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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2021  |  Volume : 32  |  Issue : 1  |  Page : 236-239
Covered Stents for Cephalic Arch Stenosis


1 Sierra Nevada Nephrology Consultant; Department of Medicine, University of Nevada Reno School of Medicine, Reno, NV, USA
2 Department of Nephrology and Hypertension, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

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Date of Web Publication16-Jun-2021
 

   Abstract 


A functional arteriovenous access is required to provide hemodialysis, which remains the most commonly used one for renal replacement therapy worldwide. In the upper arm, a brachiocephalic arteriovenous fistula is created by surgically joining the cephalic vein and brachial artery at the elbow. The outflow segment of the cephalic vein near the shoulder is called the cephalic arch. Due to its anatomical location, the cephalic arch segment is prone to developing stenosis resulting in access dysfunction and thrombosis. The management strategy to treat cephalic arch stenosis (CAS) remains a clinical challenge. We report a case of severe CAS treated successfully with endovascular therapy.

How to cite this article:
Sharma M, Vachharajani TJ. Covered Stents for Cephalic Arch Stenosis. Saudi J Kidney Dis Transpl 2021;32:236-9

How to cite this URL:
Sharma M, Vachharajani TJ. Covered Stents for Cephalic Arch Stenosis. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2021 Dec 4];32:236-9. Available from: https://www.sjkdt.org/text.asp?2021/32/1/236/318531



   Introduction Top


Arteriovenous fistula (AVF) is a lifeline and an Achilles heel for patients with end-stage kidney disease (ESKD). A brachial artery to cephalic vein fistula (BC AVF) is a common site to create an upper arm AVF. The cephalic arch is the segment of the cephalic vein that traverses the deltopectoral groove as it passes behind the clavicular head of the pectoralis major muscle and pierces the clavipectoral fascia before draining into the axillary or the subclavian vein.[1] A common problem encountered in patients with BC AVF is an outflow obstruction at the cephalic arch segment called cephalic arch stenosis (CAS). Rajan et al have proposed that the turbulence in the flow caused by the angle of the cephalic arch with increased flow causes endothelial injury resulting in hyperplasia manifesting as clinical and functional stenosis.[2] The prevalence of CAS in BCAVF has been reported to vary from 39% to 77%.[2],[3],[4] Thrombosis of AVF was more commonly seen in patients with CAS versus non-CAS patients.[3] We describe a patient whose failing BC AVF due to severe CAS was salvaged with timely endovascular intervention.


   Case Report Top


Informed consent was obtained from the patient for the publication of this case report.

A 55-year-old African American male with ESKD on hemodialysis was referred to our vascular center with findings of pulling clots during cannulation from his six-month-old BC AVF. On examination, he had a right upper arm AVF that was hyperpulsatile in the juxta-anastomotic area with decreased thrill and a barely audible bruit in the mid-body and the outflow vein. Based on the physical examination, a severe outflow vein stenosis was suspected. A fistulogram was performed that revealed a sluggish flow through a mature BC AVF with an average vein diameter measuring around 9–10 mm. A severe 99% stenosis was seen at the cephalic arch [Figure 1]. The severely stenosed segment of the cephalic vein was about 6–7 cm long with almost total vein occlusion and multiple small collaterals, none of which drained into the central veins.
Figure 1: Fistulogram showing severe 99% (almost complete) cephalic arch stenosis.

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The severity of the CAS, relatively long segment of the stenosed vein, the technical difficulty encountered while placing a wire across the tight stenosis, the historical high rates of recurrence of stenosis post angioplasty, and low primary patency prompted the decision to proceed directly toward placement of a 9 mm × 100 mm stent graft after the stenosed vein was angioplastied.[2],[3],[5] Post stent placement, angiogram showed excellent restoration of blood flow across the stented area of cephalic arch [Figure 2]. The AVF had a good thrill and the inflow was soft and no longer hyperpulsatile. The impending thrombosis of this AVF was prevented and the failing AVF was salvaged. The patient was followed up at one- and three-months poststent placement and reported no further problems with the access.
Figure 2: Placement of 9mm χ 100 mm covered stent (stent graft)in the cephalic arch segment.

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   Discussion Top


Multiple treatment options are available for CAS and include percutaneous angioplasty with standard versus cutting balloons, endovascular stent deployment (bare metal vs. covered), and surgical interventions. Although percutaneous balloon angioplasty (PTA) remains the first-line therapy and is commonly used to address the CAS, it has limited efficacy and suboptimal results because of resistant lesions and recurrence of stenosis. The primary patency at six and 12 months is dismally low at 42% and 23%, respectively.[2],[3],[4] Most of these lesions require repeated angioplasties and the primary-assisted patency is 85% at six month with an average requirement of 1.6 interventions per patient-year to maintain patency.[2] Cutting balloon angioplasty theoretically should work better by requiring lesser standard atmospheric pressure, reducing the barotrauma to the vessel wall, and thus inducing less neointimal proliferation and restenosis risk.[6] In a small retrospective study (n = 17), Heerwagen et al concluded that the use of a cutting balloon in treatment of CAS did not improve patency compared to conventional PTA but lowered the frequency of requiring re-interventions to 0.9 per patient-year.[6] With the cost of cutting a balloon being three to four times that of a conventional balloon and efficacy still in doubt,[6] placement of stent has been proposed as an alternative treatment to treat recurrent CAS.[5],[7] Two types of stents are available, bare metal or covered. Covered stents fair better than the bare-metal stents. Shemesh et al showed in a randomized clinical trial that the primary patency rates at six and 12 months were 82% and 32% for covered stents versus 39% and 0% for bare-metal stents, respectively.[5] The number of interventions required per patient-year after placement was 0.9 for covered stent versus 1.9 for bare-metal stent.[5]

Open surgical options include (a) inflow reduction, (b) surgical revision of cephalic arch, or (c) venous outflow revision and reanastomosis of cephalic vein to either basilic or axillary vein.[8],[9] Kian et al demonstrated primary six- and 12-month patency of 69% and 39%, respectively, using techniques (b) or (c).[9] Miller et al demonstrated in a retrospective study a six- and 12-month primary patency of 76% and 57%, respectively, with inflow reduction.[10] Open surgical approaches are obviously more invasive than percutaneous methods, often requiring general anesthesia and hospitalization, yet results are comparable to the percutaneous intervention involving placement of covered stents, although a direct head-to-head trial has never been conducted.


   Learning Points Top


Our case demonstrates the importance of physical examination of arteriovenous access as a monitoring technique to decide when to refer patients for an angiogram. The dialysis staff was rightfully concerned when they were pulling out clots from the AVF while trying to cannulate for dialysis. The decreased thrill and faint audible bruit on physical examination signaled an impending AVF thrombosis due to severe outflow stenosis. The severe stenosis in the cephalic arch along with no viable collaterals, as seen in this case, causes severe impediment to the return of blood flow into the central vasculature, ultimately resulting in sequentially decreased blood flow in the AVF and eventual progression to AVF thrombosis. Once the AVF is thrombosed, it becomes even more challenging and technically difficult to thread a guidewire across such tight stenosis. CAS is often recurrent and angioplasty alone or with a bare-metal stent placement has low primary patency and high rate of recurrence of stenosis. Placement of covered stents (stent grafts) for severe CAS, especially for long segments of CAS, has been shown to have comparable results as open surgical techniques, and should be the preferred percutaneous choice for intervention.

Conflict of interest: None declared.



 
   References Top

1.
Williams PL, Warwick R. Gray’s Anatomy of the Human Body. 36th ed. Edinburgh: Churchill Livingstone; 1980.  Back to cited text no. 1
    
2.
Rajan DK, Clark TW, Patel NK, Stavropoulos SW, Simons ME. Prevalence and treatment of cephalic arch stenosis in dysfunctional autogenous hemodialysis fistulas. J Vasc Interv Radiol 2003;14:567-73.  Back to cited text no. 2
    
3.
Hammes M, Funaki B, Coe FL. Cephalic arch stenosis in patients with fistula access for hemodialysis: Relationship to diabetes and thrombosis. Hemodial Int 2008;12:85-9.  Back to cited text no. 3
    
4.
Turmel-Rodrigues L, Pengloan J, Baudin S, et al. Treatment of stenosis and thrombosis in haemodialysis fistulas and grafts by interventional radiology. Nephrol Dial Transplant 2000;15:2029-36.  Back to cited text no. 4
    
5.
Shemesh D, Goldin I, Zaghal I, et al. Angioplasty with stent graft versus bare stent for recurrent cephalic arch stenosis in autogenous arteriovenous access for hemodialysis: A prospective randomized clinical trial. J Vasc Surg 2008;48:1524-31.  Back to cited text no. 5
    
6.
Heerwagen ST, Lönn L, Schroeder TV, Hansen MA. Cephalic arch stenosis in autogenous brachiocephalic hemodialysis fistulas: Results of cutting balloon angioplasty. J Vasc Access 2010;11:41-5.  Back to cited text no. 6
    
7.
Rajan DK, Falk A. A randomized prospective study comparing outcomes of angioplasty versus VIABAHN stent-graft placement for cephalic arch stenosis in dysfunctional hemodialysis accesses. J Vasc Interv Radiol 2015;26:1355-61.  Back to cited text no. 7
    
8.
Chen JC, Kamal DM, Jastrzebski J, Taylor DC. Venovenostomy for outflow venous obstruction in patients with upper extremity autogenous hemodialysis arteriovenous access. Ann Vasc Surg 2005;19:629-35.  Back to cited text no. 8
    
9.
Kian K, Unger SW, Mishler R, Schon D, Lenz O, Asif A. Role of surgical intervention for cephalic arch stenosis in the “fistula first” era. Semin Dial 2008;21:93-6. 10. Miller GA, Friedman A, Khariton A, Preddie DC, Savransky Y. Access flow reduction and recurrent symptomatic cephalic arch stenosis in brachiocephalic hemodialysis arteriovenous fistulas. J Vasc Access 2010;11:281-7.  Back to cited text no. 9
    

Top
Correspondence Address:
Mukesh Sharma
Sierra Nevada Nephrology Consultant, Reno, NV and University of Nevada Reno School of Medicine, Reno, NV
USA
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DOI: 10.4103/1319-2442.318531

PMID: 34145138

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    Abstract
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