Cephalic arch stenosis. Case report and literary review

Abstract

Dysfunctional AVF represents one of the leading causes of morbidity in the hemodialysis population, with venous stenosis-related dysfunction being the most common underlying problem.

Cephalic arch is a well-known site for the development of stenosis, especially in patients with brachiocephalic fistulas. The pathophysiology of cephalic arch stenosis (CAS) is still being investigated and various contributing factors have been suggested.

The treatment options for CAS are many and include angioplasty, endovascular stent insertion, access flow reduction and surgical interventions, but none of the current modalities are ideal. Therefore, the treatment of CAS is difficult, as the stenosis in this area tends to recur leading to the need for repeat angioplasty, stents or surgical revision.

A 57-year-old woman undergoing hemodialysis (HD) through a right brachiocephalic arteriovenous fistula was found to have high venous pressure during HD and prolonged bleeding after HD. Clinical examination revealed a hyperpulsatile fistula suggestive of outflow obstruction. Doppler ultrasound examination showed cephalic vein thrombosis, severe outflow stenosis and juxta-anastomotic area. A 10 x 40 mm stent (Cordis Smart stent) was positioned appropriately in the cephalic arch and deployed, the stenotic lesion in juxta-anastomotic area was dilated with angioplasty balloon with improvement in flow.

After 14 months, the fistula is still working perfectly with adequate flow.

Keywords: cephalic arch, stenosis, brachiocephalic fistula, hemodialysis

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Introduzione

Le complicanze dell’accesso vascolare (AV) condizionano la qualità di vita e la sopravvivenza del paziente in emodialisi e rappresentano una delle principali cause di morbilità e mortalità nella popolazione emodializzata [1]. La maggiore causa di disfunzione e successiva trombosi di una fistola artero-venosa (FAV) è la stenosi venosa.

È ben noto che la localizzazione della stenosi e i segni clinici dipendono in gran parte dal tipo di AV [2]. Vari sono i segmenti della FAV soggetti a stenosi sul versante venoso; in relazione alla sede, possiamo distinguere tra: 1) stenosi a livello di inflow, in genere post-anastomotica, tipica della FAV dell’avambraccio; 2) stenosi a livello di outflow, localizzate a livello prossimale e presenti prevalentemente nelle FAV del braccio; 3) stenosi nelle zone di venipuntura e 4) stenosi riguardanti le vene centrali [3].

Un’altra sede tipica di stenosi è l’arco cefalico (AC); particolarmente interessate sono le FAV brachiocefaliche (dal 39% fino al 77%) rispetto alle FAV radiocefaliche (dal 2% al 15%) [4]. Ciò, verosimilmente, in relazione alla portata più elevata dell’AV, alla turbolenza del flusso e a fattori anatomici a causa del restringimento e della curvatura fisiologica dell’AC attraverso la fascia clavipettorale.

 

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The new frontier in endovascular treatment of arteriovenous fistula stenosis: the role of ultrasound-guided percutaneous transluminal angioplasty

Abstract

Native arteriovenous fistula is the preferred vascular access because of it does not usually cause infections and seems to be closely related with prolonged patient survival, compared to prosthetic grafts and central venous catheters; it also is cost effective. Venous stenosis is one of the main causes of AVF failure. It is caused by a number of upstream and downstream events. The former group comprises hemodynamic and surgical stressors, inflammatory stimuli and uraemia, while downstream events involve the proliferation of smooth muscle cells and myofibroblasts and the development of neo-intimal hyperplasia. Percutaneous transluminal angioplasty is the gold standard for arteriovenous fistula stenosis. It allows the visualization of the whole vascular circuit and the immediate use of the vascular access for the next dialysis session. Ultrasound-guided percutaneous endovascular angioplasty is a feasible and safe alternative to conventional fluoroscopic technique: it is equally effective in treating arteriovenous fistula stenosis, but it presents the advantage of not using contrast media or ionizing radiation. The aim of this review is to report the latest evidence on cellular and molecular mechanisms that contribute to the development of neo-intimal hyperplasia, as well as the current and future therapeutic perspectives, especially concerning the use of anti-proliferative drugs, and the efficacy of the ultrasound-guided angioplasty in restoring and maintaining the vascular access patency over time.

Key words: Percutaneous angioplasty, ultrasound, arteriovenous fistula, hemodialysis, stenosis.

Sorry, this entry is only available in Italian. For the sake of viewer convenience, the content is shown below in the alternative language. You may click the link to switch the active language.

Introduzione

La prevalenza della malattia renale cronica terminale aumenta di anno in anno. Nel 2010, il numero dei pazienti sottoposti a terapia emodialitica in tutto il mondo era pari a 2,618 milioni e, secondo alcune recenti stime, è destinato a crescere fino a 5,439 milioni entro il 2030 [1]. A livello nazionale, i dati estrapolati dal Report 2015 del Registro Italiano di Dialisi e Trapianto evidenziano un’incidenza e una prevalenza di 154 pazienti/pmp e di 770/pmp rispettivamente [2]. Indipendentemente dalla metodica utilizzata, il buon funzionamento dell’accesso vascolare (AV) rappresenta un requisito irrinunciabile per una ottimale adeguatezza dialitica. 

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