title: Endovascular treatment of hemodialysis access pseudoaneurysms.
abstract: OBJECTIVE
  Pseudoaneurysm (PSA) formation is a complication of hemodialysis access. Open repair requires PSA resection, interposition graft placement, and insertion of a catheter as a bridge. Endovascular stent graft repair is an alternative that permits immediate use of the access site. The objective of this study was to determine the efficacy of stent grafts for repair of arteriovenous fistula and arteriovenous graft PSA.
  
  
  METHODS
  A retrospective review of medical records from October 2007 to March 2011 revealed 24 patients with a PSA who underwent endovascular repair using a stent graft. Indications for repair included PSA with symptoms (n = 11), PSA with skin erosion (n = 8), PSA with failed hemodialysis (n = 3), and PSA after balloon angioplasty of a stenosis (n = 2). Outcome measures were technical success, 30-day and 180-day patency, secondary interventions, and complications. All the statistical analyses were conducted by using software SAS 9.1 (SAS, SAS Institute, Gary, NC).
  
  
  RESULTS
  Twenty-seven self-expanding stent grafts (Viabahn, W. L. Gore, n = 25; Fluency, Bard, n = 2) were used to treat hemodialysis access (arteriovenous graft, n = 13; arteriovenous fistula, n = 11) PSA in 24 patients (16 females; mean age, 55.7 years; mean body mass index, 28.4; mean PSA diameter, 19.5 mm). Comorbidities included hypertension (n = 22; 91.7%), diabetes mellitus (n = 8; 33.3%), and coronary artery disease (n = 4; 16.67%). The median time from access creation to repair was 455 days. The technical success rate was 100%. Balloon angioplasty of an outflow stenosis was performed in 56% of stent grafts. The 30- and 180-day patency rate was 100% and 69.2%, respectively. Three secondary interventions were performed for treatment of unrelated stenosis. Treatment failure occurred in five (18.5%) stent grafts due to infection (n = 3) and thrombosis (n = 2). Treatment of PSA with skin erosion was associated with failure due to infection (odds ratio, 5.0; 95% confidence interval, .38, 66.01). The remaining 22 (81.5%) stent grafts remain patent. The mean follow-up time was 268.9 days (median, 97.5).
  
  
  CONCLUSIONS
  Endovascular therapy is an effective and durable treatment option for patients with dialysis access PSAs. This technique permits immediate use of the hemodialysis access site as well as identification and treatment of associated stenosis. It may be considered as an alternative to open repair in patients who are anatomically suitable candidates.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Houston, TX, USA.
authors.forename: Aamir S
authors.initials: AS
authors.lastname: Shah
authors.forename: Jaime
authors.initials: J
authors.lastname: Valdes
authors.forename: Kristofer M
authors.initials: KM
authors.lastname: Charlton-Ouw
authors.forename: Zhongxue
authors.initials: Z
authors.lastname: Chen
authors.forename: Sheila M
authors.initials: SM
authors.lastname: Coogan
authors.forename: Hammad M
authors.initials: HM
authors.lastname: Amer
authors.forename: Anthony L
authors.initials: AL
authors.lastname: Estrera
authors.forename: Hazim J
authors.initials: HJ
authors.lastname: Safi
authors.forename: Ali
authors.initials: A
authors.lastname: Azizzadeh
mesh_terms: D017541:Aneurysm, False / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D002408:Catheters, Indwelling / Q000009:adverse effects*; D015331:Cohort Studies; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000601:surgery*; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D011859:Radiography; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D015607:Stents; D016896:Treatment Outcome; D014654:Vascular Patency / Q000502:physiology