In the September 2004 issue of Nephrology Dialysis Transplantaion, Tessitore et al. [1] provide further evidence that arteriovenous (AV) access blood flow surveillance and pre-emptive repair of subclinical stenosis reduce the thrombosis rate and prolong the life of AV fistulae. In this report, 12 of the 43 patients with dysfunction of AV fistulae proposed for treatment with percutaneous transluminal angioplasty (PTA) were considered not to be amenable to PTA by radiologists, and thus were surgical candidates for the following reasons: stenosis segment >2.5 cm, multiple perianastomotic stenoses and critical (>90%) isolated perianastomotic stenosis.
It has been documented that 26% of the cases referred for PTA are not amenable to angioplasty [24]. In contrast, in the present study [1], the 12 patients (28%) deemed ineligible for PTA by radiology represent an exceptionally high referral rate requiring surgical intervention. Of particular concern, seven out of the 43 patients (16%) received an AV interposition graft, rendering them susceptible to recurrent stenosis [5].
Multiple reports [24,6] have demonstrated that all of the above-mentioned complex stenoses of the AVF have routinely been treated successfully with PTA by interventional nephrologists and do not require referral to a vascular surgeon (Figures 1 and 2). We consider that referral of such cases for surgical revision is rarely needed, and actually can be deleterious, leading to unnecessary conversion of fistulae to grafts as well as surgical complications.
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Division of Nephrology Section of Interventional Nephrology University of Miami School of Medicine 1600 NW 10th Ave (R 7168) Miami, FL 33136 USA Email: Aasif{at}med.miami.edu
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