Polling Station

Poll 01/04/2019 – 30/04/2019

The AV access salvage procedure

Gender: Male

Age: 75 years old

Comorbidity: End-Stage Renal Disease, Diabetes, Arterial hypertension, Dyslipidemia, on hemodialysis in the last 5 years

Symptoms:  Acute occlusion of a surgically created left-sided brachial cephalic AV fistula

Question #1

Primary treatment

Which is your primary treatment option?
  • Surgical

  • Endovascular

  • Hybrid

The expert: Alexandros Mallios
Acute thrombosis of an AVF is almost always related with one or (often) more underlying and gradually evolving stenotic inflow and/or outflow lesions. While endovascular only approach is acceptable if adequate thrombus removal is possible, depending on the existence of aneurysms tortuosity etc, a surgical only approach will for sure be inadequate. Therefore, a hybrid approach appears to be the most appropriate approach in the majority of cases. New percutaneous thrombectomy devices appear to be more efficient for thrombus removal however availability and cost considerations are limiting factors.
Question #2

Phlebography after open thrombectomy

Do you routinely perform phlebography/angiography after Shunt-/AV-fistula thrombectomy?
  • Yes

  • No

The expert: Alexandros Mallios
Not performing an angiography after AVF thrombectomy leaves a high probability of early failure and re-occlusion as the almost always present underlying stenotic lesion will be left untreated. In some cases where the culprit lesion is treated surgically and in the same time with the thrombectomy (for example reimplantation of the anastomosis with resection of the stenotic segment) it may be acceptable not to perform and angiogram if clinically the AVF is “perfect” which means good-strong thrill with no pulsatility.
Question #3

IVUS for AVF

Do you think that Intravascular Ultrasound might be a useful tool for AV Access salvage procedures?
  • Yes

  • No

The expert: Alexandros Mallios
While for some cases or research purposes it might provide some additional information most physicians can adequately treat an occluded AVF with angiography and pre and intraoperative ultrasound evaluation.
Question #4

Cephalic arch stenosis

Which is your treatment of choice in case of cephalic arch stenosis?
  • Surgical

  • Plain angioplasty

  • DCB angioplasty

  • Bare-metal stent deployment

  • Stent-graft

  • Drug-eluting stent deployment

  • Vessel preparation and DCB angioplasty

The expert: Alexandros Mallios
Most cases of AVF stenosis can adequately be treated with plain angioplasty. Commonly a high-pressure balloon may be required as these lesions tend to be resistant and very fibrotic. DCBs can be suggested for recurrent lesions and when ultrasound evaluation suggests neointimal hyperplasia as cause, however available evidence is inconclusive and recent debate on risk of mortality for PAD patients indicates that careful consideration is needed. Repeated and long dilatations most of the time suffice and stent placement is rarely needed for recoil or extrinsic compression. While stent placement will provide a very satisfactory final angiogram it will often induce an intrastent restenosis and in case of extrinsic compression a stent fracture and occlusion will invariably occur and then crossing the lesion with a wire for a subsequent occlusion can prove very difficult if not impossible.
Question #5

Central vein stenosis

Which is your treatment of choice in case of central vein stenosis?
  • Surgical

  • Plain angioplasty

  • DCB angioplasty

  • Bare-metal stent deployment

  • Drug-eluting stent deployment

  • Stent-graft

  • Vessel preparation and DCB angioplasty

The expert: Alexandros Mallios
As with cephalic arch stenosis central vein stenosis can also be treated with plain PTA. Previous catheters or pacemakers, extrinsic compression or intimal hyperplasia are common mechanisms for the development of stenosis. Same principals mentioned for cephalic arch stenosis apply for this location.
Question #6

Anastomosis stenosis

Which is your treatment of choice in case of anastomosis stenosis?
  • Surgical

  • Plain angioplasty

  • DCB angioplasty

  • Bare-metal stent deployment

  • Drug-eluting stent deployment

  • Stent-graft

  • Vessel preparation and DCB angioplasty

The expert: Alexandros Mallios
While surgical reimplantation is likely more durable the ease of a plain PTA with satisfactory results for most patients makes it our preferred treatment for most cases with the exception of very frequent and early recurrences of the stenosis. A stent should be avoided in the post-anastomotic segment as it will complicate any subsequent need for surgical revision. Furthermore a stent in this location is rarely needed; a suboptimal angiographic result after plain PTA with adequate flows should be tolerated instead of pursuing a perfect angiogram by placing a big stent and inducing a risk of a high flow AVF
Question #7

Statins for AV fistula

Do you prescribe statins to improve the patency rates of AV Access?
  • Yes

  • No

The expert: Alexandros Mallios
There is no sufficient evidence to support Statin prescription for improved AVF patency. Nonetheless patients might benefit from reduced cardiovascular mortality therefore Statin prescription should be considered by the primary care physician and patient’s nephrologist.

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