Low-flow maturation failure of distal accesses: Treatment by angioplasty of forearm arteries

• Published in: Journal of vascular surgery 2009-04, Vol.49 (4), p.995-999
• Main Authors: Raynaud, Alain, MD, Novelli, Luigi, MD, Bourquelot, Pierre, MD, Stolba, Jan, MD, Beyssen, Bernard, MD, Franco, Gilbert, MD
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Angiography; Angioplasty, Balloon - adverse effects; Arterial Occlusive Diseases - etiology; Arteriovenous Shunt, Surgical - adverse effects; Biological and medical sciences; Brachiocephalic Veins - surgery; Emergency and intensive care: renal failure. Dialysis management; Female; Forearm - blood supply; Humans; Intensive care medicine; Male; Medical sciences; Middle Aged; Radial Artery - injuries; Radial Artery - pathology; Radial Artery - physiopathology; Radial Artery - surgery; Renal Dialysis; Retrospective Studies; Rupture; Spasm - etiology; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Thrombosis - etiology; Time Factors; Treatment Failure; Ulnar Artery - injuries; Ulnar Artery - pathology; Ulnar Artery - physiopathology; Ulnar Artery - surgery; Ultrasonography, Doppler, Duplex; Vascular Patency; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2008.10.061

Background Forearm artery lesions are a frequent cause of distal fistula maturation failure. Surgical treatment is difficult because of highly calcified arteries. To redo the arteriovenous anastomosis higher up the forearm is technically difficult and often ineffective because arteries cannot be enlarged. It also causes a loss in puncture zone. Creation of brachial accesses leads to a high risk of distal ischemia. Methods From September 2000 to September 2006, we performed percutaneous transluminal angioplasty (PTA) of forearm arteries in 25 patients with failing distal access maturation. We reported immediate results of the dilatation and retrospectively analyzed the outcome of the accesses after the procedure. Results Forearm artery PTA was achieved in all 25 patients. Three main complications occurred: severe spasms precluding precise assessment of the artery patency after dilatation, rupture easily treated by prolonged low-pressure balloon inflation, and early rethrombosis leading to access loss. Follow-up was available in 23 patients. PTA failed to restore a sufficient access flow in two patients (the access loss and an insufficient increase in flow). In the remaining 21 (91%), accesses started to be used for hemodialysis without difficulties. Primary patency access rates after PTA were 83% (range, 60%-93%) at 1 year and 74% (range, 47%-89%) at 2 years. Secondary access patency rates were 86% (range, 64%-95%) at 1 and 3 years. Conclusion When a distal access fails to mature because of forearm artery lesions, PTA should be done and will salvage the fistula without risk of distal ischemia and cardiac failure. Efficacy of PTA clearly influences surgical strategy and is a major argument in favor of attempting to create distal accesses in patients with mild distal artery lesions. Even in cases of failure, such as early occlusion of the fistula, this technique does not jeopardize further proximal access creation. Forearm access creation should be avoided only in cases of extremely severe distal artery lesions.