IT IS A “THRILL”ING RIDE: A STUDY ON AVF SURVEILLANCE & OUTCOMES OF ENDOVASCULAR INTERVENTIONS BY NEPHROLOGISTS.

Introduction:

Haemodialysis patients need optimal vascular access for adequate dialysis. Compromised vascular access affect the adequacy of dialysis, and patients’ mortality. Endovascular intervention along with USG and angiography, subsequently followed by angioplasty help in improving AVF survival. In this study, we aimed to analyse the different sites of stenosis of AVF along with central venous lesions and outcomes of endovascular interventions.

Methods:

The study was designed as a retrospective observational study, which included all patients with dysfunctional HD access, screened on Doppler USG followed by angiography. Dysfunctional HD access was defined as hemodynamically significant stenosis with >50% reduction of normal vessel diameter accompanied by one or more hemodynamic, functional, or clinical abnormalities and thrombosis defined as an absence of bruit or thrill, using auscultation and palpation. Angiography followed by angioplasty was done with appropriate size balloon with a diameter 10-20% larger than the normal adjacent vein. Balloons were inflated in the stenotic/thrombotic area until the resolution of the balloon waist or the nominal inflation pressure was reached.

Results:

A total number of 386 patients were screened for access dysfunction with USG followed by angiography, 261(67.6 %) were males.

180(46.6 %) patients had Radiocephalic (RC-AVF), and 112(29%) had Brachiocephalic (BC-AVF), 18(40.6%) patients came with Brachiobasilic AVF (BB AVF) dysfunction, and 76(19.6%) patients had central venous lesions.

 Amongst RC AVF patients,112(62%) had exclusive Juxta anastomotic stenosis,14(8%) had   anastomotic site stenosis,26(14%) had outflow segment stenosis,28(16%) had multiple site stenosis,60(33.3%) patients presented with thrombosed RC AVF.

Amongst BC AVF, 18(16%) patients had stenosis at Juxta anastomotic site,49(44%) had outflow segment stenosis, and 45(40%) had cephalic arch stenosis,39(35%) had thrombosis.

18 patients had BB AVF dysfunction,3(16%) had juxta anastomotic stenosis, 5(28%) intercannulating segment lesions,10(56%) had swing point stenosis.

76(19.6%) patients had features of central venous stenosis amongst which 22(29%) had Brachiocephalic vein stenosis (BCV),18 subclavian stenosis (89%),36 had Superior vena cava with BCV stenosis.

 The immediate post angioplasty technical success rates were 94%,87 %,86 %,82 % for RC AVF, BC AVF, BB AVF and central lesions respectively, literature shows similar rates of immediate success, ranging from 84 to 96%. 6 vascular access related complications were encountered leading to loss of access.

Conclusions:

• This study showed that common sites of stenosis in RC AVF was juxta anastomotic site, but amongst patients with BC AVF, the most common site of stenosis was mid arm in outflow Cephalic vein (44%) in contrast to cephalic arch (40%) in most of other studies, this unique site of stenosis in our patients gives us a scope on further exploring causes of outflow cephalic vein stenosis in BC AV fistula.

•  Our experience suggests that with the technical success rate and low incidence of serious complications in this study, most AVF stenoses can be treated with efficacy and safety using an endovascular approach by interventional nephrology team in an outpatient setting especially in a resource constrained set up in low and low middle income countries.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.