Duplex Guided Trans-Radial Artery BAM and Fistuloplasties
Ahmad Alsheekh, M.D, Anil Hingorani, M.D, natalie marks, M.D, enrico ascher, M.D.
Total Vascular Care, Brooklyn, NY, USA.
Objective:
While arteriovenous fistulae (AVF) are the preferred mode of hemodialysis access due to their high patency rates, they are associated an appreciable rate of non-maturation. Balloon Assisted Maturation (BAM) has been described to treat this issue. BAM is defined as repeated sequential graduated dilatation of the outflow vein. This study aims to evaluate the short term complications of using radial artery as an access for BAM procedures and fisutloplasties. Trans-radial access was used preferentially with multiple lesions in the AVF that were difficult to access with a single venous puncture.
Methods:
Prospective data were collected over 3years on 27office-based duplex-guided trans-radial access BAM procedures in 20 patients. 324 cases of BAM with ultrasound guidance were performed using a venous puncture during this time period. The indication for the procedures was failure of AVF maturation and 5 cases with short segment thrombectomy. All procedures were performed with local anesthesia only. Access site puncture, vessel cannulation, wire placement, and balloon advancement and insufflation were duplex guided. The radial artery was punctured with ultrasound guidance and a 4French sheath was placed. After crossing the lesion(s), 5,000 units of heparin were given. The radial artery was used as the access vessel for all procedures except one, in which brachial artery was used in addition. Vascular injuries were classified based on post-procedural duplex assessment. All patients had follow-up duplex scans within a week.
Results:
The average age was 75.9years (±13.8SD, range 36-96 years). The types of AVF were: 14radio-cephalic, 1 radio-basilic, 2 brachio-brachial and 3 brachio-basilic. Site of lesions were 10 on the venous outflow, 6 perianatomotic and 3 in the radial artery. The balloon size ranged from 3-6 mm(18 patients) and 7-12 mm(9 patients). The most common injury was formation of wall hematoma of the outflow vein(3),extravasation or rupture at the balloon site(3), spasm of the AVF(3),formation of puncture-site hematoma(2),and intimal flap(2).Extravasation was controlled with duplex guided compression. There were no radial artery thromboses and all the AVFs were patent on completion duplex and follow-up duplex.
Conclusions:
These data suggest that the radial artery could be used as a safe access route for BAM procedures with relative low rates of complication. This approach can be considered as an adjunct in the armamentarium for angioplasty of AVF
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