Prospective study of balloon inflation pressures and other technical aspects of hemodialysis access angioplasty.
OBJECTIVE
Balloon angioplasty is a mainstay in the treatment of failing or thrombosed hemodialysis access grafts and fistulas. A sizable body of outcomes data exists concerning percutaneous transluminal angioplasty (PTA) in hemodialysis access, yet there is a relative paucity of technical information available, especially regarding dilation pressures. The aim of the present study was to compile such information, which can be critical to the choice of devices for PTA and to the design of future clinical trials seeking to improve outcomes in this area.


METHODS
Technical data were collected prospectively for 102 PTA procedures (66 prophylactic PTA procedures and 36 PTA procedures performed during access thrombectomy). Demographic data concerning the access were collected. Technical data were collected individually for each lesion treated, including lesion location; degree of stenosis (in quartiles); lesion length; PTA balloon brand, size, and length; pressure at which the waist of the balloon was effaced; residual stenosis; and reason for additional balloons or inflations if used. Outcomes data other than residual stenosis were not collected, but the endpoint for all interventions was a thrill in the access.


RESULTS
A total of 230 lesions were treated. Two (1%) could not be successfully treated with PTA despite the use of "ultra high" pressure (approximately 40 atm); one was treated successfully with parallel wire technique and the other was revised surgically after the use of a cutting balloon also failed. Overall, 55% of lesions required pressures greater than 15 atm to efface the waist. Excluding initial failures, 20% of lesions in native fistulas and 9% in grafts required very high pressure (>20 atm) to efface the waist (P = .02). High pressure was needed less frequently in PTA procedures performed in the setting of thrombectomy procedures than in prophylactic PTA procedures (P = .0001). Residual stenosis was positively correlated with severity of initial stenosis and negatively correlated with duration of inflation.


CONCLUSIONS
Conventional angioplasty balloons are inadequate for the treatment of most hemodialysis access stenoses. High pressures (>15 atm) are commonly needed for PTA in hemodialysis access. Very high pressures (>20 atm) are more frequently needed in native fistulas.
Trerotola
Scott O
SO
Department of Radiology, Division of Interventional Radiology, University of Pennsylvania Medical Center, 1 Silverstein, 3400 Spruce Street, Philadelphia, Pennsylvania 19104, USA. streroto@uphs.upenn.edu
Kwak
Andrew
A
Clark
Timothy W I
TW
Mondschein
Jeffrey I
JI
Patel
Aalpen A
AA
Soulen
Michael C
MC
Stavropoulos
S William
SW
Shlansky-Goldberg
Richard D
RD
Solomon
Jeffrey A
JA
Tuite
Catherine M
CM
Chittams
Jesse L
JL
D000800:Angioplasty, Balloon / Q000295:instrumentation / Q000379:methods*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000628:therapy*; D006801:Humans; D011312:Pressure; D011446:Prospective Studies; D015641:Radiography, Interventional; D006435:Renal Dialysis; D017131:Thrombectomy; D013927:Thrombosis / Q000628:therapy; D016896:Treatment Outcome