Strategies for Managing Resistant Stenosis · Qiantai HONG, Enming YONG, Sadhana CHANDRASEKAR,...
Transcript of Strategies for Managing Resistant Stenosis · Qiantai HONG, Enming YONG, Sadhana CHANDRASEKAR,...
Zhiwen Joseph LO
MBBS, B Med Sci, MRCS, MMed, FRCSEd, FAMS, AFACS, FICS
Qiantai HONG, Enming YONG, Sadhana CHANDRASEKAR, Glenn TAN
Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital
Singapore
Strategies for Managing Resistant Stenosis
Conflicts of Interest
• Research grants:
• NMRC, A*STAR, Konica-Minolta, Tetsuyu
• Travel honorarium:
• Acelity, BD, Smith & Nephew, Ziehm Imaging
• Speaker's honorarium:
• Acelity, Granulox, Ziehm Imaging
United States Renal Data System Annual Data Report 2014
Singapore Renal Registry Annual Registry Report 1999-2016National Registry of Diseases Office. Health Promotion Board Singapore.
Tan Tock Seng Hospital (Singapore)
• 1,500-bed university tertiary hospital
• 2000 Vascular in-patient admissions per year
• 400 AV access creation per year
• 400 endovascular AV procedures per year
2017 Annual Data ReportVolume 2, Chapter 1 ZJ Lo et al. JVA 2016
29%10%
2017 Annual Data ReportVolume 2, Chapter 1
(n=103, 2008-2015)
Ann Vasc Dis 2018; 11(3): 318-323
10-24%
8%
Ann Vasc Surg 2018; 46:331-336
(n=47, 2009-2014) (n=1259)
13%0%
Endovascular Treatment of AV Access
AVF
Assisted Primary Patency
•Balloon-assisted maturation
•Access Maintenance (stenosis)
Secondary Patency (Thrombosis)
AVG
Assisted Primary Patency
(Outflow stenosis)
Secondary Patency (Thrombosis)
2017 Annual Data ReportVolume 2, Chapter 1
National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) Practice Guidelines
• AVF intervention when:
• 5.2.1 Inadequate dialysis flow (B)
• 5.2.2 Haemodynamically significant venous stenosis (B)
• 5.3 Pre-emptive PTA in:
• AVF with >50% stenosis with clinical / physiological abnormalities (B)
• 8.4 Successful angioplasty as treatment resulting in <30% residual stenosis with clinical / physiological parameters returning to acceptable limits
NKF KDOQI 2006 Vascular Access Guidelines
2017 Annual Data ReportVolume 2, Chapter 1
National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) Practice Guidelines
• Intervention in AVG stenosis without thrombosis when lesion >50% and associated with:
• 6.4.1 Abnormal physical findings (B)
• 6.4.2 Decreased flow (<600mL/min) (B)
• 6.4.3 Elevated static pressure within graft (B)
• Treatment of AVG thrombosis:
• 6.7.1 Done urgently to prevent temporary HD catheter (B)
• 6.7.2 Either percutaneous or surgical techniques (B)
• 6.7.5 Stenoses corrected using angioplasty or surgical revision (B)
NKF KDOQI 2006 Vascular Access Guidelines
Fistuloplasty Workhorses
Strategies for Managing Resistant Stenosis
2017 Annual Data ReportVolume 2, Chapter 1Agarwal SK et al. Journal Interventional Cardiology. 2015
Cutting balloon vs high-pressure balloon
• Similar technical success rates (87% vs 84%)
• 6-month target lesion patency – 67% vs 56%
• NNT: 9
Endovascular Treatment of AV Access
AVF
Assisted Primary Patency
•Balloon-assisted maturation
•Access Maintenance (stenosis)
Secondary Patency (Thrombosis)
AVG
Assisted Primary Patency
(Outflow stenosis)
Secondary Patency (Thrombosis)
2017 Annual Data ReportVolume 2, Chapter 1
Zangan & Falk. Seminars in Intervention Radiology 2009
Balloon-Assisted Maturation (BAM)
2017 Annual Data ReportVolume 2, Chapter 1
Right RC-AVF BAM (5 months post-creation)
Mustang 6mm x 40mm
2017 Annual Data ReportVolume 2, Chapter 1
Left BC-AVF BAM (6 months post-creation)
Mustang 6mm x 40mmX2 side branches open ligation
Mustang 6mm x 40mm
2017 Annual Data ReportVolume 2, Chapter 1
Right RC-AVF (4 months post-creation)
Sterling 5mm x 40mm
Cutting 5mm x 20mm
Sterling 5mm x 40mm
Access Maintenance (Stenosis) – Anatomy
Quencer & Arici. AJR 2015
1
2 3
4
5
2017 Annual Data ReportVolume 2, Chapter 1
• >50% luminal diameter reduction within 5cm from AV anastomosis
• Most commonly seen in RC-AVF
• Aetiology hypothesis:
• Loss of vasa venosum during AVF creation dissection
• Low and fluctuating shear stress
• Downstream kinking / increased turbulence
• Torsional stress
• Leading to proinflammatory cytokines and neointimal hyperplasia
• Mortamais et al. JVIR 2013:
• 124-month
• 147 interventions in 75 RC-AVF JAS
• If residual stenosis <50%,1-year primary patency 85% and 3-year 76%
Access Maintenance (Venous) – Juxta-Anastomosis Stenosis
Quencer & Arici. AJR 2015
2017 Annual Data ReportVolume 2, Chapter 1
Juxta-Anastomosis Fistuloplasty
Lt RC-AVF (9mo)Mustang 6mm x 40mm
Rt BC-AVF (2yo)Mustang 6mm x 40mm
2017 Annual Data ReportVolume 2, Chapter 1
Juxta-Anastomosis Cutting BalloonLeft BC-AVF (15mo)
Mustang 7mm x 40mmCutting 5mm x 20mm
Mustang 7mm x 40mm
2017 Annual Data ReportVolume 2, Chapter 1
• Seen in up to 77% of dysfunctional BC-AVFs
• Rarely seen in dysfunctional RC-AVFs
• Aetiology hypothesis:
• Extrinsic compression by clavi-pectoral fascia
• Sharp turn of arch causing turbulent flow
• High concentration of valves
• Angioplasty
• 12m primary patency 23%
• 12m assisted primary patency 75%
• 1.6 interventions per patient-year
• Adjuncts:
• High pressure / Cutting balloons
• Stent grafts > bare metal stents
Access Maintenance (Venous) – Cephalic Arch
Quencer & Arici. AJR 2015 ; Sivananthan et al. JVA 2014
2017 Annual Data ReportVolume 2, Chapter 1
Cephalic Arch Fistuloplasty
Left BC-AVF (4yo)
Conquest 8mm x 40mm
Left BC-AVF (3yo)
Mustang 8mm x 40mm
Cutting 7mm x 20mm
Mustang 8mm x 40mm
2017 Annual Data ReportVolume 2, Chapter 1
• Basilic vein transits from surgically created superficial and lateral location to its naturally deep and more medial location
• 70-75% of BBT-AVF stenosis
• Beaulieu et al. JVA 2007
• 93 BBT-AVFs from 2001-2004
• 74% BBT-AVF stenosis at swing segement
• 50% of swing stenosis required >2 interventions
• 1-year primary patency 42%
• 1-year secondary patency 68%
Access Maintenance (Venous) – Basilic Swing Segment
Quencer & Arici. AJR 2015
2017 Annual Data ReportVolume 2, Chapter 1
Basilic (swing segment) Fistuloplasty
Lt BBT-AVFMustang 9mm x 40mm
Rt BBT-AVFConquest 8mm x 40mm
Ann Vasc Dis 2018; 11(3): 292-297
• Mean time from AVF creation to first central venoplasty: 24 months
• 74% required two or more central venoplasty
• Mean time to second venoplasty: 7 month
2017 Annual Data ReportVolume 2, Chapter 1
Central Venoplasty
Lt BBT-AVFSVC stenosisConquest 10mm x 40mmAtlas 14mm x 40mm
2017 Annual Data ReportVolume 2, Chapter 1
Right innominate stenting (1-month recurrence)
Rt innominate occlusion(Rt CFV access)
Rt BC-AVF & Rt CFV access
Conquest 12mm x 40mmAtlas 14mm x 40mm
Venovo 14mm x 60mm
Endovascular Treatment of AV Access
AVF
Assisted Primary Patency
•Balloon-assisted maturation
•Access Maintenance (stenosis)
Secondary Patency (Thrombosis)
AVG
Assisted Primary Patency
(Outflow stenosis)
Secondary Patency (Thrombosis)
2017 Annual Data ReportVolume 2, Chapter 1
AV Graft Salvage – Stent-graft vs POBA
Haskal et al. NEJM 2010
2017 Annual Data ReportVolume 2, Chapter 1
AVG thrombectomy and venous stent-graft
Post open thrombectomyOf Lt BA-AVG (Propaten 6mm)
Mustang 8x80Fluency 8x80
2017 Annual Data ReportVolume 2, Chapter 1
Left LL loop AVG (1yo)Open thrombectomy and outflow venoplasty with stenting
Conquest 8mm x 40mm
Covera (flared) 8mm x 60mm
Zhiwen Joseph LO
MBBS, B Med Sci, MRCS, MMed, FRCSEd, FAMS, AFACS, FICS
Qiantai HONG, Enming YONG, Sadhana CHANDRASEKAR, Glenn TAN
Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital
Singapore
Strategies for Managing Recurrent Stenosis
DCB in AVF – SR and MA
• JVS 2019
• 17 studies 1113 access
• Superior 6-month and 12-month
primary patency
• Central venous stenosis: significantly
better 6-month and 12-month primary
patency
• JVIR 2018
• 12 studies 908 patients
• Significant in patency at 3-month, 6-
month, 12-month and 24-month
• Central venous stenosis: no significant
difference
2017 Annual Data ReportVolume 2, Chapter 1
DCB in AVF
Rt BC-AVF Recurrent cephalic arch 3 monthsMustang 7mm x 80mmRanger 7mm x 60mm
(Viabahn 8mm x 50mm)Mustang 8mm x 40mm
Ranger 8mm x 80mm
2017 Annual Data ReportVolume 2, Chapter 1
Juxta-Anastomosis Stenting
Swinnen et al. JVS 2015
2017 Annual Data ReportVolume 2, Chapter 1
Juxta-Anastomosis Stenting
Lt BC-AVF (2yo)Failed BAM 6m prior
Sterling 4mm x 100mmMustang 6mm x 120mmSupera 6mm x 100mm
Mustang 6mm x 80mmSupera 6mm x 80mm
Lt RC-AVF (12mo)JA fistuloplasty x2 within 7m
Patient Age Age of fistula
(Months)
No. endovascular intervention
Type of fistula
Indication Stenosis location
Vein size
Stent deployed
1 53 12 2 RC AVF Recurrent stenosis
JAS 4mm 6X80mm
2 77 35 2 RC AVF Recurrent stenosis
JAS 3mm 6X80mm
3 73 7 1 RC AVF Recurrent stenosis
JAS 4mm 6X80mm
4 69 8 1 BC AVF FTM JAS and Cephalic
arch
3mm 6x100mm
5 66 26 1 BC AVF FTM JAS 2mm 6x80mm
RC Chong et al. JVA in-press
Juxta-Anastomosis Stenting (Pilot) • Male with mean age of 67 years old
• Mean AVF age 17.6 months
• Mean vein caliber 3mm
• Technical success rate 100%
• Average positive improvement in access flow rate of 209ml/min
• Primary patency rate 100% at 1 year
• Able to cannulate through stent
RC Chong et al. JVA in-press
2017 Annual Data ReportVolume 2, Chapter 1
Conclusion
• Ultra high pressure balloons and cutting balloons are useful adjuncts in resistant AVF/AVG lesions
• Rupture risks are low and usually amenable to balloon tamponade
• AVG outflow may be treated with ultra high pressure balloons followed by stent-graft
• In recurrent lesions, DCB may be considered
• Stenting of AVF should be reserved for final salvage
My Practice – resistant AVF/AVG lesions
AVF
• Balloon-assisted maturation – cutting balloon
• Access maintenance
• Juxta-anastomois – cutting balloon
• Venous – ultra high pressure
• Cephalic arch – ultra high pressure / cutting
• Central veins – ultra high pressure
AVG – ultra high pressure + stent-graft
Recurrent lesions (< 6months) – DCB
Final salvage – stenting