Hemodialysis International 2014; 18:785–792

Endovascular treatment of arteriovenous graft pseudoaneurysms, indications, complications, and outcomes: A systematic review Marius C. FLORESCU,1 Fang QIU,2 Troy J. PLUMB,1 Jennifer A. FILLAUS1 1

Nephrology Division, Department of Internal Medicine, University of Nebraska Medical Center, 2 College of Public Health. University of Nebraska, Omaha, Nebraska, USA

Abstract There are limited data regarding endovascular treatment of arteriovenous graft (AVG) pseudoaneurysms using stent grafts. We performed a comprehensive literature review on the use of stent grafts in the treatment of AVG pseudoaneurysms. We included 10 studies (121 patients). The mean AVG age was 3.1 years (95% confidence interval [CI]: 2.2–4) and pseudoaneurysm mean diameter was 34 mm (95% CI: 23–46). The majority (71%) of the pseudoaneurysms were located on the arterial limb of the AVG and 77% presented with venous anastomosis stenosis requiring angioplasty. The mean number of stents used to treat one lesion was 1.4 (95% CI: 1.3–1.5). The technical success rate of pseudoaneurysm isolation was 100% in all studies and 100% of patients received hemodialysis using the AVG after pseudoaneurysm treatment without the need for catheter placement. The primary patency rates for 1, 3, and 6 months were 81%, 73%, and 24%. Secondary patency was 80%, 77%, and 74% at 1, 3, and 6 months. Arteriovenous graft thrombosis occurred in 12% of patients. Arteriovenous graft infection developed in 35% of cases. Arteriovenous graft pseudoaneurysm treatment using stent grafts is effective in managing even large pseudoaneurysms and has acceptable primary and secondary patency rates. Graft infection was a relatively frequent complication. Key words: Arteriovenous graft, pseudoaneurysm, stent graft, hemodialysis

INTRODUCTION According to the United States Renal Data Systems (USRDS) 2010 data, there were 384,000 patients maintained on hemodialysis (HD) in the United States. Of these, approximately 27% were using an arteriovenous graft (AVG) for their vascular access, making the number of patients maintained on HD via an AVG to be estimated at 103,680. This is close to the reported 140,000 patients

Correspondence to: M. C. Florescu, MD, 983040 Nebraska Medical Center, Omaha, NE 68198-3040, USA. E-mail: [email protected]

(240,000 patients on HD, 58% using AVG) with AVGs in 1999 before the Fistula First Initiative. The large number of HD patients using an AVG continues to make AVG pathology relevant, despite the progress noted after the implementation of the Fistula First Initiative. Pseudoaneurysm formation is a well-known complication of AVGs, with a reported incidence rate ranging between 2% and 10%.1–3 In a study evaluating 52 surgically excised polytetrafluoroethylene AVGs, pseudoaneurysm formation was the main indication for surgical excision in AVGs older than 2 years.4 This suggests that the incidence of pseudoaneurysm formation might be more common than previously thought, especially in older grafts.

© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12152

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The 2006 National Kidney Foundation Kidney Diseases Outcomes Quality Initiative guidelines recommend surgical intervention to treat AVG pseudoaneurysms with a diameter exceeding twice the graft diameter.5 In recent years, numerous case series6–9 have reported favorable outcomes with endovascular repair of large AVG pseudoaneurysms with stent graft deployment. AVGs, being nondistensible and having a constant diameter, are well-suited for endovascular correction of pseudoaneurysms with stent grafts. Endovascular treatment allows continuous use of the AVG without the need for a tunneled catheter as would be required while recovering from a surgical revision. If unsuccessful, endovascular treatment does not preclude surgical revision.10,11 Despite being used for more than 10 years, there are still limited data regarding the endovascular treatment of AVG pseudoaneurysms. The aim of our study was to systematically evaluate the published literature regarding the indications, complications, and outcomes of endovascularly treated AVG pseudoaneurysms with stent grafts.

METHODS Literature search We searched PubMed, Embase, and Cochrane Library from their inception until February 2013. The key words used were pseudoaneurysms, arteriovenous grafts, stents, stent grafts, and covered stents. Two authors (M. C. F and J. A. F.) independently performed the literature search and study selection. Any disagreement was resolved by a third author (T. J. P.) and a final consensus was reached among all authors.

Study selection We selected studies reporting the treatment, complications, and outcomes of at least 3 cases of AVG pseudoaneurysms treated endovascularly with stent grafts. Studies reporting less than 3 patients were excluded due to small sample size. Abstracts from major vascular surgery, interventional radiology, and nephrology conferences in North America and Europe were also searched. No language restrictions were applied. The search method is presented in Figure 1.

indication for procedure, operator specialty, pseudoaneurysm size and location on the AVG (arterial vs. venous limb), type and size of stent used, use of heparin during procedure, numbers of stents used, technical success rate, ability to perform HD using the AVG after the procedure, early and late complications, primary patency, secondary patency (access survival), length of follow-up, and postoperative indications regarding cannulation of stented areas.

Definitions Technical success was defined as successful stent deployment with isolation of the pseudoaneurysm from the blood flow of the AVG. Early complications were defined as those occurring within 1 week of the procedure and included endoleaks— resumption of the blood flow between AVG and pseudoaneurysm, stent migration and AVG thrombosis. Late complications were defined as those occurring more than 1 week after the procedure and included the following: need for surgical revision for return of pseudoaneurysm pulsatility, surgical revision for large pseudoaneurysm, surgical revision for inability to cannulate the AVG, thrombosis of the AVG, stent migration, new pseudoaneurysm formation away from the stent, new pseudoaneurysm resulting from stent cannulation, and AVG infection. Primary patency was defined as the percentage of functional AVGs without the need for any intervention at a given time after pseudoaneurysm treatment. Secondary patency (access survival) was defined as the percentage of functional AVGs irrelevant of procedures needed to maintain their function at a given time after pseudoaneurysm treatment.

Statistical analysis The data were pooled using the DerSimonian and Laird random-effects model for all studies.12 The Q statistic method was used to assess statistical heterogeneity. For studies with no event of interest in a group, 0.5 was added to all cells. For studies providing median and range only for continuous outcomes, mean value and variance were estimated using the median and range.13

RESULTS Data extraction We collected the following variables: authors, journal, publication year, study design, country in which the study was performed, sample size, age, AVG location, AVG age,

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Demographics Ten studies with a total of 121 patients were included in our study. The studies included in our analysis are

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Endovascular treatment of AVG pseudoaneurysms

Figure 1 QUOROM trial flow.

described in Table 1. Patients’ mean age (6 studies, 55 patients) was 57.4 years (95% confidence interval [CI]: 50.2–64.7, Q = 27.48, P < 0.0001). Mean AVG age (5 studies, 29 patients) was 3.1 years (95% CI: 2.2–4, Q = 120.1, P < 0.0001). Pseudoaneurysm mean diameter (6 studies, 57 patients) was 34 mm (95% CI: 23–46, Q = 252.8, P < 0.0001).

Indications for interventions Table 2 outlines the indications for interventions. The presence of large pseudoaneurysms over the AVG was the reason for intervention referral in 64% of cases. In 35% of cases, rapid expansion of the pseudoaneurysm was the reason for referral, whereas thin or ulcerated skin prompted the referral in 28% of cases. Other important reasons for interventions included difficult cannulation of AVG in 18% and pain in 17% of cases. Prolonged bleeding after HD (7%), AVG thrombosis (6%), and incidental finding of the pseudoaneurysm (9%) completed the list of indications for pseudoaneurysm treatment. Some patients had more than one indication for referral explaining why their sum is greater than 100%.

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In the 3 studies reporting the location of the pseudoaneurysm (17 patients), the pseudoaneurysm was located on the arterial limb in 71% of cases (95% CI: 36–99%, Q = 4.51, P = 0.11). Venous anastomotic stenosis requiring angioplasty was present in 77% of the reported cases (2 studies, 14 patients, 95% CI: 57–97%, Q = 0.62 and P = 0.43). The mean number of stents used to treat one pseudoaneurysm was 1.4 (8 studies, 74 patients, 95% CI: 1.3– 1.5). The technical success rate of pseudoaneurysm isolation was 100% throughout the studies and 100% of patients received HD using the AVG after pseudoaneurysm treatment without the need for catheter placement. Primary and secondary patencies are presented in Table 3. There were no differences in the outcomes of primary or secondary patencies between the vascular surgery and interventional radiology operators. The stent grafts used in most of the cases were as follows: Wallgraft (Boston Scientific Corporation, Natick, MA, USA), Viabahn (Gore & Associates, Flagstaff, AZ, USA), and Fluency (Bard, Tempe, AZ, USA), with the exception of 3 (out of 121 cases) that were Cragg endoprosthesis. Unfortunately, due to lack of data, we

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Table 1 Studies included in the analysis Author

Year

Country

Hausegger et al.6

1998

Austria

Najibi et al.8

2002

United States

Ryan et al.14

2003

United States

Vesely15

2005

United States

Rhodes et al.9

2005

United States

Moszkowicz et al.16

2007

United States

Barshes et al.10

2008

United States

Pandolfe et al.11

2009

United States

Shah et al.17

2012

United States

Kim et al.18

2012

United States

Type of study Retrospective case single center Retrospective case single center Retrospective case single center Retrospective case single center Retrospective case single center Retrospective case single center Retrospective case multicenter Retrospective case single center Retrospective case single center Retrospective case single center

Period of enrolment

Blinding

Financial support

No PTS

series,

NA

No

No

3

series,

NA

No

No

8

series,

NA

No

No

3

series,

Dec 2003–Feb 2005

No

No

11

series,

Dec 2000–Aug 2003

No

No

3

series,

NA

No

No

16

series,

June 2002–Aug 2007

No

No

26

series

July 2006–Oct 2008

No

No

4

series,

Oct 2007–March 2011

No

No

13

series,

Nov 2004–Dec 2008

No

No

34

NA = not applicable.

were not able to compare the different stent brands’ performances.

Complications The combined immediate complication rate (2 studies, 24 patients) was 19% (95% CI: 4–35%, Q = 0.62, P = 0.43). The use of heparin and the operator’s specialty (vascular surgery vs. interventional radiology) did not have any effect on the immediate complication rates.

Late complications developed in 30% of patients (8 studies, 101 patients, 95% CI: 22–39%, Q = 5.32, P = 0.62). The intraoperative use of heparin and the operator’s specialty was not associated with late complications. AVG thrombosis (4 studies, 50 patients) was reported in 12% of patients (95% CI 3–21, Q = 1.18, P = 0.76). AVG infection (3 studies, 50 patients) developed in 35% of cases (95% CI: 22–48, Q = 1.58, P = 0.45). The length of follow-up ranged from 1 to 29 months (6 studies, 60 patients).

Table 2 Indications for interventions Indications for interventions Large pseudoaneurysm Rapid expansion Pain Thin skin/ulcerated skin Difficult cannulation Bleeding Thrombosis Incidental finding

Test of heterogeneity

No. of studies

No. of patients

Rate

7 5 2 3 1 2 1 1

66 59 29 40 11 27 16 11

0.64 0.35 0.17 0.28 0.18 0.07 0.06 0.09

95% CI 0.53 0.1 0.03 0.12 0.001 0.001 0.001 0.001

0.76 0.59 0.3 0.44 0.41 0.17 0.18 0.26

Q statistic

P value

7.13 15.01 0.41 2.35 — 0.07 — —

0.31 0.005 0.52 0.31 — 0.79 — —

Q statistic—low values indicate a low heterogeneity of the studies. P value > 0.05 shows that the homogeneity between studies was not rejected. CI = confidence interval.

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Endovascular treatment of AVG pseudoaneurysms

Table 3 Primary and secondary patency rates Variables 1 mo 3 mo 6 mo 1 mo 3 mo 6 mo

primary patency primary patency primary patency secondary patency secondary patency secondary patency

Studies

Patients

Rate

95% CI

Q statistic

P value

1 1 2 6 6 6

26 11 37 47 47 47

0.81 0.73 0.24 0.80 0.77 0.74

0.66–0.96 0.46–0.99 0.1–0.37 0.69–0.91 0.66–0.88 0.61–0.88

— — 0.36 2.26 1.73 6.66

— — 0.55 0.81 0.89 0.25

CI = confidence interval.

DISCUSSION It is widely accepted that the cumulative damage inflicted by repetitive needle puncture weakens the graft wall and creates conditions for pseudoaneurysm formation. In our analysis, the mean age of the grafts treated for pseudoaneuryms was 3.1 years. These data are consistent with the observations of Delorme et al.4 who, in 1992, before the advent of covered stents, found that the most common reason for excision in AVGs older than 2 years was pseudoaneurysm formation. An AVG sustains roughly 300 needle sticks a year. Reinforcing needle rotation to evenly distribute the “needle damage” over the entire length of the graft might prevent or at least delay pseudoaneurysm formation. Besides graft wall damage, another factor needed for pseudoaneurysm formation is increased intra-graft pressure. As previously described, the intra-graft pressure is significantly higher (20–40%) in the arterial segment of the graft than in the venous segment.19,20 This increased pressure might be a risk factor for pseudoaneurysm formation. Similar to the observation of Vesely,15 in the 3 studies (17 patients) that reported the pseudoaneurysm location on the AVG, we found pseudoaneurysms located on the arterial limb in 71% of cases, supporting the hypothesis that the increased intra-graft pressure in the arterial limb was instrumental in the pseudoaneurysm formation. To further support the importance of the intragraft pressure in the pseudoaneurysm formation, venous anastomotic stenosis requiring angioplasty was present in 77% of cases. The mean diameter of pseudoaneurysms successfully treated with stent grafts was 3.4 cm. This showed that even relatively large pseudoaneurysms may be appropriate candidates for endovascular treatment and making the decision to treat endovascularly vs. surgically much more complex than considering only the size of the pseudoaneurysm. In all the cases presented, the success rate for pseudoaneurysm exclusion was 100% and all the patients contin-

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ued to use their AVGs for HD. This result underscores one of the main advantages of endovascular treatment—the ability to immediately use the AVG for HD avoiding the potential complications associated with the use of a tunneled HD catheter as a bridge during the healing of surgical graft revision. As expected, the main indications for procedure referral were large pseudoaneurysms, rapid expansion of pseudoaneurysms, difficult cannulation, and pain. It is surprising that in 28% of cases, thin or ulcerated skin was the indication for referral. Many of us would consider thin or ulcerated skin an indication for surgical revision rather than for stent placement. At a closer look, stent placement can isolate the pseudoaneurysm from the AVG blood flow. Blood present inside the pseudoaneurysm can be, at least partially, aspirated, resulting in significantly decreased pressure inside the pseudoaneurysm cavity. This may allow for the skin lesion to heal without the need for surgical resection. Three studies6,10,15 including 40 patients, 12 of whom had skin lesions covering the AVG’s pseudoaneurysms reported treatment with stent grafts. None of the studies presented the outcomes of these patients separately; however, none of the studies reported progression of skin lesions or pseudoaneurysm rupture in any of their patients. The key might have been choosing skin lesions that were not very advanced and that could heal after treatment instead of progressing to severe necrosis. At the current time, we cannot offer a reliable answer whether thin or necrotic skin covering the pseudoaneurysm can be safely treated with stent grafts. We recommend that clinicians be very cautious in selecting patients with skin lesions for stent graft repair. These patients require a very close follow up to assess for signs of skin lesion progression to avoid the catastrophic bleeding associated with pseudoaneurysm rupture or infection. Given the gravity of the potential complication, this issue definitely needs further research. The mean number of stents used to treat one pseudoaneurysm was 1.4. As described by Moszkowicz et al.,16 “true pseudoaneurysms” with narrow necks can be easily

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treated with one stent, whereas wide neck pseudoaneurysms, which are rather areas of graft degeneration than pseudoaneurysms, require more than one stent and are more prone to endoleaks. All the operators used stents with diameters from 10% to 15% larger than the graft’s diameter. They used different methods to measure the graft diameter in cases where it was unknown. The large majority of the operators requested that needles not be placed through the newly stented areas of the grafts for at least 3 weeks to allow stent incorporation into the graft’s wall and formation of the dense fibrous tissue layer around the stent graft in areas covered by degenerated graft material in order to prevent bleeding after stent cannulation. Given enough time, the thrombus present inside the pseudoaneurysm can undergo retraction and fibrosis with the advantage of adding another protective layer over the stent graft.15 Pseudoaneurysm recurrence in the same location after successful stent graft exclusion has been described if the stent graft was cannulated soon after deployment. The mechanism of recurrence was thought to be leaks from needle cannulation sites that filled the old pseudoaneurysm cavity.15 The timing and safety of stent graft cannulation for HD is still a topic of debate and is not the focus of this study. Most of the patients included in our analysis had the stented areas used for cannulation. Out of 121 patients, there were only 5 reported cases of pseudoaneurysm recurrence because of HD needles placed through the stents. This should not support the assumption that cannulating the stents is safe. The stent grafts used for pseudoaneurysm treatment are not Food and Drug Administration approved for AVG pseudoaneurysm treatment or for HD needle cannulation. Protrusion of the fractured stent strut through a patient’s skin endangering not only the patient but also the HD staff has been described.21 Immediate complication (endoleaks, stent migration, AVG thrombosis) rate, occurring within 1 week of the stenting, was 19%. This rate seems to be acceptable, considering that a reintervention can restore the access patency. Late complications occurred in 30% of cases. There were 7 cases (out of 121) where surgical revision was necessary to remove the pseudoaneurysm because of one of the following: difficult AVG cannulation, recurrence of pulsatility, large pseudoaneurysm, or stent migration. It is likely that these patients should have had surgical revision instead of endovascular treatment. However, these cases were a minority and most patients did well with endovascular treatment. This highlights the importance of patient selection. Not all the AVG pseudoa-

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neurysms are amenable to endovascular treatment nor should all the AVGs be treated endovascularly. If the graft degeneration is extensive, there are no appropriate areas for needle puncture, or the skin damage is advanced, surgical revision of the graft is likely a better option than endovascular repair. When planning to treat an AVG pseudoaneurysm with a stent graft, there are a few questions that should be considered. Can the pseudoaneurysm be isolated with stents? Is there enough length of normal graft to avoid cannulation of the stented area for 3–4 weeks? Is the remaining length of the AVG already severely damaged and likely in need of surgical revision soon? Are there areas of extensive skin thinning or skin necrosis that increase the risk of bleeding or infection? When the graft is extensively damaged and the patient needs a revision or a new graft, there is no advantage in stenting the pseudoaneurysm. Selecting patients requires expertise and knowing the limitations of what endovascular therapy can do. In our study, there was 1 episode of AVG thrombosis per 7.4 patient-months (1.6 episodes per patient-year) of follow-up. Overall, the AVG thrombosis rate depends heavily on the surveillance method used, and for this reason, it is difficult to report a unified thrombosis rate. Before surveillance had been introduced, the AVG thrombosis rate was 1 to 1.5 episodes per patient-year of follow-up22,23 and decreased to 0.89 per patient-year with surveillance and early intervention.24 Infection seemed to be the most important late complication of AVG pseudoaneurysms treated with stent grafts. Our review detected an infection rate of 35%. For comparison, the reported overall AVG infection rate varies between 11% and 35%.25–31 Thirty-four out of 50 patients included in the infections rate analysis came from the Kim et al.,18 study who presented a single-center retrospective analysis of the infections developed in AVG pseudoaneurysms treated with stent grafts. In this study, the authors found 70 patients with AVG pseudoanurysms; 34 were stented and 14 (41.2%) developed infection. Only 4 of the 36 (11.1%) AVGs with pseudoaneurysms left untreated developed infections (P = 0.006).18 The stented grafts had a much higher risk of infection than the grafts where the pseudoaneurysms were left unstented. Furthermore, the authors reported an infection rate of 42.1% if the stent graft was placed intra-graft to treat a pseudoaneurysm vs. 13.5% infection rate for AVG with stent grafts placed intra-graft for any other reason than pseudoaneurysm (P = 0.003).18 The median time from stenting to graft excision for infection was 8.9 months. A previous study,32 showed that the entry site of infection in the graft was the puncture site in 47% of cases. Assuming that all the

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intra-graft placed stents were cannulated for HD and the infection entry site was the puncture site, the question that arises is why the AVGs stented for pseudoaneurysms have a much higher rate of infection than the AVGs stented for other reasons? The time to infection (8.9 months) suggests that the pseudoaneurysm was not infected or colonized at the time of stenting but most likely the infection seeded the old, now closed, pseudoaneurysm cavity when the HD needles passed through it while attempting to cannulate the graft. The location of the pseudoaneurysm in areas of frequent needle placement further increases the likelihood of infection. Assuming our hypothesis is correct, this is a reason to avoid cannulating the portions of the AVG where the stent graft was placed. Given the high incidence of infections, there is an acute need for additional studies to assess the risk factors for infections and strategies to minimize the infection risk in this patient population. Primary patency rates of AVG treated with stent grafts for pseudoaneurysm in our study (1 month—81%, 3 months—73%, 6 months—24%) are comparable with those reported for AVG which have been angioplastied for stenosis (1 month—87.4%, 3 months—77.2%, 6 months—66.4%).24 We find the primary patency to be acceptable, considering that the alternative would be graft surgical revision. The secondary patency rates (80%, 77%, and 74% at 1, 3, and 6 months) were also acceptable, taking into consideration the mean AVG age of 3.1 years in the reported patient population. We consider that these reported primary and secondary patency results support endovascular treatment of AVG pseudoaneurysms, with the caveat that it should be done in carefully selected cases. Our paper has inherent limitations imposed by the nature of the studies included in the analysis. All of the studies were retrospective, included a relatively small number of patients, and had only one arm. Not all of the studies reported all the events that we evaluated and different types of stent grafts were used. The strength of our paper consists of gathering 121 patients among the studies included in the analysis and the studies included had a low heterogeneity as shown by the low values of the Q statistic and high P values. The heterogeneity between the studies was low and remained relatively low even in the subset analyses. Despite the need for more patients, we excluded the studies presenting less than 3 patients in order to decrease the presentation bias.

CONCLUSION Arteriovenous graft pseudoaneurysm treatment using stent grafts is effective in managing even large pseudoan-

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eurysms and has acceptable primary and secondary patency rates. Graft infection was a relatively frequent complication. Important questions remain unanswered: What is the pathogenesis of infection? What can be done to prevent post-stenting AVG infections? Can we stent AVG’s pseudoaneurysms covered by thin or ulcerated skin? Is there any stent better than another one for this indication? Are there any pseudoaneurysms that are better off left unstented? Obviously, further studies are needed to answer those important clinical questions.

DISCLOSURE There was no support/funding for this paper. None of the authors has any potential conflict of interest to declare.

Manuscript received October 2013; revised January 2014.

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9 Rhodes ES, Silas AM. Dialysis needle puncture of Wallgrafts placed in polytetrafluoroethylene hemodialysis grafts. J Vasc Interv Radiol. 2005; 16:1129–1134. 10 Barshes NR, Annambhotla S, Bechara C, et al. Endovascular repair of hemodialysis graft-related pseudoaneurysm: An alternative treatment strategy in salvaging failing dialysis access. Vasc Endovascular Surg. 2008; 42:228–234. 11 Pandolfe LR, Malamis AP, Pierce K, Borge MA. Treatment of hemodialysis graft pseudoaneurysms with stent grafts: Institutional experience and review of the literature. Semin Interv Radiol. 2009; 26:89–95. 12 DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986; 7:177–188. 13 Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005; 5:13. 14 Ryan JM, Dumbleton SA, Doherty J, Smith TP. Technical innovation. Using a covered stent (wallgraft) to treat pseudoaneurysms of dialysis grafts and fistulas. AJR Am J Roentgenol. 2003; 180:1067–1071. 15 Vesely TM. Use of stent grafts to repair hemodialysis graft-related pseudoaneurysms. J Vasc Interv Radiol. 2005; 16:1301–1307. 16 Moszkowicz A, Behrens G, Gueyikian S, Patel NH, Ferral H. Occlusion of a rapidly expanding hemodialysis graft pseudoaneurysm with placement of a stent graft. Semin Interv Radiol. 2007; 24:34–37. 17 Shah AS, Valdes J, Charlton-Ouw KM, et al. Endovascular treatment of hemodialysis access pseudoaneurysms. Vasc Surg. 2012; 55:1058–1062. 18 Kim CY, Guevara CJ, Engstrom BI, et al. Analysis of infection risk following covered stent exclusion of pseudoaneurysms in prosthetic arteriovenous hemodialysis access grafts. J Vasc Interv Radiol. 2012; 23:69–74. 19 Sullivan KL, Besarab A, Bonn J, Shapiro MJ, Gardiner GA Jr, Moritz MJ. Hemodynamics of failing dialysis grafts. Radiology. 1993; 186:867–872. 20 Besarab A, Frinak S, Aslam M. Pressure measurements in the surveillance of vascular accesses, Chapter 21. In: Gray R, ed. A Multidisciplinary Approach for Hemodialysis Access. Philadelphia (PA), Lippincott Williams & Wilkins. 2002; 137–150.

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21 Asif A, Gadalean F, Eid N, Merrill D, Salman L. Stent graft infection and protrusion through the skin: Clinical considerations and potential medico-legal ramifications. Semin Dial. 2010; 23:540–542. 22 Beathard G. Complications of Vascular Access. New York, Marcel Dekker, Inc. 2000. 23 Beathard GA. Percutaneous angioplasty for the treatment of venous stenosis: A nephrologist’s view. Semin Dial. 1995; 8:166. 24 Dember LM, Holmberg EF, Kaufman JF. Randomized controlled trial of prophylactic repair of hemodialysis arteriovenous graft stenosis. Kidney Int. 2004; 66:390– 398. 25 Bosman PJ, Blankestijn PJ, Van der Graaf Y, Heintjes RJ, Koomans HA, Eikelboom BC. A comparison between PTFE and denatured homologous vein grafts for haemodialysis access: A prospective randomised multicentre trial. The SMASH Study Group. Study of graft materials in access for haemodialysis. Eur J Vasc Endovasc Surg. 1998; 16:126–132. 26 Tordoir JH, Herman JM, Kwan TS, Diderich PM. Longterm follow-up of the polytetrafluoroethylene (PTFE) prosthesis as an arteriovenous fistula for haemodialysis. Eur J Vasc Surg. 1988; 2:3–7. 27 Schild AF, Perez E, Gillaspie E, Seaver C, Livingstone J, Thibonnier A. Arteriovenous fistulae vs arteriovenous grafts: A retrospective review of 1700 consecutive vascular access cases. J Vasc Access. 2008; 9:231–235. 28 Zibari GB, Rohr MS, Landreneau MD, et al. Complications from permanent hemodialysis vascular access. Surgery. 1988; 104:681–686. 29 Zibari GB, Gadallah MR, Landreneau M, et al. Preoperative vancomycin prophylaxis decreases incidence of postoperative hemodialysis vascular access infections. Am J Kidney Dis. 1997; 30:343–348. 30 Padberg FT, Lee BC, Curl GR. Hemoaccess site infection. Surg Gynecol Obstet. 1992; 174:103–110. 31 Akoh JA, Patel N. Infection of hemodialysis arteriovenous grafts. J Vasc Access. 2010; 11:155–158. 32 Deneuville M. Infection of PTFE grafts used to create arteriovenous fistulas for hemodialysis access. Ann Vasc Surg. 2000; 14:473–479.

Hemodialysis International 2014; 18:785–792

Endovascular treatment of arteriovenous graft pseudoaneurysms, indications, complications, and outcomes: a systematic review.

There are limited data regarding endovascular treatment of arteriovenous graft (AVG) pseudoaneurysms using stent grafts. We performed a comprehensive ...
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