1. Viabahn Covered Stents for Cephalic Arch Stenosis Can Improve Patency and Longevity of Upper Arm AV Fistulas
Toufic Safa, MD, FACS
Vascular & Endovascular Surgery
St. Francis Hospital, Roslyn NY

2. CEPHALIC ARCH STENOSIS: Achilles Heel of Upper arm B-C AV Fistulas
1- Why it happens? Not fully understood
2- 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 Hemodialysis
3- Diagnosis can be suspected on physical exam and confirmed by duplex scanning or an angiogram

3. ANEURYSMAL AV FISTULAS

4. CEPHALIC ARCH STENOSIS: Types of Lesions
1- Focal Lesion at the cephalic/Subclavian vein junction (Most Common Type)
2- Focal Lesion in the Mid Cephalic Arch
3- Diffuse Long Segment Stenosis of the cephalic arch

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

6. Focal Lesion in Mid Cephalic Arch

7. Diffuse Long Segment Stenosis of the Cephalic Arch

8. CEPHALIC ARCH STENOSIS: Management Options
1- Percutaneous Balloon Angioplasty
2- Angioplasty and Stenting (Bare Metal vs. Covered Stent)
3- Open Surgical Patch Angioplasty
4- Cephalic Vein “Turndown” or transposition and anastomosis to a deep vein
5- Surgical bypass with PTFE: Cephalic vein to Internal Jugular vein
6- Ligate/Abandon upper arm AV fistula and create a new one elsewhere

9. ANGIOPLASTY:. 6 month patency 22%. Fear of Rupture of Vein
ANGIOPLASTY: 6 month patency 22% Fear of Rupture of Vein Rapid Restenosis ANGIOPLASTY + BM STENT: 6 month patency 43% Rapid in stent stenosis Stent Fractures Subclavian vein occlusion

10. BM STENT FRACTURE with OCCLUSION

11. Open Patch Angioplasty of the cephalic arch

12. SURGICAL BYPASS OF THE CEPHALIC ARCH STENOSIS

13. CHOICE of COVERED STENT: VIABAHN® (W.L.GORE)
- Extremely Flexible with Excellent Radial Support
- Very Easy to Handle and Deploy

14. Viabahn is a Flexible Stent Graft

15. CASE EXAMPLE #1

16. CASE EXAMPLE #2

17. CASE EXAMPLE #3

18. 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 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 right
3 patients died during follow-up due to non access related causes

19. VIABAHN IN THE CEPHALIC ARCH: Our Experience
RESULTS:
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%

20. RECURRENT CEPHALIC ARCH STENOSIS
PRE:
POST:

21. VIABAHN IN THE CEPHALIC ARCH: Our Experience
RESULTS:
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

22. VIABAHN IN THE CEPHALIC ARCH: Our Experience
CONCLUSION:
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

23. THANK YOU