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Why is it interesting to look at drug eluting balloons for the treatment of dysfunctional AV fistulas?

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Previn Diwakar

on 17 September 2012

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Transcript of Why is it interesting to look at drug eluting balloons for the treatment of dysfunctional AV fistulas?

Drug-Eluting Balloons (DEB) in the treatment of dysfunctional AV fistulas? Why is it interesting to look at.... Dr. Previn Diwakar
Consultant Vascular Interventional Radiologist Backround Why might we need DEB? What's the Evidence? The Dialysis Outcomes Quality Initiative Guidelines of the National Kidney Foundation recommend PTA for the treatment of HD access stenosis, BUT...... Asif et al (2006) 73 Forearm + arm 97% 51% 90%
Maeda et al (2005) 60 Forearm 92% 53% 84%
Manninen et al (2001) 53 Forearm 91% 44% 85%
Clark et al (2002) 53 Forearm + arm 94% 26% 82%
Lay et al (1998) 31 Forearm 90% 64% 81%
Turmel-Rodrigues et al (2000) 155 Forearm + arm 95% 51% 85% no. type succ rate 12 mth Prim Patency 12 mnth Sec Patency Primary patency rates remain too low (<<50%) and the clinical burden of repeated interventions and reduced lifespan of the access site too high Juxta-anastomotic region Stenosis are most prevalent within 3cm of the AV anastomosis (64% Rajan, Radiology 2004)

Juxta-anastomotic stenoses are the most common lesion observed (98/112, Asif, Kidney Int 2006)

Juxta-anastomosis is a critical area for poor angiographic results and lower patency rates vs. non-anastomotic stenosis, although the difference is not statistically significant (Manninen, 2001) Rationale for Drug Therapy in AV fistula Juxta-anastomotic lesions of native AV fistula are usually related to intimal hyperplasia especially for anastomotic and venous stenoses (Bertrand Long et al, J Vasc Surg Vol 53, 1, 108-114, 2011)

Animal data support the benefit of local anti-proliferative drugs such as sirolimus and paclitaxel to decrease neointimal hyperplasia at the venous side of haemodialysis access (Kohler et al, J Vasc Surg Vol 45, 1029-1037, 2007) Some Examples Conclusions Paclitaxel eluting balloons seem to improve primary patency after angioplasty of dysfunctional AV fistula

initial experience with the In.Pact DEB indicates safety and effectiveness

92% primary patency at 9 mnths looks very promising and remarkably better than literature derived data with standard PTA

Lower re-intervention rates and associated reduced hospital stays suggest a potential cost-effectiveness benefit of DEB vs PTA

Need further RCT's to confirm and explore promising results so far
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