Clinical Predictors of recurrent stenosis and the need for re-intervention in the cephalic arch in patients with brachio-cephalic AV fistulas




Balamuthusamy, Saravanan
Raghunath, Raju
Nguyen, Peter
Vallurupalli, Avinash
Afolabi, Oladapo
Bireddy, Suman


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  1. Introduction: Cephalic arch stenosis is one of the most common reasons for repeated endovascular intervention and eventual abandonment of access in hemodialysis patients with an upper arm brachio-cephalic AV fistula. It would be relevant to identify the clinical predictors of recurrent cephalic arch stenosis and develop a mathematical model to predict BC fistulas that may require repeated endovascular interventions.
  2. Methods: Single center retrospective analysis of 143 patients with a BC fistula with cephalic arch stenosis who underwent angioplasty and were subsequently referred to the vascular clinic for access dysfunction were included for the analysis. Twenty patients were excluded due to unavailability of data. The data was analyzed for 12 months post index angioplasty. Clinical parameters were analyzed using parametric, non-parametric and multiple regression models using SPSS software.
  3. Results: The mean age of the study population was 62.5 years. The mean need for re-intervention was 2.46/ year. There was a statistically significant correlation for the need for re-intervention with the severity of stenosis at index visit (0.873), access flow (0.863), vessel wall diameter proximal to the stenosis (0.822), average venous pressure [greater than] 50% of Qb (0.746) and prolonged bleeding for [greater than] 30 minutes as a reason for referral (0.528). Step-wise multiple regression analysis reveals significant risk for re-intervention with all the 4 variables above. Three equations have been derived for calculating the need for re-intervention based on the diameter of the vessel wall proximal to the stenosis.
  4. Conclusion: Risk stratification of BC fistulas utilizing the above parameters would enable us to identify accesses that are at risk for multiple re-interventions. Early appropriate intervention can be planned for accesses that are at high risk for repeated re-interventions at the cephalic arch which may prolong access survival and reduce the cost involved with repeated interventions. However the risk prediction equations need to be validated in a well powered prospective randomized study.