Stent Graft for Nephrologists: Concerns and Consensus

The role of the stent graft is emerging in the management of arteriovenous dialysis access. Physicians are incorporating this device in the management of three distinct problems vein-graft anastomotic stenosis, pseudoaneurysm formation, and cephalic arch stenosis with varying degrees of success. Indeed, a recent randomized, controlled trial to evaluate the role of angioplasty plus stent graft versus angioplasty alone for the management of stenosis at the vein-graft anastomosis led to the approval of the stent graft by the Food and Drug Administration; however, several elements of the management of stenosis at the vein-graft anastomosis/cephalic arch as well as the repair of pseudoaneurysms by stent graft remain controversial. The situation is further complicated and warrants a cost-to-benefit ratio analysis when the added cost of the device is appended to the procedure. In contrast to the controversies, angioplasty-induced complete vascular rupture is one situation in which a stent graft is indicated beyond any doubt. With recent conditional Food and Drug Administration approval, it is anticipated that the use of stent grafts might increase in our patients. In this context, it is critically important that nephrologists be familiar with the current controversies and consensus that surround the use of stent grafts for dialysis access. Just as therapeutic interventions are analyzed in other disciplines within nephrology, these experts must appraise the use of this device for dialysis access. This report presents an up-to-date synopsis on the use of the stent graft that would assist renal physicians in requesting or rejecting the device for the optimal management of their patient's vascular access dysfunction. Clin J Am Sec Nephrol 5: 1347-1352, 2010. doi: 10.2215/CJN.02380310