Long-term outcomes of primary angioplasty and primary stenting of central venous stenosis in hemodialysis patients.

INTRODUCTION: Central (superior vena cava, brachiocephalic, or subclavian) venous stenoses are a major impediment to long-term arteriovenous access in the upper extremities. The optimal management of these stenoses is still undecided. The purpose of this study was to determine the outcomes of primary angioplasty (PTA) vs primary stenting (PTS) in a dialysis access population at a tertiary referral academic medical center.

METHODS: A database of consecutive hemodialysis patients undergoing endovascular treatment for central venous stenosis was developed for the period 1995 through 2003. This database was retrospectively reviewed. Vessels exposed to either primary high-pressure balloon angioplasty or primary stenting were examined. Vessels undergoing stenting after failed or suboptimal angioplasty were defined as failures at the time of stenting despite the potential continued patency upon completion of stenting. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Cox proportional hazards analysis was performed for time-dependent variables. Data are presented as mean +/- standard deviation where appropriate.

RESULTS: PTS was used to treat 26 patients (35% male; average age, 57 +/- 15 years) with 26 central venous stenoses, and 47 patients (45% male; average age, 57 +/- 18 years) with 49 central venous stenoses were treated with PTA. The PTS group underwent 71 percutaneous interventions per stenosis (average, 2.7 +/- 2.4 interventions), and the PTA group underwent 98 interventions per stenosis (average, 2.0 +/- 1.6 interventions). The PTS group hemodialysis access site was an average of 1.0 +/- 1.3 years old at the time of the initial intervention, and the hemodialysis access in the PTA group was an average of 1.1 +/- 1.2 years old. Primary patency was equivalent between groups by Kaplan-Meier analysis, with 30-day rates of 76% for both groups and 12-month rates of 29% for PTA and 21% for PTS (P = .48). Assisted primary patency was also equivalent (P = .08), with a 30-day patency rate of 81% and 12-month rate of 73% for the PTA group, vs PTS assisted patency rates of 84% at 30 days, and 46% at 12 months. Ipsilateral hemodialysis access survival was equivalent between groups.

CONCLUSIONS: Endovascular therapy with PTA or PTS for central venous stenosis is safe, with low rates of technical failure. Multiple additional interventions are the rule with both treatments. Although neither offers truly durable outcomes, PTS does not improve on the patency rates more than PTA and does not add to the longevity of ipsilateral hemodialysis access sites.