Hemodynamically significant arterial inflow stenosis in dysfunctional hemodialysis arteriovenous fistulae and grafts.
OBJECTIVE
Hemodynamically significant arterial inflow stenosis in dysfunctional fistulae and grafts is poorly understood. No reliable clinical methods exist to detect arterial inflow stenosis. In this study, we assessed the accuracy of a novel screening method to detect arterial inflow stenosis in dysfunctional fistulae and grafts following successful juxta-anastomotic and venous outflow intervention.


METHODS
We prospectively evaluated all patients (N= 204) referred to our academic center for angiographic evaluation of a dysfunctional dialysis fistula/graft from May 1, 2006 to June 30, 2007. Following successful angioplasty/stenting of the venous outflow and juxta-anastomotic areas, patients were screened for arterial inflow stenosis. The screening method involved detection of 1) weak thrill, or sluggish blood flow on the post-intervention angiogram, 2) low mean arterial blood pressures in the dialysis access arm compared to the contralateral arm, and 3) inadequate blood flow at the first hemodialysis session post-intervention. If patients screened positive for any of these, they were further evaluated for arterial inflow stenosis.


RESULTS
Fifteen patients (15/204) were positive for arterial inflow stenosis on screening study. Eleven of those 15 had arterial stenosis on angiography, giving our screening method a positive predictive value of 73.3%. Eight patients were successfully treated by angioplasty/stenting. Two patients successfully underwent surgical intervention. Two year patency of revascularization was 91% (10/11).


CONCLUSIONS
Hemodynamically significant arterial inflow stenosis occurs and can be detected by simple clinical methods. Interventions for correction of the arterial inflow stenosis are successful.
Section of Interventional Nephrology, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA. wu.steven@mgh.harvard.edu
Steven
S
Wu
Jennifer M
JM
Joe
Diego A
DA
Covarrubias
Sanjeeva P
SP
Kalva
D000046:Academic Medical Centers; D000800:Angioplasty, Balloon / Q000295:instrumentation; D062186:Arterial Pressure; D001158:Arteries / Q000503:physiopathology*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D001783:Blood Flow Velocity; D001795:Blood Pressure Determination; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D003251:Constriction, Pathologic; D003935:Diagnostic Techniques, Cardiovascular; D005260:Female; D006083:Graft Occlusion, Vascular / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D010173:Palpation; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012039:Regional Blood Flow; D006435:Renal Dialysis; D015607:Stents; D016896:Treatment Outcome