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Complications of Endovascular Grafts in the Treatment of Pseudoaneurysms and Stenoses in AV Access
Jill Zink, MD, Victor Erzurum, MD, Robert Netzley, MD, Dennis Wright, MD.
Akron General Medical Center, Akron, OH, USA.
OBJECTIVES: Endovascular stent grafts are utilized in the rescue of failing AV access. Reports claim the superiorty of stent grafts and recommended these as a first line treatment. We have observed a rise in the number of complications related to stent grafts in our patients. The following study was undertaken to assess the severity of these complications and their effect on access site maintenance.
METHODS: We reviewed all patients who had endovascular stent grafts placed for treatment of failing dialysis access over the last 44 months. A series of 38 consecutively placed stent grafts was reviewed for stent migration, fracture, erosion, hemorrhage and rupture at the site of the stent grafts. Hospital charts were reviewed to assess for indications, hemodynamic stability, transfusion requirement, and outcome.
RESULTS: Of 38 stent grafts placed, 9 were for pseudoaneurysm (PS), 20 for stenosis (ST), and 9 for a combination (PS/ST). The average length of follow-up was 218.6 days. Primary patency was 49% with an assisted primary patency of 76%. Eleven patients (28.9%) presented with complications (Table 1) related to migration, fracture, erosion, or rupture. Six were in the PS, three in the PS/ST and two in the ST treatment groups. In all cases migration or fracture of the stent graft lead to recurrent pseudoaneurysm formation or erosion. Rupture occurred after a herald bleed in 4 cases. Once complication occurred 10 of the 11 access sites had to be abandoned.
CONCLUSIONS: Significant life threatening complication can arise when fracture and migration of the stent grafts used for treating AV access occur. Herald bleed with a previously placed stent graft may be a harbinger of future rupture. Complications appear less likely when stent grafts are used to treat stenosis however when complications occur access site salvage is rare. Surgical revision in the case of pseudoaneurysm should be considered for access preservation.
Table 1| Presentation and outcomes of stent graft complications | # of pts | | Presented with significant bleeding episode | 6 | | Required emergent/urgent operation | 6 | | Attempted access site salvage | 6 | | Herald Bleed (At least 72 hrs prior to presentation) | 4 | | Significant hemodynamic instability (SBP <90) | 4 | | Required blood transfusion (> 1 unit PRBC) | 3 | | Erosion without bleed | 2 | | Cardiopulmonary Arrest | 1 | | Mortality | 1 |
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