Cephalic Arch Stenosis Treatments Need Evidence

Cephalic arch stenosis was on the agenda Tuesday June 7 as Gaspar Mestres, MD, a vascular surgeon at the Hospital Clinic at the University of Barcelona, Spain took to the podium. Dr. Mestres, who is the surgeon in charge of the main vascular access unit, the largest in Spain, said: “It is a controversial topic, and there are controversial treatments.”

Cephalic arch stenosis occurs frequently, he added, noting that it affects a third of patients with brachiocephalic fistulas, and is the most common cause of proximal arm fistula dysfunction. “Surprisingly then, there is not a generally approved approach to solve this problem,” Dr. Mestres said. “Guidelines do not give a straightforward solution; there are different treatment options – all lacking evidence – and in the end, what we have is an unsolved problem!”  Indeed, Dr. Mestres underlined that there are no guidelines published on a practical approach.

Dr. Mestres said that although covered stents seem to work significantly better than other options, research suggests a great deal of variation between devices. “This is not commonly reported,” he added. “An additional disadvantage of covered stents is that they are expensive and impede other procedures too. Surgery–which seems to be a better solution–is more aggressive but also impedes other possible endovascular solutions.”

There is also very little evidence regarding drug-coated balloons, said Dr. Mestres.

In addition, there are no trials comparing the many different techniques. “In other words, I am presenting the available evidence, or lack of evidence!” he joked. “So, the decision as to which is the appropriate treatment is not easy.”

The way forward, therefore, is clear in one sense, said Dr. Mestres. “We need more evidence, more trials and more comparative studies to understand the best approach to this disease,” he reasoned. “We are moving to treat it with more covered self-expandable stents, because results seem better, mainly when using flexible self-expanding stents (instead of balloon-expandable stent grafts),” he said. However, when they should be used (from the beginning, for example) is unclear. “The research comparing plain balloons and surgery is still lacking,” he added.

Ideally, a prospective comparative study or randomized trial comparing stent grafts from the first diagnosis to a multiple angioplasty strategy, and to surgery is required. “It’s vital that research looks at outcomes from the first diagnosis, and not as a rescue technique, which is today’s reality,” he said.

The challenge will be to identify the best approach from the time of diagnosis. “We want to avoid multiple useless reinterventions,” he said. “The diagnosis, also, should be performed promptly to avoid diffuse fistula dilatation and access abandonment.”

So, perhaps the most promising way to combat this condition is to diagnose it quickly. “Prompt diagnosis and prompt treatment is as important as the best treatment modality, and it is usually forgotten,” said Dr. Mestres. Misdiagnosis, on the other hand, can lead to diffuse arteriovenous fistula dilatation (and eventual fistula abandonment).

In the interim, treatments should be chosen carefully, before solid research becomes available. “Take into account the poor results of conventional angioplasty and BMS, and the benefit of using stent grafts or open surgery,” Dr. Mestres advised. “However, the best treatment strategy is still unknown.”