Endovascular treatment of hemodialysis arterio-venous fistula with drug-coated balloon angioplasty

UVOD Disfunkcija dializnega pristopa je eden najpomembnejših vzrokov obolevnosti in hospitalizacije hemodializnih bolnikov. Najpogosteje je povezana z zožitvijo venskega dela arteriovenske fistule, ki je posledica kombinacije neointimalne hiperplazije in remodeliranja. Neointimalna hiperplazija je posledica poškodbe žilne stene, ki je posledica vsakršne manipulacije žile (dializa, kirurška manipulacija, angioplastika). Poškodbi sledi migracija endotelnih in gladkomišičnih celic, kar na koncu vodi v neointimalno hiperplazijo. Z novimi metodami zdravljenja, kamor spada tudi perkutana transluminalna angioplastika z balonom, prekritim s paklitakselom, skušamo vplivati na te procese in jih zavreti. Namen naše raziskave je bil oceniti učinek perkutane transluminalne angioplastike hemodializnih arteriovenskih fistul z uporabo balonov, prekritih s paklitakselom in predhodno pripravo zožitve arteriovenske fistule z navadnim balonskim katetrom (drug coated balloon percutaneous transluminal angioplasty with plain balloon vessel preparation). MATERIALI IN METODE V raziskovalni skupini smo zdravili 31 bolnikov (16 moških, povprečna starost 62,8 +/- 17,2 let) s hemodinamsko pomembno zožitvijo v predelu hemodializne arteriovenske fistule, pri katerih smo izvedli perkutano transluminalno angioplastiko zožitve z navadnim balonskim katetrom. Rezultate smo primerjali s kontrolno skupino (31 bolnikov, 15 moških, povprečna starost 67,0 +/- 8,44 leta), pri katerih je bil poseg opravljen samo z navadnim balonskim katetrom za perkutano transluminalno angioplastiko. Ko smo dosegli angiografski uspeh (< 30 % rezidualne zožitve), smo v raziskovalni skupini uporabili še balone, prekrite s paklitakselom, le za nanos zdravila. Določili smo 6-, 12- in 24-mesečni interval opazovanja. Primerjali smo primarno, primarno asistirano in sekundarno prehodnost tarčne lezije. Statistično značilnost smo določili kot p < 0,05. REZULTATI Primerjali smo primarno prehodnost tarčne lezije v obeh skupinah in ugotovili, da je bila prehodnost v raziskovalni skupini glede na kontrolno skupino bistveno daljša po 6 (90,3 % vs. 61,3 %, p = 0,016), 12 (77,4 % vs. 29 %, p = 0.0004) in 24 mesecih (45,2 % vs. 16,1 %, p = 0,026) opazovanja. Kaplan-Meierjeva krivulja preživetja je pokazala tudi pomembno razliko v primarni prehodnosti tarčne lezije med raziskovalno in kontrolno skupino (534,2 vs. 315,7 dni, p = 0,0004). Samo 38,7 % bolnikov v raziskovalni skupini je bilo zdravljenih dvakrat ali več v primerjavi z 80,6 % bolnikov v kontrolni skupini (p = 0,002). V sekundarni in primarni asistirani prehodnosti tarčne lezije nismo opazili statistično pomembnih razlik. ZAKLJUČEK Perkutana transluminalna angioplastika z uporabo balonov, prekritih s paklitakselom in pripravo zožitve z navadnim balonskim katetrom v prvih 24 mesecih podaljša primarno prehodnost tarčne lezije − zožitve hemodializne arteriovenske fistule in zmanjša število posegov, potrebnih za ohranjanje sekundarne prehodnosti. Menimo, da je pred uporabo balonov, prekritih s paklitakselom, smiselna priprava zožitve z navadnim balonskim katetrom. Balon, prekrit s paklitakselom, pa se uporabi šele takrat, ko smo z navadnim balonskim katetrom dosegli hemodinamski uspeh. Na ta način se zmanjša izguba paklitaksela pri prehodu balona skozi lezijo, hkrati pa priprava zožitve izboljša kontakt balona, prekritega s paklitakselom z žilno steno, kar vodi k boljši absorpciji zdravila.INTRODUCTION Arteriovenous access dysfunction is one of the main causes of morbidity and hospitalization in hemodialysis population. Arteriovenous fistula disfunction is most often associated with the stenosis of the venous part of the arteriovenous fistula. This is due to a combination of neointimal hyperplasia and vessel remodeling. Neointimal hyperplasia is a result of vascular wall damage, which is caused by manipulation of the vessel (dialysis, surgical manipulation, angioplasty). Vessel wall injury results in endothelial and smooth muscle cell migration, which ultimately leads to neointimal hyperplasia. With new treatment options, including percutaneous transluminal angioplasty with drug coated balloons, we try to influence this process. The goal of our study was to evaluate the effect of percutaneous transluminal angioplasty (PTA) of hemodialysis fistulas utilising drug-coated balloons with plain balloon vessel preparation. MATERIALS AND METHODS In study group, 31 patients (16 menmean age 62.8 +/- 17.2 years) with failing arteriovenous fistula were treated, with drug-coated balloon PTA with plain balloon vessel preparation and compared with control group (31 patients15 menmean age 67.0 +/- 8.44 years), in which only plain balloon PTA was performed. Every stenosis was dilated with regular PTA balloons. After achieving angiographic success (< 30 % residual stenosis), drug-coated balloons were used for drug administration in the study group. The observation intervals were 6, 12 and 24 months. Target lesion primary patency, primary assisted patency and secondary patency were compared. The significance was set at 0.05. RESULTS Target lesion primary patency was compared in both groups and was significantly higher in study group at 6 months (90.3 % vs. 61.3 %p = 0.016), 12 (77.4 % vs. 29 %p = 0.0004) as well as 24 months (45.2 % vs. 16.1 %p = 0.026). Kaplan-Meier survival curve also showed significant difference for target lesion primary patency (534.2 vs. 315.7 daysp = 0.0004). Only 38.7 % of patients in study group were treated twice or more vs. 80.6 % in control group (p = 0.002). There were no significant differences in target lesion primary assisted and secondary patency. CONCLUSION Percutaneous transluminal angioplasty using drug-coated balloons in combination with vessel preparation increases target lesion primary patency rates in the first 24 months and decreases the rate of reinterventions. We think that prior to the use of a drug-coated balloon, vessel preparation with a plain balloon should be performed. A drug-coated balloon should only be used after achieving hemodynamic success with a plane balloon. In our opinion, this reduces the drug loss during the introduction of the drug-coated balloon. We also believe, that vessel preparation improves the contact of the drug-coated balloon with the vessel wall, resulting in better absorption of the drug to the vessel wall

Treatment of tongue cavernous haemangioma with direct puncture and sclerotization with ethanol

Background. Haemangiomas of tongue are rare type of malformations. They can be treated mostly conservatively but in some cases they need more aggressive treatment with preoperative intra arterial embolization and surgical resection. Lesions of tongue that are localized superficially can also be treated with direct puncture and injection of sclerosing agent (absolute ethanol). Case report. We present a case of a 48 years old female patient, where we performed embolization of cavernous haemangioma with mixture of absolute ethanol and oil contrast. After the procedure the patient received analgetics and antioedematous therapy. After the sclerotization the planed surgery was abandoned. Control MRI examinations 6 and 12 months after the procedure showed only a small remnant of haemangioma and no signs of a larger relapse. Conclusion. In our case the direct puncture of haemangioma and sclerotherapy with ethanol proved to be a safe and effective method to achieve preoperative devascularization of the lesion. Direct puncture of the lesion is not limited by the anatomy of the vessels or vasospasm, which can occur during the intra-arterial approach