Contrast-Free Evaluation and Intervention of Hemodialysis Access Guided by Intravascular Ultrasonography

Purpose: Ultrasound and digital subtraction angiography are the standard of care for evaluation of hemodialysis (HD) arteriovenous access. However, in patients with a severe allergy to iodinated contrast such as anaphylaxis, alternative techniques can be used, including use of noniodinated contrast agents and ultrasonography. Although transcutaneous ultrasonography use is common, intravascular ultrasound (IVUS) can provide real-time anatomic information regarding luminal patency and can potentially be used as the primary diagnostic tool in certain scenarios. This report describes the utility of IVUS and transcutaneous ultrasonography to perform contrast-free interventions on HD accesses.

Materials and Methods: Two patients, a 42-year-old man and a 47-year-old man, underwent a total of three procedures to address HD access issues in a left upper extremity arteriovenous graft and left thigh loop graft, respectively. Both patients had severe (anaphylaxis) allergies to iodinated contrast, and the decision was made to perform contrast-free evaluation of and intervention on their HD access using transcutaneous ultrasonography, fluoroscopy, and IVUS.

Results: All procedures began with antegrade access central to the arterial anastomosis, and pullback IVUS assessment was performed from the central venous system to the sheath access. Graft stenoses were identified on IVUS, and cross-sectional area measurements were calculated at the narrowest regions. Over-the-wire balloon angioplasties and balloon inflation were directly visualized under transcutaneous ultrasonography, which did not demonstrate any extraluminal fluid accumulation after angioplasty suggestive of vascular or graft compromise. Subsequent IVUS assessment demonstrated significant luminal gain in treated graft segments with increased cross-sectional areas at the areas of previous stenosis. Postprocedurally, a strong palpable thrill was palpable in all patients.

Conclusions: IVUS is safe and effective at guiding HD access interventions in patients with contraindications to iodinated contrast administration. IVUS can provide advanced information such as differentiation of intraluminal pathology and specific cross-sectional area measurements. Additional studies with long-term follow-up are needed to clearly define the role of IVUS as a primary imaging modality for vascular access interventions in the presence or absence of contrast administration.