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Arterial Anastomotic "Slippery Slope"
Posted By Kevin C. Harned, Thursday, February 9, 2017
Updated: Thursday, February 9, 2017

*Image to follow

 

An issue I've come across a few times but honestly have only relied on standard and drug-coated balloons for my intervention has been the refractory anastomotic stenoses at a terminal artery.  By this, I mean either a Radial-Cephalic AVF where the Radial Artery distal to the AVF is completely occluded (and thus all flow to the hand is via the Ulnar Artery, with the Radial Artery essentially merely supporting flow to the AVF itself), or in an upper arm AVF where the surgeon inadvertently vs intentionally used a High-Takeoff Radial Artery for the inflow and again the artery distal to the anastomosis becomes quite atretic, thereby leaving the Brachial/Ulnar to supply the forearm/hand.  I have not seen lasting (and honestly nor did I expect) results from either standard/DCB's of the arterial anastomosis.

 

Today was another such example.  Aside from sending the patient back to surgery to move the arterial anastomosis more proximal, have any of you simply stented this region into the artery itself since the atretic segment of the artery distal to the anastomosis is essentially non-functional anyway (provided you have first documented adequate flow to the Palmar Arch via another vessel)?

 

As you can see from the (soon to be uploaded) picture, I'd hate to lose such an otherwise nice AVF during a proximalization of the arterial anastomosis.  However, we're also talking about already small vessels here, so would a 5mm Viabahn vs other stent actually provide enough increased vascular lumen to make a difference?

 

Regards,

 

Kevin Harned, MD

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Permalink | Comments (9)
 

Comments on this post...

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Antoine Samaha says...
Posted Thursday, February 9, 2017
U r absolutely right about ur description of this phenomenon of atresia or involution of the artery that distal to the anastomosis especially in the example of proximal radial artery anastomosis. Assuming u have used a high pressure balloon to open the lesion and it is highly elastic (not spastic) and it is impacting the flow, there is nothing wrong with stenting this lesion (with a 5mm Viabahn) in this specific anatomy...
Tony Samaha
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Daniel V. Patel says...
Posted Thursday, February 9, 2017
I've seen this many times over the years, and it's always a challenge. As you mentioned, my approach too has always been to angioplasty this area as much as possible.

I like the idea of a Viabahn here in your particular case, but my only general concern would be the development of steal - with diversion of flow to the fistula from whatever ulnar or arterial flow is supplying the hand.

The feeding artery appears fairly robust in your image, and that may potentially correlate with a healthy ulnar artery to the hand (which you should further confirm with Doppler/ arteriogram.)

Many times the arteries are quite small when I've encountered this scenario. If this is someone with a poor cardiac or vascular history, I would be much more concerned about steal.

If you're ready to abandon or revise this access and your arterial studies look good, this may be a reasonable case to stent-graft- just be cautious and vigilant to follow up for steal. You don't want to be responsible for digit ischemia.


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Ryan D. Evans says...
Posted Thursday, February 9, 2017
I too have placed a bare metal stent across the Radial artery in a forearm fistula that developed a rupture at the anastomosis following angioplasty. This was before the advent of stent-grafts during my training. We placed it in a u-configuration, after confirming a patent ulnar artery. It did eliminate distal radial flow. Worked well.

I think this technique could also be helpful in a patient with palsy steal syndrome. Instead of ligating (coil or cut-down) the Radial artery distal to the anastomosis, one could wrap a stent-great from the artery to the fistula. I wonder if anyone has done that?

Also, in terms of the images shared in this case, is might be surgically challenging to proximalize the anastomosis. If this fistula has been cannulated for some time, it might be difficult to dissect free and mobilize to the artery. The vein is also much bigger than the artery. Maybe placing an afferent PTFE limb would be easier.....
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Wesley A. Gabbard says...
Posted Thursday, February 9, 2017
I think you could use a Viabahn here. Similarly, a Viabahn could be used to treat forearm steal. If you have a Viabahn for salvage, why. It use an ultra-high pressure balloon across the anastomosis and into the radial artery. Balloon augmentation of the radial artery has been shown to be effective when the radial artery does not dilate enough to support the fistula. I have done this several times. The operator needs to be vigilant for extravasations and pseudoaneurysms that may occur. Also, the patient needs adequate sedation as this is quite painful. I have over-sized the radial artery to 4 and 5mm. An arteriogram should be done first to show good flow in the ulnar artery with a continuous palmar arch.
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Jeffrey Packer says...
Posted Friday, February 10, 2017
One caveat, an angiogram from the feeding artery may not demonstrate patency of the artery distal to the anastomosis at times. I'd get an image from (in this case) th brachial and follow flows through the ulnar and palmer arch with and without mannual compression (occlusion) of the AFV outflowand also assess oximetry pulse waves with and without compression of the outflow vein. Remember no fix is permanent. If this is truly the anatomic equivalent of an end-to-end anastomosis, then a stent (something flexible like a Viabahn) will likely do no harm. I also concur with Dr Evans comments about surgical options.
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Jeffrey Packer says...
Posted Friday, February 10, 2017
One caveat, an angiogram from the feeding artery may not demonstrate patency of the artery distal to the anastomosis at times. I'd get an image from (in this case) th brachial and follow flows through the ulnar and palmer arch with and without mannual compression (occlusion) of the AFV outflowand also assess oximetry pulse waves with and without compression of the outflow vein. Remember no fix is permanent. If this is truly the anatomic equivalent of an end-to-end anastomosis, then a stent (something flexible like a Viabahn) will likely do no harm. I also concur with Dr Evans comments about surgical options.
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Thierry M. POURCHEZ says...
Posted Sunday, February 12, 2017
Comments from Dr Evans about surgical options forget the possibility to create an end to side anastomosis, if the vein is fixed, because of former punctures.
It is relatively easy to free the artery, to ligate it near the old anastomosis, and to make a new anastomosis at the inferior or lateral part of the vein. The use of a tourniquet is almost mandatory, or you need to clamp the vein with the skin.
The difficulty is coming from a former balloon dilatation of the whole artery giving also adhesion of the artery to the tissue.
For a surgeon familiar with fistula creation, the anastomosis between a small and a big vessel is not a problem. The thickness of the vessels is the real challenge.
I do not see many interest for a prosthesis placement in this situation, either endovascular or surgical.
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Marc Webb says...
Posted Tuesday, February 14, 2017
Sorry to get to the party late - it's been a hairball month.
Echoing Dr. Packer, I'd be very careful about my imaging - going up to the axilla to fully image the arterial system, doing fistula compression views, etc, to be completely sure of what I was doing.
Agreeing with Thierry (sorry, old friend, the trip to Lille was hurried, and we ran out of time) it would prefer not to stent, nor to proximalize. The leading inch of so of a fistula is rarely cannulated, and should be unscarred and easy to mobilize enough to move up a cm or so on the artery. I would ligate at the anastomosis, then move up for a new side to end.
Note the little twigs coming off the artery - they are going downstream, and their cumulative effect may be important - I would avoid ligating ANY branches of the artery, no matter how small.
For that reason, I would ABSOLUTELY not proximalize more than a cm or so. The fistula likely keeps the artery patent back to it's origin or significant branches, and without enough flow may thrombose (several cases). The patient has pain, some local muscular ischemia, maybe a new neurologic symptom. For that reason (only) I prefer to distalize rather than proximalize when the artery is sizable - it may start to sludge from reduced flow and not stay open otherwise
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Wesley A. Gabbard says...
Posted Tuesday, February 14, 2017
The only issue that I would suggest in this situation is that an interventionalist would need a surgeon willing to revise the anastomosis. This can be an impediment in some areas. I have even had surgeons who would ligate this access to place a graft instead of revising it. A Viabahn could work here in such a situation. Also, I would not worry about the downstream radial artery (near the hand) even when atretic. As Dr. Webb states, there is likely still some flow here. Additionally, when a patient develops forearm steal, the treatment is ligate or coil this region of the artery (if the palmar arch is continuous and the ulnar blood flow is good).
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