Toufic Safa , MD, FACS Vascular & Endovascular Surgery St. Francis Hospital, Roslyn NY
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Viabahn Covered Stents for Cephalic Arch Stenosis Can
Improve Patency and Longevity of Upper Arm AV Fistulas
Toufic Safa, MD, FACSVascular & Endovascular Surgery
St. Francis Hospital, Roslyn NY
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CEPHALIC ARCH STENOSIS: ACHILLES HEEL OF UPPER ARM
B-C AV FISTULAS1- Why it happens? Not fully understood2- Symptoms Include:
a- Aneurysmal Degenaration with expansion of Fistula vein size
b- Increased Pulsatility of Vein with excessive bleeding after decannulation
c- Poor Clearance on Hemodialysis3- Diagnosis can be suspected on physical exam and confirmed by duplex scanning or an angiogram
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ANEURYSMAL AV FISTULAS
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CEPHALIC ARCH STENOSIS:
TYPES OF LESIONS1- Focal Lesion at the cephalic/Subclavian vein junction (Most Common Type)2- Focal Lesion in the Mid Cephalic Arch3- Diffuse Long Segment Stenosis of the cephalic arch
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Focal Lesion at the Cephalic-Subclavian Junction (Most Common type)
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Focal Lesion in Mid Cephalic Arch
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Diffuse Long Segment Stenosis of the Cephalic Arch
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CEPHALIC ARCH STENOSIS: MANAGEMENT OPTIONS
1- Percutaneous Balloon Angioplasty2- Angioplasty and Stenting (Bare Metal vs. Covered Stent)3- Open Surgical Patch Angioplasty4- Cephalic Vein “Turndown” or transposition and anastomosis to a deep vein5- Surgical bypass with PTFE: Cephalic vein to Internal Jugular vein6- Ligate/Abandon upper arm AV fistula and create a new one elsewhere
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ANGIOPLASTY: 6 month patency 22%Fear of Rupture of VeinRapid Restenosis
ANGIOPLASTY + BM STENT: 6 month patency 43%Rapid in stent stenosisStent FracturesSubclavian vein occlusion
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BM STENT FRACTURE with OCCLUSION
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Open Patch Angioplasty of the cephalic arch
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SURGICAL BYPASS OF THE CEPHALIC ARCH
STENOSIS
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CHOICE OF COVERED STENT:
VIABAHN® (W.L.GORE)
- Extremely Flexible with Excellent Radial Support- Very Easy to Handle and Deploy
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Viabahn is a Flexible Stent Graft
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CASE EXAMPLE #1
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CASE EXAMPLE #2
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CASE EXAMPLE #3
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VIABAHN IN THE CEPHALIC ARCH:OUR EXPERIENCE
Retrospective analysis: 21 patients (13 males and 8 females) treated with angioplasty and Viabahn Stent placement in the cephalic arch over a 2 year period.
Age Range is 44-87 years
Stent size was 7-10mm in diameter and 10cm long (8mm was the most common diameter)
17 fistulas were in the left upper extremity and 5 in the right3 patients died during follow-up due to non access related causes
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VIABAHN IN THE CEPHALIC ARCH:OUR EXPERIENCERESULTS:7 patients returned for repeat interventions: 5 interventions were due to recurrent lesions at the cephalic arch and the others were due to lesions elsewhere in the fistula
1° Patency was 66%2° Patency was 100% Freedom from TLR was over 75%
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RECURRENT CEPHALIC ARCH STENOSIS
PRE: POST:
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VIABAHN IN THE CEPHALIC ARCH:OUR EXPERIENCERESULTS:Recurrent stenoses post VIABAHN stent placement in the cephalic arch tend to be EDGE stenoses similar to stenoses that develop in the SFA after VIABAHN stent therapy
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VIABAHN IN THE CEPHALIC ARCH:OUR EXPERIENCECONCLUSION:- Excellent access patency rates and
freedom from TLR can be achieved when VIABAHN stent grafts are used in the cephalic arch
- Larger patient population and longer follow-up period are necessary to validate our statements
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THANK YOU