PurposeTo determine safety and effectiveness of percutaneous interventions performed by interventional radiologists at a single institution over 2 decades in patients with dialysis access steal syndrome (DASS).Materials and MethodsA retrospective review of fistulograms from 2001 to 2021 (N = 11,658) was performed. In total, 286 fistulograms in 212 patients with surgically created dialysis accesses met inclusion criterion of fistulography for suspected DASS. Chart review collected data regarding patient demographics, comorbidities, access characteristics, fistulography findings, intervention(s) performed, and outcomes. Procedures with and without DASS intervention were compared. Odds ratios (ORs), adjusted for age, sex, comorbidities, access characteristics, and multiple within-patient events, were calculated using logistic regression to determine associations between steal intervention status and outcome variables: (a) major adverse events, (b) access preservation, and (c) follow-up surgery. A percutaneously treatable cause of DASS was present in 128 cases (45%). Treatment of DASS lesions was performed in 118 cases. Fifteen embolizations were also performed in patients without DASS lesions.ResultsTechnical success of DASS interventions, defined by the Society of Interventional Radiology (SIR) reporting standards, was 94%; 54% of interventions resulted in DASS symptom improvement at a median follow-up of 15 days. Patients with steal intervention had 60% lower odds of follow-up surgery (OR, 0.4; P = .007). There was no difference in major adverse events (P = .98) or access preservation (P = .13) between groups.ConclusionsIn this retrospective cohort study, approximately half of DASS fistulograms revealed a percutaneously treatable cause of steal. Over half of DASS interventions resulted in symptomatic relief. Percutaneous intervention was associated with lower odds of follow-up surgery without compromising access preservation.

Purpose: To examine the effect of end-stage renal disease (ESRD) on the likelihood of major adverse limb events (MALEs) in patients with Rutherford Category 4-6 critical limb ischemia (CLI) who underwent percutaneous vascular intervention (PVI). Materials and Methods: Two contemporaneous cohorts of patients who underwent PVI for symptomatic CLI from 2012 to 2022, differing in ESRD status, were matched using propensity score methods. This database identified 628 patients who underwent 1,297 lower extremity revascularization procedures; propensity score matching yielded 147 patients (180 limbs, 90 limbs in each group). Kaplan-Meier and Cox proportional hazard analyses were used to assess the effect of ESRD status on MALEs, stratified into major amputation (further stratified into above-knee amputation and below-knee amputation [BKA]) and reintervention (PVI or bypass). Results: After PVI, 31.3% of patients in the matched cohorts experienced a MALE (45.7% ESRD vs 18.2% non-ESRD), and 15.6% experienced a major amputation (27.1% ESRD vs 5.2% non-ESRD). Cox proportional hazards analysis revealed that ESRD was an independent predictor of MALE (hazard ratio [HR], 3.15; 95% CI, 1.58-6.29; P = .001), major amputation (HR, 7.00; 95% CI, 2.06-23.79; P = .002), and BKA (HR, 7.56; 95% CI, 1.71-33.50; P = .008). Conclusions: ESRD is strongly predictive of MALE and major amputation risk, specifically BKA, in patients undergoing PVI for Rutherford Category 4-6 CLI. These patients warrant closer follow-up, and new methods may become necessary to predict and further reduce their amputation risk.

Purpose To assess the outcome and safety of radiofrequency (RF) wire recanalization in patients with end-stage renal disease (ESRD) and chronic central venous occlusions (CVO). Materials and Methods A retrospective review of ESRD patients who underwent RF-wire recanalization of symptomatic chronic thoracic CVO from January 2017 to August 2022 yielded 20 patients who underwent 21 procedures. All patients had undergone at least one prior unsuccessful attempt at central venous recanalization using conventional catheter-based techniques. Technical success was defined by the ability to cross the CVO using RF-wire recanalization enabling endovascular treatment. Access circuit patency was evaluated based on follow-up imaging and symptomatic improvement. Results Radiofrequency wire recanalization was successful in 17/21 procedures (81%) with all patients (100%) reporting resolution of arm ± facial swelling. Three major complications occurred (14%): two hemothoraces and one hemopericardium. Medial stent diameter was 13 mm (range, 9–14 mm). Mean duration of hospital stay was 2 days ± 3 days. Mean procedure time was 158 ± 46 min with a mean fluoroscopy time of 31.7 ± 16.3 min. Primary unassisted patency at 6 and 12 months was 94 ± 6% and 85 ± 10%, respectively. Additional interventions resulted in significantly increased stent graft patency ( P = 0.006). Conclusion Radiofrequency wire-enabled recanalization of CVO in symptomatic dialysis patients has a high rate of technical success with resolution of arm and facial swelling and resumed use of the ipsilateral dialysis access. Although a superior safety profile was seen than with needle-based techniques such as sharp recanalization, major complications were not infrequent indicating that this RF-wire procedure should be performed in centers equipped to manage central venous perforations.

Hemodialysis access is the lifeline for end-stage renal disease patients. However, dialysis access is associated with a host of complications, including thrombosis, recurrent stenosis, infection, aneurysmal changes and bleeding. Although endovascular therapy remains the first-line treatment owing to its less invasive nature, there are certain situations where surgical referral is recommended or even necessary. Regardless, management of dialysis access complications requires a multidisciplinary approach. Interventional radiologists should be familiar with the appropriate timing for surgical referral to better serve the complex patient population.

Endovascular revascularization is an established treatment modality for Rutherford 5-6 critical limb ischemia (CLI), with the goal of establishing in-line arterial flow to the wound bed. Although there is abundant evidence for above-the-ankle (ATA) procedures, below-the-ankle (BTA) procedures are not well studied. The present study aims to assess the safety and efficacy of BTA interventions in patients with Rutherford 5-6 CLI. A retrospective search identified 48 CLI patients who underwent 79 BTA procedures in 57 limbs. Mean age was 62.6 years (36 to 88 years). There were 20 females (41.7%) and 28 males (58.3%). Thirty-six patients (75%) had diabetes, and 13 (27.1%) had end-stage renal disease. All procedures were performed by two operators at a single tertiary medical center. Adverse events (AE) and technical outcomes were assessed per procedure. Technical success was defined as successful revascularization of the target artery. Limb salvage was assessed per limb and defined as freedom from major amputations (above the ankle). There were concurrent ATA interventions in 75 procedures, including 25 femoropopliteal and 75 tibial interventions. BTA treated arteries included 52 dorsalis pedis, 26 lateral plantar, 4 medial plantar, 21 pedal arches, and 2 metatarsal arteries. Mean follow-up time was 13.1 months (0.2 to 48.8 months). AE rate was 13.9%, all of which were minor, including 3 arterial dissections, 2 thrombotic events, 3 arterial perforations, and 1 arteriovenous fistula, all successfully managed with intraprocedural thrombectomy and/or angioplasty. There was 1 groin access hematoma managed conservatively. There was a single minor AE related directly to a BTA intervention; perforation managed with balloon tamponade. The technical success rate was 93.7%. Following revascularization, there were 22 repeat BTA percutaneous vascular interventions. Minor amputation rate was 28.1% including 12 toe/ray and 4 transmetatarsal amputations. There were 13 major amputations resulting in a limb salvage rate of 77.2% (44/57) at a mean follow-up time of 11.1 months (2.9 to 41.3 months). Concurrent BTA and ATA revascularization procedures were safe and technically feasible, with a high limb salvage rate. Further research is needed to determine the added benefit of BTA interventions in comparison to ATA interventions alone.

Dialysis-associated steal syndrome (DASS) occurs in 1–8

Background: Whereas general anaesthesia is commonly used for haemodialysis fistula creation, regional or local anaesthesia has been posited to lead to better fistula maturation outcomes. We sought to measure the association between anaesthesia type and arteriovenous fistula maturation. Methods: We performed a secondary analysis of data from the Hemodialysis Fistula Maturation study, a multicentre prospective cohort study of advanced chronic kidney disease patients who underwent single-stage upper extremity fistula creation between 2010 and 2013. We evaluated the relationship between anaesthesia type and unassisted (without maturation-facilitating interventions) or overall (unassisted or assisted) fistula maturation using multivariable logistic regression. Results: Among 602 participants, 336 (55.8%) received regional/local anaesthesia and 266 (44.2%) received general anaesthesia. Unassisted maturation occurred in 164/309 patients (53.1%) after regional/local vs 91/226 patients (40.3%) after general anaesthesia (P=0.003). After adjustment for patient factors and fistula type, regional/local anaesthesia was associated with greater odds of unassisted maturation than general anaesthesia (odds ratio 1.72, 95% confidence interval 1.24-2.39; P=0.001). However, after further adjustment for clinical centre fixed effects, odds of unassisted maturation did not differ by anaesthesia type (odds ratio 1.03, 95% confidence interval 0.78-1.36; P=0.830). Similar findings were observed for overall maturation and composite endpoints accounting for potential survivorship bias. Conclusions: Regional/local anaesthesia was associated with increased odds of fistula maturation when adjusting for patient factors and fistula type. However, this association did not persist after adjusting for centre fixed effects. Future research is needed to better understand the relationship between anaesthesia type and centre factors to optimise outcomes after fistula surgery.

To compare outcomes in dialysis access steal syndrome (DASS) procedures with steal-related percutaneous intervention versus without

There is a common belief, grounded in previous hemodynamic research,1 that PTA of a brachial artery (BA) stenosis peripheral to hemodialysis access anastomosis would worsen dialysis access steal syndrome (DASS) by permitting greater retrograde flow into the access. To test this theory, this study compared outcomes of DASS patients who did versus did not receive PTA for distal BA stenosis.

Ramadan, Omar I. MD; Dember, Laura M. MD; Ng, Jia Hwei MD, MSCE; Mantell, Mark P. MD; Wang, Grace J. MD, MSCE; Neuman, Mark D. MD, MSc Author Information

Purpose. The Outback device (Cordis) enables true lumen re-entry during subintimal recanalization of chronic total occlusions (CTOs). This study compared outcomes of patients who underwent subintimal recanalization of lower-extremity arterial CTOs utilizing the Outback device via antegrade and retrograde approaches. Methods. A retrospective analysis identified 39 patients with Rutherford 3 (n = 13), 4 (n = 13), and 5 disease (n = 13) where the Outback device was utilized (19 antegrade crossing femoropopliteal CTOs, 20 retrograde [17/20 transpedal access crossing femoropopliteal/tibioperoneal CTOs, 3/20 femoral access crossing iliac CTOs]) after conventional techniques failed. Mean age was 70.5 years and 67% were men. Most patients had multifocal and/or long-segment occlusions, with 41% having combined above- and below-knee disease. Results. Overall technical success was 90% (95% antegrade and 85% retrograde cohort; P=.15). There were no major complications and 4 minor complications (prolonged bleeding, femoral pseudoaneurysm requiring thrombin injection, and 2 small access-site hematomas). Fifteen percent of the retrograde cohort subsequently underwent distal bypass, compared with 0% in the antegrade cohort (P=.23). A single amputation occurred, in the antegrade group. Twelve-month target-vessel unassisted primary patency was higher with antegrade use (76% in the antegrade group vs 48% in the retrograde group; P=.03), but 12-month assisted primary patency was similar (85% in the antegrade group vs 79% in the retrograde group; P=.85). Conclusion. The Outback can be used safely and effectively from both antegrade and retrograde approaches during recanalization of CTOs. Lower target-vessel unassisted primary patency using the retrograde transpedal approach indicates the need for closer surveillance to achieve high rates of limb salvage.

Vascular closure device (VCD) use following antegrade femoral access is not indicated by the Food and Drug Administration, and may present unique anatomic challenges relative to retrograde access. We compared safety and efficacy of three devices between antegrade and retrograde access cohorts undergoing percutaneous intervention. A consecutive series of 107 limbs in 84 patients underwent VCD arteriotomy closure following percutaneous revascularization using an antegrade approach (VCD-A). These were compared with a contemporaneous control group of 402 limbs in 306 patients who underwent closure following retrograde access (VCD-R) (n = 509) during revascularization and/or embolization procedures. Device deployment success, patient time to ambulation, and major/minor complications were compared between the two groups. Antegrade closure was attempted in the VCD-A cohort using 53 StarClose (Abbott, Santa Clara, CA), 35 Perclose (Abbott), and 19 Angio-Seal (Terumo, Somerset, NJ) devices. Hemostasis (without supplemental manual compression) was achieved in 86/107 (80.4%) limbs. In the VCD-R group, closure was attempted using 215 StarClose, 120 Perclose, and 67 Angio-Seal devices, with hemostasis achieved in 357/402 (88.8%) limbs without supplemental manual compression. Device deployment failure occurred in 7/107 (6.5%) of VCD-A patients and 20/402 (5.0%) of VCD-R patients (P = 0.48). Femoral pseudoaneurysm developed in 1/107 and 1/402 of VCD-A and VCD-R patients (P = 0.38). Major hematoma requiring further intervention developed in 1/107 and 1/402 of VCD-A and VCD-R patients (P = 0.38), and minor hematoma not requiring further intervention developed in 3/107 and 8/402 of the VCD-A and VCD-R (P = 0.71). Mean time to ambulation was 204.1 minutes in the VCD-A group and 204.8 minutes in VCD-R (P = 0.97). In both VCD-R and VCD-A groups, the StarClose, Perclose, and Angio-Seal devices were associated with similar rates of deployment failure (P = 0.080; P = 0.67). Antegrade femoral closure among the studied devices was associated with high rates of technical success and low complications, similar to retrograde closure. Time to ambulation was similar among VCD-A and VCD-R groups.Tabled 1ComplicationVCD-R (n = 402)VCD-A (n = 107)PDevice failure2070.48Pseudoaneurysm110.38Major hematoma110.38Minor hematoma830.71Supplemental manual compression25140.030 Open table in a new tab

Purpose: To compare outcomes of transradial access for endovascular treatment of nonmaturing hemodialysis fistulae compared to brachial arteriography followed by unidirectional or bidirectional fistula access for intervention. Materials and Methods: In this institutional review board-approved, retrospective, case-control study, 56 consecutive patients with nonmaturing arteriovenous fistulae underwent percutaneous intervention between 2015 and 2018. The transradial group (n = 28) underwent radial artery access for diagnostic fistulography and intervention. The control group (n = 28) underwent retrograde brachial army access for fistulography followed by unidirectional/bidirectional fistula access for intervention. Both groups had similar demographics, fistula characteristics, and stenosis locations. Results: Fewer punctures were required in the transradial group compared to controls (1.2 vs 2.4, P < .0001), and procedure time was shorter (64.9 vs 91.3 minutes, P = .0016). Anatomic, technical, and clinical success rates trended higher in the transradial group compared to controls (93% vs 86%, 96% vs 89%, and 82% vs 64%, respectively). Nonmaturation resulting in fistula abandonment was lower in the transradial group (3.7% vs 25%, P = .025). Primary unassisted patency at 3, 6, and 12 months was 77.1%+/- 8.2%, 73.1% +/- 8.7%, and 53.3% +/- 10.6% in the transradial group, respectively, and 63.0% +/- 9.3%, 55.6% +/- 9.6%, and 48.1% +/- 9.6% in the control group, respectively (P = .76). Primary assisted patency at 12 months was 92.3% +/- 5.3% in the transradial group compared to 61.8% +/- 9.6% at 12 months in the control group (P = .021). No major complications occurred. Minor complications were lower in the transradial group than in the control group (14% vs 39%, P = .068). Conclusions: Treatment of nonmaturing fistulae via a transradial approach was safe, improved midterm patency, and was associated with lower rates of fistula abandonment.

To compare outcomes of patients who underwent subintimal recanalization of lower extremity arterial lesions utilizing the Outback re-entry device via antegrade and retrograde approaches. The Outback is one of several devices using a directional needle mechanism to enable true lumen re-entry during subintimal recanalization of chronic total occlusions (CTOs). A retrospective review from January 2010 to June 2019 identified 39 patients with Rutherford 3 (n = 13), 4 (n = 13) and 5 (n = 13) disease where the Outback device was utilized (19 Antegrade (all femoropopliteal CTOs), 20 Retrograde (17/20 transpedal access crossing femoropopliteal/tibioperoneal CTOs, 3/20 femoral access crossing iliac CTOs) after conventional endovascular crossing techniques had failed. Mean age of the group was 70.5 years; 67% were male. Most patients had multifocal and/or long segment occlusions with 49% involving the femoropopliteal segments and 41% with combined above and below knee disease. Overall technical success was 90% (95% in the antegrade cohort and 85% in the retrograde cohort, P = 0.15). There were no major complications and 4 minor complications (prolonged bleeding, femoral pseudoaneurysm requiring thrombin injection and two small access site hematomas). 15% of patients in retrograde cohort subsequently underwent distal bypass, compared to 0% in the antegrade cohort (P = 0.23). A single amputation occurred, in the antegrade group. No significant difference in all-cause mortality (P = 0.50) was identified. Subgroup Kaplan-Meier analysis of antegrade vs. retrograde transpedal cohorts among technically successful Outback utilization showed superior 12-month target vessel primary unassisted patency with antegrade use (76% vs. 48%, P = 0.03) but similarly high 12-month assisted primary patency (85% vs. 79%, P = 0.85). The Outback device can be used safely and effectively from both antegrade and retrograde approaches during recanalization of chronic total occlusions. Lower target vessel primary unassisted patency using the retrograde transpedal approach underscores the need for closer surveillance to achieve high limb salvage.