Restoring flow to a brachioaxillary AV graft after multiple failed PTA revisions

Fistulography with recurrent stenosis noted at venous outflow anastomosis.

Image: Fistulography with recurrent stenosis noted at venous outflow anastomosis.
Images courtesy of Nicolas Mouawad, M.D. Used with permission. 

Challenge

  • 48-year-old male with end stage renal disease secondary to hypertensive nephrosclerosis and diabetic nephropathy 
    •  Relevant patient history: 
      • Diabetes mellitus, chronic anemia, paroxysmal atrial fibrillation, coronary artery disease, hypertension, hyperlipidemia, COPD, tobacco use 
      • Left brachioaxillary arteriovenous (AV) graft 4-7 mm implanted June 26, 2018. Two revisions, April 8, 2019 and August 23, 2019, each with an BD® ULTRASCORE® Focused Forced PTA Balloon followed by a 9 mm x 40 mm BD® LUTONIX® 035 Drug Coated Balloon PTA Catheter 
  • Presented after two failed percutaneous transluminal angioplasty (PTA) revisions of the venous anastomosis of an arteriovenous graft, preventing successful hemodialysis. 

 

Combined angiogram

Left image: Lesion preparation with pre-dilatation using 8 x 40 mm noncompliant balloon. 
Right image: Post-PTA outflow fistulography in preparation for GORE® VIABAHN® Endoprosthesis deployment.
Images courtesy of Nicolas Mouawad, M.D. Used with permission. 

Procedure

  • Planned definitive treatment with outflow stenting 
  • Advanced the TERUMO® RADIFOCUS® GLIDEWIRE® ADVANTAGE .035" Guidewire across the target lesion (Left image)
  • Pre-dilated the stenotic lesion with an 8 x 40 mm MEDTRONIC EVERCROSS PTA BALLOON Catheter (Left image)
  • Placed a 9 mm x 5 cm .035" guidewire compatible low profile GORE® VIABAHN® Endoprosthesis (Right image)
  • Post-dilated with a 9 x 40 mm MEDTRONIC EVERCROSS PTA BALLOON Catheter PTA (Right image) 

 

Fistulogram following stent deployment with complete resolution of stenosis.

Image: Fistulogram following stent deployment with complete resolution of stenosis.
Images courtesy of Nicolas Mouawad, M.D. Used with permission.

Result

  • Excellent outflow without any recurrent complication at eight months post-intervention. 

 

Case Takeaways

The outcome of this case aligns to the well-established findings that the GORE® VIABAHN® Endoprosthesis with Heparin Bioactive Surface* offers value through reduced frequency of repeat interventions as compared to PTA.1

Enhanced access and visibility in challenging anatomies is enabled by a low profile and radiopaque markers on the proximal and distal ends of the device.

At eight months post-placement, the VIABAHN® Device has exceeded results achieved with prior PTA treatments; primary patency of the stent graft is maintained, with no circuit reinterventions post VIABAHN® Device placement to date.

Diagram of GORE VIABAHN Endoprosthesis results

* As used by Gore, Heparin Bioactive Surface refers to Gore’s proprietary CBAS Heparin Surface.

  1. Mohr BA, Sheen AL, Roy-Chaudhury P, Schultz SR, Aruny JE; REVISE Investigators. Clinical and economic benefits of stent grafts in dysfunctional and thrombosed hemodialysis access graft circuits in the REVISE Randomized Trial. Journal of Vascular & Interventional Radiology 2019;30(2):203-211.e4. https://www.jvir.org/article/S1051-0443(18)31772-X/fulltext

The outcomes and observations reported are based on individual case experience and the patients treated. The steps described here may not be complete, and are not intended to be a replacement for the Instructions for Use or the education, training and professional judgment of Healthcare Providers. Healthcare Providers remain solely responsible for making decisions about patient care and the use of medical technologies.

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BD, LUTONIX and ULTRASCORE are trademarks of Becton, Dickinson and Company.
MEDTRONIC and EVERCROSS are trademarks of Medtronic, Inc.
TERUMO and RADIFOCUS are trademarks of Terumo Medical Corporation.

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