Hemodialysis Grafts: On the Controversial Decision to Stent Venous Anastomotic Stenoses

To the Editor We read with great interest the article by Vesley et al. (1). We agree that there is no definitive answer to the controversial therapy of stenting a venous anastomotic stenosis in hemodialysis graft. The primary patency rate of 54% at 6 months with stent placement is enviable, as it certainly extends the ‘‘life-line’’ for these dialysis patients. But the question we have is: How does one deal with lesions that reappear after stenting? As discussed in this article, the endpoint of primary patency generally was a development of a significant stenosis at a new location in the circuit. How does one treat these new lesions? Should we treat forearm loop grafts and upper arm straight grafts differently? Especially, with forearm loop grafts, should these new lesions be treated with additional stents, if they fail angioplasty? Should we be stacking up stents in the proximal vein with each new lesion? Or should we try to identify patients with grafts that would be candidates for proximal fistulas. The identification of candidates for secondary fistulas could easily be accomplished during percutaneous interventions or by performing simple physical examination (2).Asif et al. recently reported the validity and success of creating secondary fistulas (3). This approach can also increase the prevalence of fistulas and is supported by the Fistula First Initiative (4). We have recently started a vascular access center and have come across patients who have multiple stents placed in the proximal vein in an attempt to maintain assisted or secondary patency. The end result is shown in Figures 1 and 2, virtually converting the entire proximal vein into a ‘‘stent-track.’’ Such a scenario has been recently reported (5). Eventually, when these grafts are abandoned, the patient loses both the proximal and distal segment of the upper extremity for future access placement. Finally, even though rare, the situation could turn into a catastrophic event if the patient were to develop stent-related infection (6). A multi-center prospective trial comparing stent versus surgical revision (at least when lesions recur after initial stent deployment) may possibly give us a better insight into this very crucial issue.