Complications of endovascular grafts in the treatment of pseudoaneurysms and stenoses in arteriovenous access.

OBJECTIVE

Endovascular stent grafts are utilized in the rescue of failing arteriovenous (AV) access. Reports claim the superiority of stent grafts and recommend these as a first-line treatment. We have observed a rise in the number of complications related to stent grafts in our patients. The following study was undertaken to assess the severity of these complications and their effect on access site maintenance.

METHODS

We reviewed all patients who had endovascular stent grafts placed for treatment of failing dialysis access over the last 44 months. A series of 38 consecutively placed stent grafts was reviewed for stent migration, fracture, erosion, hemorrhage, and rupture at the site of the stent grafts. Hospital charts were reviewed to assess for indications, hemodynamic stability, transfusion requirement, and outcome.

RESULTS

Of 38 stent grafts placed, nine were for pseudoaneurysm (PS), 20 for stenosis (ST), and nine for a combination (PS/ST). The average length of follow-up was 218.6 days. Primary patency was 49%, with an assisted primary patency of 76%. Eleven patients (28.9%) presented with complications related to migration, fracture, erosion, or rupture. Six were in the PS, three in the PS/ST, and two in the ST treatment groups. In all cases, migration or fracture of the stent graft led to recurrent pseudoaneurysm formation or erosion. Rupture occurred after a herald bleed in four cases. Once complication occurred, 10 of the 11 access sites had to be abandoned.

CONCLUSIONS

Significant life-threatening complication can arise when fracture and migration of the stent grafts used for treating AV access occur. Herald bleed with a previously placed stent graft may be a harbinger of future rupture. Complications appear less likely when stent grafts are used to treat stenosis; however, when complications occur, access site salvage is rare. Surgical revision in the case of pseudoaneurysm should be considered for access preservation.