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Techniques for angioplasty of the arteriovenous hemodialysis access

Author
Gerald A Beathard, MD, PhD
Section Editors
Steve J Schwab, MD
David L Cull, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS

INTRODUCTION

Percutaneous intervention has become a standard therapy for the management of venous stenosis affecting hemodialysis arteriovenous access because it is safe, effective, and easily performed [1-7]. Venous stenosis may also be corrected by surgical revision or endovascular stent placement. (Stent placement is reviewed separately). Compared with surgical revision, percutaneous angioplasty has the principal advantage of preserving potential venous access sites by avoiding jump grafts and sacrificing a segment of vein.

Percutaneous intervention for the treatment of hemodialysis arteriovenous access stenosis is an outpatient procedure, with the access immediately available for dialysis once the lesion is corrected. Lesions in all locations within the arteriovenous access and its draining veins, both peripheral and central, are effectively and safely treated [1]. There is minimal to no blood loss, hospitalization is avoided, and there is minimal postprocedure discomfort. However, lesions about 15 percent of lesions may be resistant to dilation or elastic, recoiling after what initially appeared to be a successful dilation [8,9]. In a study of 102 angioplasty procedures [8], two cases were noted that could not be treated even using pressures up to 40 atm. In another study, which analyzed 154 stenotic lesions [9], a 15 percent incidence of elastic lesions was observed. The elastic lesion was defined as recurrent luminal narrowing greater than 50 percent within 15 minutes after full effacement of the stenosis by the angioplasty balloon.

Techniques used for percutaneous angioplasty of arteriovenous hemodialysis access are reviewed here. Issues related to monitoring and diagnosis of stenosis of chronic hemodialysis access and indications for intervention in patients with hemodialysis arteriovenous (AV) fistulas and grafts are discussed in detail separately. (See "Clinical monitoring and surveillance of the mature hemodialysis arteriovenous fistula" and "Monitoring and surveillance of hemodialysis arteriovenous grafts to prevent thrombosis" and "Percutaneous intervention for the treatment of stenosis in the arteriovenous access".)

PREPROCEDURE EVALUATION AND PREPARATION

In addition to a general history and physical examination directed toward the risks of the procedure, the pre-procedure evaluation should include a detailed physical examination of the access and access arm, and should include the use of Doppler ultrasound [10]. A dysfunctional arteriovenous (AV) access is often obvious by physical examination. (See "Maturation and evaluation of the newly created hemodialysis arteriovenous fistula" and "Physical examination of the arteriovenous graft".)

The preprocedure examination of the hemodialysis arteriovenous access is important for several reasons.

                                     

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Literature review current through: Nov 2016. | This topic last updated: Mon Jul 18 00:00:00 GMT+00:00 2016.
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