title: Prevalence and treatment of cephalic arch stenosis in dysfunctional autogenous hemodialysis fistulas.
abstract: OBJECTIVE
  Cephalic arch stenosis (CAS) is a recently recognized cause of dysfunction in autogenous hemodialysis fistulas. The prevalence of this lesion among dysfunctional autogenous fistulas is described, as are outcomes after percutaneous therapy.
  
  
  METHODS
  A cohort of 177 dysfunctional autogenous fistulas treated over a 48-month period was retrospectively analyzed for the presence of CAS. Of these, 116 (66%) were radiocephalic fistulas and 61 (34%) were brachiocephalic fistulas. CAS was identified in 26 fistulas among 24 patients. Fifty dilations and three stent placements in the cephalic arch were performed. Surveillance was conducted after percutaneous therapy by means of ultrasound dilution technique and measurement of dialysis flow rates. Patency rates were estimated with use of the Kaplan-Meier method. No patients were lost to follow-up.
  
  
  RESULTS
  The prevalence of CAS was 15% (26 of 177). There was a significant difference in the prevalence of CAS between brachiocephalic and radiocephalic fistulas (39% vs 2%; P <.001). High-pressure noncompliant balloon catheters were required in 29 of 50 dilations (58%) to efface the lesion. Primary patency rates (+/-SE) at 3, 6, and 12 months were 76% +/- 8, 42% +/- 10, and 23% +/- 9, respectively. Primary assisted patency rates (+/-SE) at 3, 6, and 12 months were 96% +/- 4, 83% +/- 8, and 75% +/- 10. Complications occurred in three cases (6%). A major complication with rupture of the cephalic arch resulted in thrombosis and fistula loss (n = 1); two minor complications of cephalic arch rupture were salvaged with placement of a Wallstent (n = 1) or prolonged balloon inflation (n = 1).
  
  
  CONCLUSIONS
  CAS is common among failing brachiocephalic arteriovenous fistulas. With aggressive percutaneous intervention and surveillance, favorable primary assisted patency rates can be achieved.
authors.affiliation: Division of Vascular and Interventional Radiology, Toronto Western Hospital, University Health Network-University of Toronto, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada. dheeraj.rajan@uhn.on.ca
authors.forename: Dheeraj K
authors.initials: DK
authors.lastname: Rajan
authors.forename: Timothy W I
authors.initials: TW
authors.lastname: Clark
authors.forename: Nikunj K
authors.initials: NK
authors.lastname: Patel
authors.forename: S William
authors.initials: SW
authors.lastname: Stavropoulos
authors.forename: Martin E
authors.initials: ME
authors.lastname: Simons
mesh_terms: D000368:Aged; D000792:Angiography; D000800:Angioplasty, Balloon; D001132:Arm / Q000098:blood supply*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D016121:Brachiocephalic Veins / Q000601:surgery; D002404:Catheterization; D003251:Constriction, Pathologic; D005260:Female; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000628:therapy*; D006801:Humans; D008297:Male; D016017:Odds Ratio; D015641:Radiography, Interventional; D006435:Renal Dialysis; D012189:Retrospective Studies; D015607:Stents; D014463:Ultrasonography; D014654:Vascular Patency