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Endograft Salvage of Failing Hemodialysis Access: A Feasibility Study
Alison J. Kinning, M.D..
Michigan Vascular Center, Flint, MI, USA.

Introduction
The incidence of ESRD is on the rise. In 2008, approximately 355,000 individuals were on hemodialysis (HD) with about 103,000 new patients annually. The most common cause of hospitalization in these patients is HD access placement, maintenance, and associated complications - including, pseudoaneurysm (PA) formation, skin erosion, graft thrombosis, and infection.
Proximal venous outflow stenosis causes increased resistance leading to weakening and dilatation of the vein or graft. PAs that are not repaired may result in skin erosion, rupture, or infection. Current standard of treatment of PAs is surgical revision.
We hypothesize that percutaneous covered stent placement is a viable and safe alternative to surgical resection for maintaining access patency.
Methods
A micropuncture sheath was placed, and a diagnostic fistulogram was obtained. Patients were anticoagulated using intravenous heparin at the discretion of the interventionalist. Fluency self-expanding covered stents were deployed, and a 6-French sheath was placed following deployment. Duplex ultrasound studies were performed at two- and six-month post-operative intervals.
Results
From July 2005 to May 2010, we prospectively evaluated 32 patients of whom 24 were enrolled. Ten patients had multiple PAs. Nine had previous interventions consisting of angioplasty of stenotic areas. There were no complications from the PA repairs. Two-month follow-up duplex was completed on 83% (20/24) of patients and six-month follow-up duplex was completed on 58% (14/24). One patient requested stent removal secondary to pain after the two-month follow-up. One patient died before completing six-month follow-up. One patient has not been enrolled for six months. Three patients had stent explantation before two-month follow-up duplex. Two patients had the stent removed due to infection before six-month follow-up. Two- and six-month duplex showed 100% patency and effective exclusion of PAs. One patient developed a late complication of stent fracture with new PA formation. To date, the longest duration of patency is 54 months.
Conclusion
Results show that minimally invasive endovascular techniques can be safely used to exclude PAs while prolonging use of the access site. In our study, infection was the most common cause for endograft removal. A larger sample size and additional follow-up is needed to validate and support our current results. It should be noted that late complications may arise, and patients should continue to be followed at regular intervals.


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