Duplex Ultrasound-Guided Angioplasty of Arteriovenous Fistulas

Duplex ultrasound-guided angioplasty (DA) of hemodialysis vascular access for treatment of arteriovenous fistulas (AVF) is efficacious and safe, according to study findings published in the Journal of Vascular Surgery.

Despite advantages of economics, radiation protection, and no need for nephrotoxic contrast, the practice of duplex ultrasound for AVF angioplasties is underutilized, perhaps due to insufficient documentation of efficacy and safety.

Investigators aimed to show no significant differences exist between observed rates and DA of AVF in the recommended thresholds of clinical success, postintervention patencies, and minor and major complications (the main outcomes of AVF angioplasty).

They conducted a single-center retrospective study using the medical database of the Vichy District Hospital, France, and included all 141 patients (298 DAs performed) with chronic kidney disease and upper limb AVF treated by DA from January 2015 through December 2019. The investigators collected ultrasound parameters up to 30 days before DA, at the end of angioplasty, and 30 days postprocedure (some echographic data missing after insertion of covered stent). They excluded declotting of acute thrombosis procedures or recanalization of chronic occlusion, as well as proximal venous, x-ray-guided, or arterial angioplasty.

Of the patients, 74% (mean [SD] age, 69.7 [12.4] years; 66% men) had AVF dialysis access before intervention, 14% were not yet on dialysis, 12% had central venous catheters, and 96% had native type AVF. Overall, 64% of patients had received previous angioplasty. AVF localization was split between forearm (42%), wrist (30%), and elbow (28%), and mean (SD) time between ultrasound examination and procedure was 7.1 (10) days. Among the 298 DAs, almost half (49%) involved 1 stenotic lesion, 42% had 2 lesions, and 9% had 3 to 4 lesions. Stenosis was located in inflow (42%), outflow (39%), and both inflow and outflow (19%).

Clinical success occurred in 95.3% of DAs, hemodynamic success occurred in 95.0% of DAs, and anatomical success occurred in 47.7% of DAs. Minor complications that required no adjunctive treatment were found in 52.7% of DAs, much higher than expected rates (balloons, 54% vs 8%, P <.001; stents, 36% vs 7%, P <.001).

Major complications were higher than expected rates but not significantly (balloons, 2.6% vs 2%, P =.55; stents, 5% vs 1.5%, P =.28). Major complications requiring specific therapy occurred in 8 patients (2.7%).

Overall postintervention primary patency (PP) was 34.0% at 12 months and 23.2% at 24 months. Primary assisted patency (PAP) was 87.4% and secondary patency (SP) was 92.5% at 12 months, and 78.4% and 90.5% at 24 months, respectively. No significant between-group differences of patency rates were noted (with or without minor complications [P-value for PP =.08; P-value for PAP =.08; P-value for SP =.23] or residual stenosis [P-value for PP=.82; P-value for PAP=.46; P-value for SP=.63]). Further improvement was noted at day 30 postangioplasty in duplex parameters.

Study limitations include the retrospective monocentric design, the confounding effect of multiple stenotic lesions, and some stenosis may not have been treated.

“Duplex-guided hemodialysis vascular access angioplasty is safe and efficient,” the investigators wrote “It presents postintervention patency and complications rates within the recommended threshold and provides duplex ultrasound parameters that could facilitate the definition of new efficiency criteria in the future.”