Feasibility of an antegrade-retrograde single-sheath inverse technique via vertical puncture in dysfunctional hemodialysis arteriovenous fistula angioplasty

Background: Stenosis resulting in dysfunctional dialysis access may occur simultaneously on the anastomotic and central venous side. The purpose of this study was to retrospectively evaluate the feasibility of a single sheath inverse technique using the vertical puncture approach to perform bidirectional transvenous percutaneous transluminal angioplasty (PTA) from a single sheath for such dialysis access stenoses.

Materials and methods: Twenty patients (26 cases; 13 males; median age, 74 [range: 50-89] years) who underwent PTA using the sheath inverse technique for dysfunctional arteriovenous fistula stenoses between April 2019 and June 2023 were included. All procedures were performed in an outpatient setting. A 4-cm sheath (4Fr, four cases; 5Fr, 19 cases; 6Fr, three cases) was inserted by vertical puncture through a cutaneous vein in the forearm (20 cases) or upper arm (six cases). After treating one side of the lesion, the sheath was reversed to treat the lesion on the opposite side. The vessel diameter at the sheath insertion site, the success rate of sheath inversion, the number of PTA balloon catheters used, the PTA success rate, adverse events, and primary and secondary patency rates up to one year after PTA were evaluated.

Results: The median diameter at the sheath indwelling site was 5.2 (range: 3.6-9.5) mm, and sheath inversion was successful in all cases, eliminating the need to place an additional sheath at another site for contralateral stricture treatment. The number of balloon catheters used was one and two in 17 (65%) and eight cases (31%), respectively, and three in one case wherein a drug-coated balloon was used. PTA was successful in all cases and major complications were not observed. However, in one case wherein a sheath had to be placed at the arterial needle puncture site, the skin was hard, leading to difficulty in inversion, and transient venous spasm occurred post-inversion. The primary patency rates at 3, 6 and 12 months after the PTA were 87.5%, 41.7%, and 20.8%, respectively. The secondary patency rates at 6 and 12 months were 100% and 75%, respectively.

Conclusion: The single-sheath inverse technique for arteriovenous fistulas was feasible without sheath withdrawal.