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Hot off the Press!!!!

Posted By Abigail Falk, Tuesday, August 9, 2016
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Adrian Sequeira MD FACP FASN FASDIN says...
Posted Saturday, August 13, 2016
The RESCUE study is a prospective RCT evaluating the benefit of treating bare- metal in-stent stenosis with a stent graft (FLAIR) in the outflow track of patient with AVGs & AVFs compared to just balloon angioplasty (BA) with a 2 year f/u.
The end points:
1) Access circuit primary patency (ACPP)– defined as the interval from treatment to the next thrombosis or repeat intervention anywhere in the access.
2) Treatment area primary patency (TAPP)- interval from treatment until repeat intervention at the original treatment site.
3) Index of primary function (IPF)- Time from the study procedure to access abandonment divided by the number of interventions performed on the access circuit to maintain vascular access.

Some thoughts:
Patients with lower extremity accesses were not included as were those with cephalic arch lesions. I am not too sure why cephalic arch lesions were excluded as this would be an expected site of stenosis in those with BC AVFs.

The predominant site of central stenosis was the subclavian while the axillary vein was the predominant site of peripheral stenosis.

Looking at the ACPP Kaplan Meier graph, by the end of 2 years, the probability of maintaining ACPP was equivalent in both groups. There is a separation 3-6m in the stent graft group with fewer patients needing interventions compared to the PTA group. This benefit disappears by 2 years as more patients in the stent graft group needed interventions. Remember ACPP is influenced by issues anywhere in the access circuit and not just at the site of stent stenosis.

Looking at the TAPP Kaplan Meier, by the end of 2 years, the probability of maintaining TAPP was greater for the stent graph group but it too showed that over time more patients needed intervention, though a statistically significant separation remained over the 2 year period. This separation starts as early as 3m. By 24 months, rates were 15% for the stent graft group versus 2% for the angioplasty group.

IPF: Fewer interventions were reflected in the IPF data. IPF was higher in the stent graft group at 2 years: 177 vs 143.

Thus, in the end: Instent stenosis improves by placing a stent graft. The benefit is however modest with fewer procedures required over 2 years at the site of stent graft placement. PTA is stubbornly repetitive as the stenosis gets angrier each time PTA is performed.

I would be interested in hearing from Dr Falk and the other authors.
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Abigail Falk says...
Posted Wednesday, August 17, 2016
Your analysis of the trial is well summarized.

Cephalic arch lesions were excluded to to the acuity of the angle, as well as any lesions that had an angle of greater than 90 degrees.

I hope this helps.

Dr. Falk
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