NEJM: Stent grafts best balloon angioplasty for renal disease

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Stent grafts have proven to provide more long-term relief and independence from repeat interventions than standard balloon angioplasty for the percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft, according to Ziv Haskal, MD, of the division of vascular and interventional radiology at the University of Maryland Medical Center in Baltimore, and colleagues.

In a prospective, multicenter study published in the Feb. 11 issue of the New England Journal of Medicine, the researchers sought to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for the revision of venous anastomotic stenosis in failing hemodialysis grafts.

“The long-term durability of balloon angioplasty is limited and may necessitate repeated invasive procedures with attendant complications and costs,” the authors wrote.

Haskel and colleagues recruited 190 patients (121 women and 69 men) for their study who had a venous anastomotic stenosis and who were undergoing hemodialysis. Utilizing patency of the treatment area and patency of the entire vascular access circuit, they randomly assessed participants to either undergo balloon angioplasty alone or balloon angioplasty plus placement of the stent graft.

“The polytetrafluoroethylene self-expanding stent graft is a less-invasive endovascular approach for revision of failing prosthetic arteriovenous grafts that is intended to mimic open surgical revision of a graft," explained the authors.

In 97 patients, interventional radiologists implanted 125 stents grafts. Of the patient population, 75 percent received a single device and 67 percent of the stent grafts were flared, 16 percent were straight and 17 percent consisted of overlapping straight and flared grafts.

At the six-month follow-up mark, the incidence of patency of the access circuit and patency of the treatment area was found to be significantly greater in the stent-graft group than in the balloon-angioplasty group (51 vs. 23 percent), said the authors.

The researchers also found that participants in the stent graft group compared to those in the balloon angioplasty group were noted as needing significantly less subsequent interventions at six months (32 vs. 16 percent).

Despite restenosis being noted as occurring more in the balloon-angioplasty group, the authors found the incidence of adverse events to be equivalent in the two treatment groups.

“Unlike surgery, a percutaneous approach optimally allows for immediate use of the graft, which might obviate the need for interim catheter dialysis and its associated costs, risks of bloodstream infection and other complications,” concluded the researchers.