NEJM: Stent Graft versus Balloon Angioplasty for Failing Dialysis-Access Grafts

Fistual maybe first (Fistula First), but sometimes there is a need to use an alternative and that is usually synthetic vascular graft. Arteriovenous (AV) grafts are commonly used as a second choice for vascular access for hemodialysis. One of the main reasons we do not prefer AV grafts is because these foreign bodies placed under the skin have the propensity to clot. The AVG usually clots at the venous anastamosis and the management of this is angioplasty. Angioplasty can be used early when signs appear that the AVG may be closing down, or late to open up a clotted access.

This week in the New England Journal of Medicine there is a prospective, randomized, multi-center trial of 190 hemodialysis patients with AVG clotting at the venous anastamosis. The patients were assigned to undergo either balloon angioplasty alone, or balloon angioplasty with the addition of a stent. Primary endpoints were the patency of the treatment area and patency of the entire graft circuit.

Stents are used commonly to improve patency in other vessels after angioplasty but have been controversial in this setting. This study however demonstrated that in the setting of clotting at the venous anastamosis of an AVG, the addition of a stent led to an improved the long term patency as well as freedom from repeat interventions when compared with angioplasty alone.