Interventional strategies for haemodialysis fistulae and grafts: interventional radiology or surgery?

Surgery In 1966, Brescia, Cimino and colleagues described the surgical creation of an arteriovenous fistula. Access Arteriovenous fistulae. A great variety of surgical techsurgery developed remarkably over the next decade niques and tricks are available to manage arteriovenous introducing various types and sites of anastomoses and fistula(e) complications like stenosis, thrombosis, and learning how to manage several complications. Graft aneurysms dependent on the experience and skill and materials were introduced during the 1970s including on the patience and imagination of the surgeon ePTFE (expanded polytetrafluoroethylene). During the involved. In the forearm and in the lower upper arm, following 25 years, access surgery failed to achieve this is easily performed and mostly done under local really new technical developments. An increasing use anaesthesia. Elective correction of stenosis will prevent of mainly ePTFE grafts (arteriovenous graft(s)) was thrombosis. Once established, thrombectomy will be observed with a well-known high complication rate followed by correction of the underlying anatomical although the Brescia–Cimino fistula is considered ‘the lesion. Peripheral, post-anastomotic stenoses may be best available form of vascular access’. Modifications replaced by a short graft segment, or preferably a new and minor innovative procedures only came up in the anastomosis just a few centimetres proximally. The field of management of complications. The main comresult is a remodelling of the inner surface and the plications of arteriovenous fistula(e) and arteriovenous lumen of the vein, providing long-term function of the graft(s) are identical: stenosis, thrombosis, arteriovenous fistula. The great variety of local condi(pseudo-)aneurysm, and infection (mainly in grafts). tions, common in arteriovenous fistulae, makes it Special problems arise in cases with high flow rates difficult to compare published results. Revisions in the and peripheral ischaemia/steal syndrome. A great varihigh upper arm and along the central veins are difficult to achieve, often requiring major surgery in these ety of surgical techniques have been described and are highly comorbid patients. Here, interventional procedsuccessfully practised. ures are the better option. In the early 1980s, percutaneous balloon angioplasty Arteriovenous grafts. Although elective revision was introduced by interventional radiologists for the would be welcomed in cases of elevated venous prestreatment of stenoses followed by a series of other sure, thrombosis is the leading complication, mainly non-invasive approaches including thrombolysis, due to intimal hyperplasia at the graft–vein anastommechanical/pharmaco-mechanical thrombectomy, osis. Thrombectomy is followed by a patch plasty (not endo-vascular stents, and atherectomy techniques. recommended), a bypass-like jump graft, or replaceA remarkable geographical difference developed ment of the stenotic segment by new graft material. during this time: Europe continued to prefer native The better the remodelling of the lumen, the longer arteriovenous fistulae with a proportion of graft use will be the next complication-free interval. of 20–30%, whereas in the United States in 70–80% of patients graft material is used. Available data show that native arteriovenous fistulae are less likely to Interventional radiology result in complications. The high complication rates of arteriovenous grafts encouraged many radiologists to Arteriovenous fistulae. Indications for correction of adopt these new approaches. stenosis by percutaneous balloon angioplasty have changed with increasing experience. Excellent primary results suffer from a high recurrence rate. Therefore, easily accessible lesions should be treated surgically. Correspondence and offprint requests to: K. Konner, Medizinische In more centrally located stenoses, interventional proKlinik I, Krankenhaus Merheim, Oatmerheimer Strasse 200, D-51109 Köln, Germany. cedures are the preferred option. To overcome elastic