Stent graft versus balloon angioplasty for failing dialysis-access grafts.
BACKGROUND
The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis. Balloon angioplasty, the first-line therapy, has a tendency to lead to subsequent recoil and restenosis; however, no other therapies have yet proved to be more effective. This study was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous anastomotic stenosis in failing hemodialysis grafts.


METHODS
We conducted a prospective, multicenter trial, randomly assigning 190 patients who were undergoing hemodialysis and who had a venous anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft. Primary end points included patency of the treatment area and patency of the entire vascular access circuit.


RESULTS
At 6 months, the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group (51% vs. 23%, P<0.001), as was the incidence of patency of the access circuit (38% vs. 20%, P=0.008). In addition, the incidence of freedom from subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32% vs. 16%, P=0.03 by the log-rank test and P=0.04 by the Wilcoxon rank-sum test). The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than in the stent-graft group (78% vs. 28%, P<0.001). The incidences of adverse events at 6 months were equivalent in the two treatment groups, with the exception of restenosis, which occurred more frequently in the balloon-angioplasty group (P<0.001).


CONCLUSIONS
In this study, percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use of a stent graft, which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty. (ClinicalTrials.gov number, NCT00678249.)
Division of Vascular and Interventional Radiology, University of Maryland Medical Center, 22 S. Greene St., GK214, Baltimore, MD 21201, USA. ziv2@mac.com
Ziv J
ZJ
Haskal
Scott
S
Trerotola
Bart
B
Dolmatch
Earl
E
Schuman
Sanford
S
Altman
Samuel
S
Mietling
Scott
S
Berman
Gordon
G
McLennan
Clayton
C
Trimmer
John
J
Ross
Thomas
T
Vesely
D000800:Angioplasty, Balloon / Q000009:adverse effects; D001166:Arteriovenous Shunt, Surgical / Q000379:methods; D002408:Catheters, Indwelling / Q000009:adverse effects; D005260:Female; D005500:Follow-Up Studies; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000628:therapy*; D006801:Humans; D057194:Intention to Treat Analysis; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D006435:Renal Dialysis; D015607:Stents / Q000009:adverse effects; D017211:Treatment Failure; D014654:Vascular Patency