J Korean Soc Radiol.  2013 Nov;69(5):351-360. 10.3348/jksr.2013.69.5.351.

Clinical Usefulness of Doppler Ultrasonography before Percutaneous Transluminal Angioplasty for Immature Native Arteriovenous Fistula

• Kim JE
• Cho YK
• Sim JC
• Lee SY
• Sung SA
• Hwang YH

• KMID: 2002855
• DOI: http://doi.org/10.3348/jksr.2013.69.5.351

Abstract

PURPOSE
To report the clinical efficacy of preprocedural doppler ultrasound examination for the treatment of immature arteriovenous fistula by means of percutaneous transluminal angioplasty (PTA) and the efficacy of PTA about its treatment.
MATERIALS AND METHODS
From November 2008 to May 2013, 28 patients who were diagnosed with immature arteriovenous fistula using doppler ultrasound examination and obtained successful maturation of it after PTA were included in this study. A retrospective comparative analysis was performed according to the findings between doppler ultrasound examination and fistulography during the procedure. The success rate of PTA and patency of fistula were evaluated in each patient.
RESULTS
Doppler ultrasound examination revealed stenosis in twenty three patients and thrombotic total occlusion in five patients. Stenosis was located in the proximal cephalic vein 2 cm from the anastomosis in 67.8% (19/28). In the five cases of thrombotic total occlusion, the lesions were long lesions from the anastomosis to the entire proximal cephalic vein at the elbow joint level. Fistulography revealed 5 patients with thrombotic total occlusion and 24 stenosis sites in 23 patients, respectively. The location and characteristics of all lesions were consistent on doppler ultrasound examination. Only four cases were observed as non-thrombotic total occlusion on fistulography, which had more than 90% stenosis on doppler ultrasound examination. The initial success rate of PTA for immature arteriovenous fistula was 96.4% (27/28). In three patients, clinical success was obtained after four times of additional PTA. Six additional PTAs were performed during follow-up, no complications related to the procedures were found. The primary patency rate was 92.9% at 3 months, 60.7% at 6 months and 39.3% at 12 months. The estimated mean survival of arteriovenous fistula was 347.9 days and the estimated median survival was 232 days. Also, the 12 months primary patency rates between the stenosis group and occlusion group showed no significant statistical difference.
CONCLUSION
Assessment of immature arteriovenous fistula using doppler ultrasound examination is a very useful method that can replace diagnostic fistulography. Also, PTA of immature arteriovenous fistula is considered an effective initial treatment for inducing successful growth maturation.

MeSH Terms

Angioplasty*
Arteriovenous Fistula*
Constriction, Pathologic
Elbow Joint
Fistula
Follow-Up Studies
Humans
Renal Dialysis
Retrospective Studies
Transplantation, Autologous
Ultrasonography
Ultrasonography, Doppler*
Veins

Figure

• 

  Fig. 1 An 80-year-old male with immature radiocephalic arteriovenous fistula. A. The gray-scale of doppler ultrasonography shows a diameter of anastomosis, a serial caliber difference of proximal venous limb and depth of fistula. B. The pulse wave doppler measurement shows a small volume flow along proximal venous limb of fistula.

• 

  Fig. 2 A 51-year-old male with immature radiocephalic arteriovenous fistula (AVF). Comparison between color doppler ultrasound examination and angiography. A. The color doppler ultrasonography shows a less 2 mm diameter of anastomosis and proximal venous limb of radiocephalic AVF (arrowheads). B. The angiography after puncture of left brachial artery shows a focal severe stenosis of proximal venous limb of radiocephalic AVF (arrows).

• 

  Fig. 3 A 77-year-old male with immature radiocephalic arteriovenous fistula (AVF). Comparison between color doppler ultrasound examination and angiography of totally thrombotic occluded radiocephalic AVF. A. The color-scale longitudinal doppler ultrasonography shows a totally occluded flow and large amount of echogenic thrombus through entire proximal venous limb of fistula (arrowheads). B. The angiography after puncture of left brachial artery shows a totally occluded proximal venous limb of fistula from just distal from anastomosis (arrow). C. After percutaneous balloon angioplasty with 3 mm × 15 cm balloon catheter, the final angiography shows a completely recanalized entire proximal venous limb of fistula without residual stenosis, but small amount remained thrombi was observed around venous wall of proximal venous limb of fistula (arrows).

• 

  Fig. 4 A 78-year-old male with a pseudoaneurysm of proximal venous limb of radiocephalic arteriovenous fistula (AVF) after percutaneous transluminal angioplasty (PTA). A. The angiography after puncture of brachial artery shows a focal severe stenosis of proximal venous limb of immature radiocephalic AVF (arrowhead). B. After PTA with 3.0 mm × 4 cm balloon catheter, the final angiography shows an acute onset of pseudoaneurysm at most stenosis site of proximal venous limb of immature radiocephalic AVF (arrow).

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  Fig. 5 Clinical success analysis of all patients. A. Kaplan-Meier estimation of primary patency of arteriovenous fistula after percutaneous transluminal angioplasty. B. The Log Rank test estimation of statistical difference between stenosis group and occlusion group.

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