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IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE
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IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE

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Is stenting to maintain Vascular Patency going to be the future? Dr.Jitendra Kumar

Is stenting to maintain Vascular Patency going to be the future? Dr.Jitendra Kumar

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  • 1. " IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTURE - CONTRARY VIEWS " Dr Jitendra Kumar(MD DNB DM) Sr Consultant & head Dept of Nephrology Asian Institute Of Medical Sciences Faridabad
  • 2. Technology vs Simplicity
  • 3. Topic- a clarification No Controversy: • AVATAR (Association of Vascular Access & intervenTionAl Renal physician ) • Good AVF • Angioplasty if needed • Stents – BIG NO
  • 4. The Evolution • Coronary Angiplasty – Andreas Gruentzig 1977 • AVF angioplasty – Novelline RA: AJR Am J Roentgenol 135: 983–988, 1980 – Glanz S, et al Radiology 152: 637–642, 1984 • Coronary Stenting 1986 – Sigwart U, Puel J. N Engl J Med316 :701– 706,1987 • AVF Stent 1988 – Zollikofer CL, et al Cardiovasc Intervent Radiol 15: 334–341, 1992 – Gu¨ nther RW, et al. Cardiovasc Intervent Radiol 12: 29–31, 1989
  • 5. Status of Stent • Coronary- Established – Overused? – Bias? • AVF- Not Established
  • 6. A bad start • Zollikofer et al. – – seven patients received stents for 13 AVF outflow lesions – The mean assisted patency rate was 9.7 mo – on follow-up angiography, all patients were noted to have in-stent restenosis. Radiology183 :493– 498,1992
  • 7. ……Bad news • Beathard GA • 1993 • Prospective, randomized • 58 patients • no significant difference in any parameter before treatment, in the response to intervention, or in the patency rates • 90-, 180-, and 360-d survival of – 85% to 92%, 72% to 82%, and 17% to 19% for stents – 79%, 64%, and 28% for PTA, (P > 0.07) Kidney Int43 :872– 877,1993
  • 8. ……More bad news • Quinn et al. • Prospective, randomized 1995 • 87 patients, • Primary patency rates at 60, 180, and 360 d – PTA 55%, 31%, and 10%, – Stent 36%, 27%, and 11% (P = 0.6528). • No difference was noted in secondary patency rates between the PTA and stent groups J Vasc Interv Radiol6 :851– 855,1995
  • 9. ……Bad news continues • Hoffer EK • Prospective, randomized 1997 • 37 patients, (AVG) • Primary patency of 128 d and secondary patency of 431 d were similar for both groups. • The adjunctive stent placement increased the cost of the procedure by 90% J Vasc Interv Radiol8 :965– 973,1997
  • 10. Cost factor • AVF costs Rs 10000 to 15000 • Intervention cost 10 to 20 times • Stent cost = 1 year cost of dialysis
  • 11. Complications of Stent Placement • shortening, • movement ,migration • fracture. • Infectious complications – Shortly after placement of an uncovered stent, the metallic struts are covered by endothelium. The stent can become infected, before full endothelialization – In covered stents, endothelialization is delayed, and infection is a risk for a longer duration of time. – Fatal infection is reported- Radiology192 :363– 365,1994
  • 12. KDOQI Vascular Access Clinical Practice • percutaneous transluminal angioplasty or surgical revision if the stenosis is >50% of the lumen diameter and is associated with clinical or physiologic abnormalities • The potential long-term patency rate following PTA is well established • If angioplasty is required more than 2 times within 3 months, the patient should be referred for surgical revision if such an option is available and if the patient is a good surgical candidate. • stents are useful in selected instances – limited residual access sites, – surgically inaccessible lesions, – contraindication to surgery – when PTA fails. Simply stated, stents are used as a PTA bailout.
  • 13. Debate Ends?
  • 14. Heart vs AVF superficial vs deep
  • 15. Heart vs AVF Anatomy predictable
  • 16. Heart vs AVF • Easy to operate on superficial vein • No mortality risk • Cost cheap • Too many options of vein • Factors of restenosis • Experience with Obesity outcome
  • 17. Problem of restenosis • Vesely T, Pilgram T, Amin MZ • 70 subjects were retrospectively evaluated with stent placement • The primary patency of the vascular access was 81%, 70%, and 54% at 1, 3, and 6 mo. • Secondary patency of the vascular access was 89%, 82%, and 74% at 3, 6, and 12 mo. • Primary patency of the stent per se was 96%, 93%, 87%, and 47% at 1, 3, 6, and 12 mo. • This investigation suggests that other areas of the access circuit are the likely culprits in its ultimate demise. Seminars in Dialysis21 :100– 104,2008
  • 18. America is different • High efficiency shorter duration dialysis vs longer duration dialysis – Fast food vs Biryani • insertion of polytetrafluoroethylene (PTFE) grafts occurred almost twice as often as construction of native accesses in the 1990 incident cohort of patients US Renal Data System: X. The cost effectiveness of alternative types of vascular access and the economic cost of ESRD. Am J Kidney Dis 26:S140-S156, 1995 (suppl)
  • 19. Stent placement increase (%) 1998–2005. Yevzlin A , Asif A CJASN 2009;4:996-1008 ©2009 by American Society of Nephrology
  • 20. Studies continued • Quest for best • Driving force of the industry
  • 21. More Studies • Zaleski GX, Funaki B, Rosenblum J: Metallic stents deployed in synthetic arteriovenous hemodialysis grafts. AJR176 :1515– 1519,2001 • Oderich GS, Treiman GS, Schneider P, Bhirangi K: Stent placement for treatment of central and peripheral venous obstruction: A long- term multi-institutional experience. J Vasc Surg32 :760– 769,2000 • Hatzimpaloglou A, Velissaris I, Gourasas I, Grekas D, Kiskinis D, Kaitzis D, Louridas G: Stenting of central venous stenoses and occlusions to maintain hemodialysis vascular access. J Vasc Access3 :10– 13,2002 • Quinn SF, Kim J, Sheley RC: Transluminally placed endovascular grafts for venous lesions in patients on hemodialysis. Cardiovascular and Interventional Radiology26 :4365– 4369,2003 • Aytekin C, Boyvat F, Yağmurdur MC, Moray G, Haberal M: Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients. Eur J Radiol49 :81– 85,2004
  • 22. More studies • Pan HB, Liang HL, Lin YH, Chung HM, Wu TH, Chen CY, Fang HC, Chen CK, Lai PH, Yang CF: Metallic stent placement for treating peripheral outflow lesions in native arteriovenous fistula hemodialysis patients after insufficient balloon dilatation. AJR184 :403– 409,2005 • Sreenarasimhaiah VP, Margassery SK, Martin KJ, Bander SJ: Salvage of thrombosed dialysis access grafts with venous anastomosis stents. Kidney Int67 :678– 684,2005 • Liang HL, Pan HB, Lin YH, Chen CY, Chung HM, Wu TH, Chou KJ, Lai PH, Yang CF: Metallic stent placement in hemodialysis graft patients after insufficient balloon dilation. Korean J Radiol7 :118– 124,2006 • Naoum JJ, Irwin C, Hunter GC: The use of covered nitinol stents to salvage dialysis grafts after multiple failures. Vasc Endovascular Surg40 :275– 279,2006 • Lombardi JV, Dougherty MJ, Veitia N, Somal J, Calligaro KD: A comparison of patch angioplasty and stenting for axillary venous stenoses of thrombosed hemodialysis grafts. Vasc Endovascular Surg36 :223– 229,2002
  • 23. Common factors… • Observational studies • Lack of comparison group • Small sample size • Subjectivity and bias? • Difficult to apply these results to clinical practice.
  • 24. Some good news. • Vogel et al. J Vasc Interv Radiol15 :1051– 1060,2004 • In 64 patients shape memory alloy stents at 69 locations in the venous outflow system. Twenty stents were deployed in cases of elastic recoil after PTA, venous rupture, or recurrent stenosis less than 3 mo after PTA. Stents were placed in 15 central veins and 54 peripheral veins, with a 97% clinical success rate. The primary access patency was 14.9 mo and 8.9 mo in patients who received central and peripheral stents. In 19 patients whose central or peripheral venous stenoses were previously treated with angioplasty, the mean primary access patency was increased from 2.5 mo to 10.6 mo after placement of the stents (P < 0.005). Angiography in 29 patients showed 55% mean in-stent restenosis after an average of approximately 1 yr. • Conclusion- this type of stent (nitinol alloy) is safe and effective for treating dialysis-access venous stenoses that are resistant to standard angioplasty.
  • 25. Really? • While the results were encouraging • Several limitations. – Retrospective – lack of randomization, – AVGs and AVFs were mixed in the analysis, – the type of lesion (e.g., inflow, outflow, or central) was not uniform – patient characteristics (e.g., diabetic or not) were not accounted for in the analysis. • The presence of these confounding factors does not conclusively establish the superiority of stents over percutaneous balloon angioplasty.
  • 26. Chasing Blood Flow • Chan MR, Bedi S. • Retrospective study (n = 211), with uncovered, nitinol stents. • Primary assisted AVG patency was significantly longer for the stent group as compared with angioplasty, with a median survival of 138 versus 61 d, respectively (P < 0.001). • The primary assisted AVF patency did not differ significantly between the stent and angioplasty groups. • Improved after-intervention peak blood flow (Qa), 1627.50 ml/min versus 911.00 ml/min (P = 0.008), change in Qa from before to after intervention, 643.54 ml/min versus 195.35 ml/min (P = 0.012), and change in URR from before to after intervention, 5.85% versus 0.733% (P = 0.039). Clin J Am Soc Nephrol3 :699– 705,2008
  • 27. How big is big enough?
  • 28. Delete the spam mail
  • 29. Flair • multi-center • randomized study that evaluated the role of a covered stent (FLAIR; Bard Peripheral, Tempe, AZ) • 227 patients were included in this study at 16 US investigational sites • Primary patency at six months in the stent graft group was significantly higher than that found in the balloon angioplasty cohort (stent graft = 50.55%, angioplasty = 23.28%; P < 0.001 • This is the first and thus far the only stent graft that is approved by FDA for use in dialysis access. • AVG Haskal ZJ, Trerotola S, Dolmatch B, et al. Stent graft versus balloon angioplasty for failing dialysis-access grafts. N Engl J Med. 2010;362:494-503
  • 30. Stent and Thrombosed Access • Maya et al. • graft patency following thrombectomy • 14 patients with thrombosed AVGs treated with a stent at the venous anastomosis. • The outcomes of these grafts were historically compared • The primary patency rate was greater for the stent group, with a median survival of 85 versus 27 d (P = 0.02). Kidney Int69 :934– 937,2006
  • 31. Stents and Central Venous Stenosis • The role of stent placement in the treatment of central venous stenosis (CVS) is less controversial than in the peripheral veins.
  • 32. America is different • High efficiency shorter duration dialysis vs longer duration dialysis – Fast food vs Biryani • insertion of polytetrafluoroethylene (PTFE) grafts occurred almost twice as often as construction of native accesses in the 1990 incident cohort of patients US Renal Data System: X. The cost effectiveness of alternative types of vascular access and the economic cost of ESRD. Am J Kidney Dis 26:S140-S156, 1995 (suppl)
  • 33. Problem with stent in AVF • Lack of efficacy • Complications • Prohibitive cost • Easily available surgery • Yet not recommended • Surgery First
  • 34. Apollo data Apollo dialysis in last 12 month-31740 New Patients inducted-700 Old Maintance patients-128 New AV fistula-318 2nd fistulas/Repairs redoo-48 Permacath placement-42 Complicated Permacath pullout-8(SVC block)
  • 35. Have another fistula
  • 36. NKF KDOQI GUIDELINES for vascular access • GUIDELINE 29 • Patients should be re-evaluated for possible construction of a primary AV fistula after failure of every dialysis AV access.
  • 37. Future • As longevity improves on dialysis • More of AVF problems • Will Stent provide long term solution? – NO
  • 38. Future • Better AVF planning and care – Fistula First National Vascular Access Improvement Initiative. http://www.fistulafirst.org/. Accessed April 27, 2010. • Expanding transplant pool – ABO incompatibles – Xenotransplant • Artificial Kidney
  • 39. Concorde Retires

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