How the GORE® VIABAHN® Endoprosthesis changed the natural history of a rapidly failing arteriovenous (AV) access circuit.

Challenge

  • Severe stenosis across the elbow of a 78-year-old patient
  • A rapidly failing forearm loop graft that thrombosed three times over a 40-day period
  • The graft worked well for nearly two years before the first of the three thrombosis events
angiogram

First intervention — Declot percutaneous transluminal angioplasty (PTA) was chosen to treat the thrombosed graft

Declot PTA procedure:
  • The thrombosed graft was secondary to a severe venous anastomotic stenosis
  • The circuit had been working well for nearly two years
Treatment rationale:
  • Give the lesion an opportunity to “declare its natural history”
  • KDOQI 6.7 – treatment of thrombosis and associated stenosis
    • 6.7.5 stenoses should be corrected by using angioplasty or surgical revision
Result:
  • Nice angiographic result initially with restored flow however, the patient returned 12 days later with a clotted graft

Images courtesy of Minneapolis Vascular Physicians. Used with permission.

angiogram

Second intervention — Declot PTA was chosen again to treat the thrombosed graft

Declot PTA procedure
  • Only 12 days passed after the first intervention
  • Patient again presented with thrombosed graft secondary to severe venous anastomotic stenosis
Treatment rationale:
  • Continue to allow the lesion an opportunity to “declare its natural history”
  • KDOQI 6.6 – If angioplasty of the same lesion is required more than two times within a three-month period, the patient should be considered for surgical revision if the patient is still a good surgical candidate
    • Still has not exceeded the KDOQI recommendation
Result:
  • Again, nice angiographic result achieved initially with restored flow however, the patient returned 28 days later with a clotted graft

Images courtesy of Minneapolis Vascular Physicians. Used with permission.

angiogram

Third intervention — GORE® VIABAHN® Endoprosthesis placed across the elbow to treat recurrent severe venous anastomotic stenosis

The GORE® VIABAHN® Endoprosthesis procedure
  • Placed the GORE® VIABAHN® Endoprosthesis across the elbow instead of abandoning circuit
Treatment rationale:
  • Exceeded KDOQI 6.6 recommendation – If angioplasty of the same lesion is required more than two times within a three-month period, the patient should be considered for surgical revision if the patient is still a good surgical candidate
  • Accurate deployment of the GORE® VIABAHN® Endoprosthesis allows for treatment of stenosis across elbow while saving upper arm real estate
Results:
  • Nice angiographic result. Flow was restored.
  • Accurate deployment left open the possibility of upper arm fistula
  • Long term, the GORE® VIABAHN® Endoprosthesis broke the clotting cycle of this graft
  • The patient returned for three interventions (two PTA of stenosis and one declot) from May 2012 to January 2016, with an average of 414 days between interventions

Images courtesy of Minneapolis Vascular Physicians. Used with permission.

Case Takeaways

before and after data
  • Placing the GORE® VIABAHN® Endoprosthesis across the elbow extended the life of the graft without sacrificing the opportunity for an upper arm access

The outcomes and observations reported are based on individual case experience and the patients treated. The steps described here may not be complete, and are not intended to be a replacement for the Instructions for Use or the education, training and professional judgment of Healthcare Providers. Healthcare Providers remain solely responsible for making decisions about patient care and the use of medical technologies. 

Refer to Instructions for Use at eifu.goremedical.com for complete description of all indications, warnings, precautions and contraindications for the markets where this product is available.  

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