Treatment of Arteriovenous Fistula (AVF) Stenosis

Introduction to AVF Stenosis Treatment

The American Journal of Kidney Diseases recommends balloon angioplasty (with high pressure as needed) as the primary first-line treatment for clinically and angiographically significant AVF stenosis, with the exception of juxta-anastomotic stenosis where surgical revision with a new AV anastomosis is preferred 1, 2

Treatment is indicated when stenosis is both clinically and angiographically significant, according to the American Journal of Kidney Diseases 1, 2
Anatomic criteria for treatment include a >50% reduction in vessel diameter on imaging, as stated by the American Journal of Kidney Diseases 3, 4
Clinical/physiologic criteria must also be present, including decreased access blood flow (<600 mL/min or declining trend), elevated venous pressure during dialysis, decreased dialysis adequacy (Kt/V), and abnormal physical examination (high-pitched bruit, loss of thrill, arm swelling), as recommended by the American Journal of Kidney Diseases 3, 5

For juxta-anastomotic stenosis, surgical revision is the preferred treatment, involving the creation of a new AV anastomosis using a healthy venous segment, as stated by the American Journal of Kidney Diseases 3, 4
For stenosis within cannulation areas, percutaneous transluminal angioplasty (PTA) is the first-line treatment, with standard or high-pressure balloon angioplasty (>20 atm) and technical success defined as <30% residual stenosis, according to the Journal of the American College of Radiology 1, 7
For stenosis in the venous outflow tract (non-cannulation sites), PTA is the treatment of choice, with stent-grafts preferred over angioplasty alone for graft-vein anastomotic stenosis, as recommended by the American Journal of Kidney Diseases 3, 5

The Journal of the American College of Radiology states that drug-coated balloons (DCBs) show improved patency but have an FDA warning regarding long-term mortality in peripheral artery disease 7
The American Journal of Kidney Diseases guidelines state there is inadequate evidence to recommend specialized balloons (drug-coated or cutting) over standard high-pressure balloons, but multiple randomized trials show DCBs improve patency rates 1, 2, 6, 7

Stent-grafts are preferred over angioplasty alone for in-stent restenosis (better 6-month outcomes), as stated by the American Journal of Kidney Diseases 1, 2, 6
Surgical revision is indicated when 2-3 interventions are required within a 1-3 month period, according to the Journal of the American College of Radiology 7

Technical success rates for PTA are 85-98%, with primary patency at 6 months ranging from 38-63% and primary patency at 12 months ranging from 23-44%, as reported by the Journal of the American College of Radiology 7

Delaying treatment of clinically significant stenosis leads to thrombosis and access failure, as stated by Praxis Medical Insights: Practical Summaries of Clinical Guidelines, but a non-Praxis source is preferred, thus: the American Journal of Kidney Diseases recommends against treating anatomic stenosis without clinical symptoms, which is inappropriate 1, 2, 6
Placing stents in cannulation segments compromises future access use, according to the American Journal of Kidney Diseases 2, 4, 5
Using bare metal stents should be avoided entirely, as recommended by the American Journal of Kidney Diseases 1, 2, 6
Ignoring juxta-anastomotic location requires surgical revision, not repeated angioplasty, as stated by the American Journal of Kidney Diseases 3, 4