September 2021 | Issue 91
10 Advertorial
Issue 91 | September 2021
Advertorial 11
THIS ADVERTORIAL IS SPONSORED BY BD
Treating the dysfunctional vascular access: The expert’s low-pressure, low-dose approach Panagiotis M Kitrou (Patras University Hospital, Patras, Greece) advocates a lowpressure, low-dose approach in order to address stenosis—the main culprit behind vascular access dysfunction.1 While high-pressure balloon angioplasty is currently considered the gold standard of treatment, the assistant professor of interventional radiology highlights associated issues of vascular wall trauma and restenosis. In the following case report, Kitrou proposes vessel preparation with the low-pressure Ultrascore™ focused force percutaneous transluminal angioplasty (PTA) balloon (BD) followed by angioplasty with the low-dose Lutonix™ 035 drug-coated balloon (DCB) PTA catheter (BD) as a way of addressing these two key issues and still successfully treating a dysfunctional vascular access.
A
s described by the latest Kidney Disease Outcomes Quality Initiative (KDOQI), a preferred way to treat a stenosis within the vascular access circuit, on a baseline level, is highpressure balloon angioplasty.2 However, as high pressures are frequently needed, up to 40atm, the vascular wall is traumatised due to barotrauma. This leads to a healing process which, at the same time, causes vessel restenosis. As an opinion, there are two key elements in this Sisyphean cycle of events. The first is to achieve an immediate lumen gain provoking the least trauma possible and the other is to slow down the inevitable process of restenosis. The scoring balloon is a relatively new technology proposed to treat vascular access stenosis at low pressures, an example of which is the Ultrascore focused force PTA balloon. The theory behind the technology is that when the balloon is inflated, it
pushes the wires against the vascular wall creating “cracks” in the stenotic tissue. In the case of vascular access stenosis, this could be very helpful confronting the fibrous part of the lesion. However, it should be noted there is inadequate evidence in the current KDOQI Guidelines to make a recommendation on the use of scoring balloons. Slowing down the process of restenosis is proposed to be achieved with the use of DCBs using paclitaxel
A final angiogram showed neither signs of residual stenosis nor significant flaps after scoring angioplasty.”
as the drug of choice.3 The Lutonix 035 DCB PTA catheter is a low-dose (2μg/mm2) paclitaxel-coated device. It has been investigated in several studies for the treatment of the dysfunctional vascular access. The Lutonix Panagiotis M Kitrou Global AV registry, a multicentre, single-arm study by Karnabatidis et al, recruited 320 subjects from Europe and Asia, who underwent DCB angioplasty in 392 treatment areas. Access and lesion characteristics reflected real-world scenarios encountered by physicians in their everyday practice. The study included both arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) in a 3:1 proportion. The study demonstrated a target lesion primary patency of 73.9% at six months.4
Case
The patient was a 52-year-old male on dialysis with a radiocephalic AVF for three years. He had recurrent stenosis that was treated with high-pressure balloons three times in the previous six months. Ultrasound examination revealed no significant stenosis in the upper part of the AVF, but a significant stenosis at the outflow region near the anastomosis and at the area of the anastomosis were observed (Figure 1). Volume flow measurements were 604.4ml/min at the level of the brachial artery and 259.5ml/min at the level of the radial artery. Access was gained from the cannulation zone, above the level of stenosis, in a retrograde approach and an angiogram was performed (Figure 2). Anastomosis was negotiated with a 0.018” wire and a 4Fr angled catheter. For vessel preparation a 4x40mm Ultrascore focused force PTA balloon at the level of the anastomosis and a 7x60mm for the level of the outflow vein were used. Balloons were gradually inflated at the nominal pressure (6atm) for two minutes (Figure 3). Following scoring balloon angioplasty, the Lutonix 035 DCB PTA
Figure 2. Initial angiogram Figure 3. Angioplasty with the Ultrascore focused force PTA balloon at the level of the anastomosis (a) and outflow vein (b)
Figure 4. Lutonix 035 PTA DCB catheters used in the outflow vein stenosis and the anastomosis (a.b.c.). An image overlay shows sufficient overlap of devices and treated areas to avoid geographic miss (d).
Continued overleaf
Figure 1. Ultrasonographic evaluation of vascular access and correlation with the anatomy. From bottom to top: stenosis at the anastomosis; stenosis at the segment following the anastomosis; segment without significant stenosis at the level of the cannulation zone.
Above: Ultrascore Focused Force PTA balloon