vein at the elbow region was noted. Ultrasound exam revealed that this narrowing was caused by external compression from the accompanying brachial artery (not shown). C. An 8×60 mm nitinol Luminexx stent (arrow) was deployed at the venous anastomosis across the elbow joint. Note the crisscross appearance of the brachial vessels. A: brachial artery. V: brachial vein. E: elbow joint.

• 

  Fig. 2 A 51-year-old female patient with a thrombosed straight graft over her right upper arm. A. A large pseudoaneurysm at the venous anastomosis after PTA was noted, which failed to response to the prolonged balloon inflation. B. After a nitinol Memotherm stent (8×40 mm) was placed and one session of balloon inflation (5 min), small residual contrast extravasation (arrows) was still noted. C. With a second balloon inflation in the stent for another 5 min, the follow-up venogram showed complete exclusion of the pseudoaneurysm.

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  Fig. 3 A 74-year-old male patient with a thrombosed straight graft over his left upper arm. A. Recoil (arrow) and kinked (arrowhead) stenosis at the venous anastomosis after PTA was noted. B. A Wallstent (10×80 mm) was deployed across the venous anastomosis with overlapping of the stent with the graft matrix (arrow). C. Stent shortening and migration caused early re-occlusion of the access one month after its placement. D. After simple balloon dilation, the vascular flow was restored, but the access was eventually abandoned another month later.

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  Fig. 4 The diagram showed the overall primary and secondary patency rates of the 23 graft patients after metallic stent placement.

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