Treatment Strategies for Cephalic Arch Stenosis in Patients with Brachiocephalic Arteriovenous Fistula

Background: Cephalic arch is one of the sites most susceptible to stenosis in brachiocephalic arteriovenous fistula (BCAVF). We performed a retrospective study to identify the incidence of cephalic arch stenosis (CAS) in BCAVF, to compare the patency of percutaneous transluminal balloon angioplasty (PTA) with that of cephalic vein transposition (CVT), and to establish the optimal treatment strategy for CAS. Methods: Between January 2011 and June 2016, 462 patients underwent BCAVF creation. CAS was defined as >50% stenosis at the confluence of the cephalic and axillary veins on ultrasonography. Treatment was planned for clinically significant CAS, which was defined as >25% reduction in flow volume compared to previous examination, elevation of venous pressure, delayed puncture site hemostasis, and/or acute thrombotic occlusion. Results: Seventy-seven (16.7%) patients had CAS and 42 of them (54.5%) were treated for clinically significant CAS. PTA was performed in 36 patients (85.7%), and CVT was done in 6 patients (14.3%) as the initial treatment. Nine patients underwent CVT after PTA, resulting in a total of 15 patients treated with CVT. Investigation of the patency of the 36 cases of PTA and 15 cases of CVT revealed that primary-assisted patency rates at 6 and 12 months were 68.2% and 57.3% for PTA and 100.0% and 87.5% for CVT, respectively (P = 0.038). Secondary patency rates at 6 and 12 months were 72.0% and 56.9% for PTA and 100% and 100% for CVT, respectively (P = 0.010). The median intervention rate was 2.5 interventions per access-year in the 36 cases treated with PTA and 1.5 interventions per access-year in the 15 cases treated with CVT. Conclusions: CAS is a common cause of BCAVF dysfunction, and careful surveillance is warranted. CVT should be considered for treatment of CAS to achieve better long-term patency with fewer reinterventions.