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Letters to the Editor |
Department of Radiology, University of Chicago Hospitals, 5840 South Maryland Avenue, Chicago, IL 60637
Editor:
We read with interest the recent article by Dr Patel and colleagues (1) in the November 1998 issue of Radiology, "Patency of Wallstents Placed across the Venous Anastomosis of Hemodialysis Grafts after Percutaneous Recanalization." In their discussion of the prevalence of angioplasty-induced venous rupture, Dr Patel and colleagues cite our 1997 article on the subject (2). They then state, "Prior reports of PTA [percutaneous transluminal angioplasty] of hemodialysis access–related stenoses have not routinely included uncovered, metal stent placement as an option for treatment of vessel rupture complicating balloon dilation." We find this surprising since this was the subject of our article. In our series, we reported the patency rates of Wallstents placed for venous rupture in 23 patients. Raynaud et al (3) reported similar results in a series of 37 ruptures, and, more recently, Rundback et al (4) reported results in seven patients. The study by Dr Patel and colleagues included four patients. They stated, "The mechanism that enables an uncovered stent to prevent continued extravasation across a perforated venous anastomosis is not well understood. We postulate that the stent does not actually seal the perforation, but rather it provides a low-pressure conduit through which blood can flow." In our 1997 article (2), we stated, "Although the mechanism of the successful Wallstent treatment of venous extravasation is not entirely clear, we believe that, after Wallstent deployment, the resistance to forward blood flow is less than the resistance to lateral extravasation."
In summary, we agree with Dr Patel and colleagues' observations; however, we believe that the subject of stent placement for venous rupture is not new. Similarly, the possible mechanism of successful Wallstent placement has been discussed previously in the literature.
References
Division of Vascular and Interventional Radiology, Beth Israel Medical Center, First Avenue at 16th Street, New York, NY 10003
I thank Drs Funaki and Zaleski for their letter regarding the article by me and my colleagues (1). Commenting on the discussion section of our article, they stated that the treatment of percutaneous transluminal angioplasty (PTA)-induced venous rupture during hemodialysis graft intervention is not new and that the possible mechanism that allows this maneuver to be a technical success has been described previously in the literature.
I agree with Drs Funaki and Zaleski that the idea of stent deployment across PTA-induced venous ruptures is one that has been described prior to our series. The first description that I could find is by Vorwerk et al (2). However, a routine protocol that included uncovered stent placement for treatment of venous rupture–complicating PTA had not been described until 1997 (3). The article by Funaki et al (3) does represent such a protocol. The line from the discussion of our article would be more appropriate had it read, "Most prior reports of PTA of hemodialysis access–related stenoses have not routinely included uncovered, metal stent placement as an option for treatment of vessel rupture complicating balloon dilation." The oversight may be because the majority of the discussion section of our manuscript was written during the spring of 1997. The proposed mechanism for reduced extravasation following stent deployment was also conceived and written before August 1997.
Our article did not profess to be the first to introduce the idea of uncovered stent deployment for PTA-induced venous ruptures, nor did it state that it was the first to describe the safety, efficacy, or possible mechanism of stent deployment for this indication. Instead, the intent of our article was to add to the body of knowledge about stent use and specifically their patency in certain situations. A review of prior articles on the subject led to the creation of a list of some of the shortcomings of those series. It was our intent to try to overcome some of these shortcomings and devise a protocol that would shed some light on how to use these endoprostheses.
References
This article has been cited by other articles:
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  J. V. Lombardi, M. J. Dougherty, N. Veitia, J. Somal, and K. D. Calligaro A Comparison of Patch Angioplasty and Stenting for Axillary Venous Stenoses of Thrombosed Hemodialysis Grafts Vascular and Endovascular Surgery, May 1, 2002; 36(3): 223 - 229. [Abstract] [PDF]
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