Viabahn Covered Stents for Cephalic Arch Stenosis Can

Improve Patency and Longevity of Upper Arm AV Fistulas

Toufic Safa, MD, FACSVascular & Endovascular Surgery

St. Francis Hospital, Roslyn NY

CEPHALIC ARCH STENOSIS: ACHILLES HEEL OF UPPER ARM

B-C AV FISTULAS1- Why it happens? Not fully understood2- Symptoms Include:

a- Aneurysmal Degenaration with expansion of Fistula vein size

b- Increased Pulsatility of Vein with excessive bleeding after decannulation

c- Poor Clearance on Hemodialysis3- Diagnosis can be suspected on physical exam and confirmed by duplex scanning or an angiogram

ANEURYSMAL AV FISTULAS

CEPHALIC ARCH STENOSIS:

TYPES OF LESIONS1- Focal Lesion at the cephalic/Subclavian vein junction (Most Common Type)2- Focal Lesion in the Mid Cephalic Arch3- Diffuse Long Segment Stenosis of the cephalic arch

Focal Lesion at the Cephalic-Subclavian Junction (Most Common type)

Focal Lesion in Mid Cephalic Arch

Diffuse Long Segment Stenosis of the Cephalic Arch

CEPHALIC ARCH STENOSIS: MANAGEMENT OPTIONS

1- Percutaneous Balloon Angioplasty2- Angioplasty and Stenting (Bare Metal vs. Covered Stent)3- Open Surgical Patch Angioplasty4- Cephalic Vein “Turndown” or transposition and anastomosis to a deep vein5- Surgical bypass with PTFE: Cephalic vein to Internal Jugular vein6- Ligate/Abandon upper arm AV fistula and create a new one elsewhere

ANGIOPLASTY: 6 month patency 22%Fear of Rupture of VeinRapid Restenosis

ANGIOPLASTY + BM STENT: 6 month patency 43%Rapid in stent stenosisStent FracturesSubclavian vein occlusion

BM STENT FRACTURE with OCCLUSION

Open Patch Angioplasty of the cephalic arch

SURGICAL BYPASS OF THE CEPHALIC ARCH

STENOSIS

CHOICE OF COVERED STENT:

VIABAHN® (W.L.GORE)

- Extremely Flexible with Excellent Radial Support- Very Easy to Handle and Deploy

Viabahn is a Flexible Stent Graft

CASE EXAMPLE #1

CASE EXAMPLE #2

CASE EXAMPLE #3

VIABAHN IN THE CEPHALIC ARCH:OUR EXPERIENCE

Retrospective analysis: 21 patients (13 males and 8 females) treated with angioplasty and Viabahn Stent placement in the cephalic arch over a 2 year period.

Age Range is 44-87 years

Stent size was 7-10mm in diameter and 10cm long (8mm was the most common diameter)

17 fistulas were in the left upper extremity and 5 in the right3 patients died during follow-up due to non access related causes

VIABAHN IN THE CEPHALIC ARCH:OUR EXPERIENCERESULTS:7 patients returned for repeat interventions: 5 interventions were due to recurrent lesions at the cephalic arch and the others were due to lesions elsewhere in the fistula

1° Patency was 66%2° Patency was 100% Freedom from TLR was over 75%

RECURRENT CEPHALIC ARCH STENOSIS

PRE: POST:

VIABAHN IN THE CEPHALIC ARCH:OUR EXPERIENCERESULTS:Recurrent stenoses post VIABAHN stent placement in the cephalic arch tend to be EDGE stenoses similar to stenoses that develop in the SFA after VIABAHN stent therapy

VIABAHN IN THE CEPHALIC ARCH:OUR EXPERIENCECONCLUSION:- Excellent access patency rates and

freedom from TLR can be achieved when VIABAHN stent grafts are used in the cephalic arch

- Larger patient population and longer follow-up period are necessary to validate our statements

THANK YOU