Role of surgical intervention for cephalic arch stenosis in the "fistula First" era

Cephalic arch stenosis (CAS) is a frequent cause of vascular access dysfunction in patients with brachiocephalic fistulae. While percutaneous balloon angioplasty has been used to treat CAS, the results of this approach have been poor due to multiple factors including resistant nature of the stenosis, development of early restenosis, as well as poor patency and high vein rupture rates. In this analysis, we report the results of an alternative approach to manage this problem. Thirteen patients with frequently recurring CAS were referred for surgical intervention. Angiographic images recorded during the prior percutaneous procedures were made available to the surgeons. The surgical procedure entailed transecting the healthy portion of the cephalic vein distal to the stenotic segment in the arch, transposing and anastomosing it to the upper basilic/axillary vein. Following surgical revision, development of access dysfunction was treated with percutaneous balloon angioplasty. Patency rates for angioplasty before and after the surgical revision were evaluated. Primary patency rates for angioplasty before the surgical revision were 23%, 8% and 0% at 3, 6, and 12 months, respectively. Following surgical revision, all patients needed angioplasty procedure. However, primary patency increased to 92%, 69%, and 39% at 3, 6, and 12 months, respectively (p = 0.0001). Secondary patency before the surgical revision at 3, 6, and 12 months was 100%, 39%, and 8%, respectively, compared with 92% at 3, 6, and 12 months postsurgical revision (p = 0.0003). The results of this study demonstrate that surgical transposition of the cephalic vein in frequently recurring CAS is a viable option and yields better patency rates for future angioplasty procedures.