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Introduction: Sheath placement in dialysis access interventions is traditionally necessary to obtain imaging, guide percutaneous angioplasty, and evaluate results. The aim of this study was to assess the feasibility of performing sheathless Arterio-venous (AV) access interventions using a novel percutaneous angioplasty balloon catheter. Methods: Between May and September 2017, data on all dialysis access interventions using a novel percutaneous angioplasty balloon with a dedicated injection port were collected. All procedures were performed without a sheath. Success was established as no conversion to sheath placement. Demographic data, location of lesion, time to perform procedure, amount of contrast used, radiation exposure, and access complications were recorded. Ultrasound was used to evaluate access site complications. Results: Sheathless interventions were successful in 24 patients with the mean age of 62 years (29–94). There were 5 PTFE grafts and 19 native fistulas. Lesions were located anywhere from the arterial anastomosis to the cephalic arch. The average balloon size was 6 mm (5–7 mm), and the procedure time was 15.8 min (8–45 min). No access site complications were observed. Conclusion: Sheathless intervention is feasible with several potential advantages, including short procedure time, minimal contrast volume, and reduced radiation exposure. Finally, the lower profile at the access site may result in fewer complications.

Objective To determine how frequent inflow stenosis is a contributing factor in the etiology of arteriovenous access-induced steal (AVAIS). Methods A retrospective review of hemodialysis patients who underwent interventions from October 1998 to December 2011 for AVAIS was conducted at Mount Sinai Hospital. Patients with grade 3 AVAIS and complete arch and upper extremity vascular imaging were included. Demographics, access history, time to AVAIS, pre-operative angiographic imaging and interventions performed were analyzed. Results A total of 52 patients were diagnosed with grade 3 (severe) AVAIS requiring intervention over the study period. Forty-seven percent of the patients were male, average age was 62 years, 47% were of African American race and 88% were diabetic. Seventeen consecutive patients, with imaging, were included in this study. The average time to presentation of steal symptoms was 147±228 days. All of the accesses were proximal, and 65.7% were autogenous. Imaging studies consisted of angiography ( 14 ) and computed tomography angiography ( 3 ). Five patients had imaging evidence of >50% luminal inflow stenosis (29.4%). The location of stenosis was the subclavian (3 cases) and brachial (2 cases) arteries. Patients underwent distal revascularization and interval ligation ( 3 ), ligation ( 1 ) and angioplasty/stenting ( 1 ). Conclusion In our population, nearly one-third of the patients with severe AVAIS had a significant subclavian or brachial artery stenosis. The implications of this finding suggest the importance of complete pre-operative imaging. The treatment of the inflow stenosis by itself may not be curative, but the correction may serve as an adjunct and contribute to the success of other therapeutic procedures.