Assessing Eefficacy of Interrupting Rivaling Access-flow with Non-surgical Image-guided-ligation (IRANI) procedure in hemodialysis access

Investigate efficacy of a novel image-guided ligation technique to obliterate collateral veins arising from venous outflow of hemodialysis circuit as well as application of the technique to other dialysis interventions including ligation of arteriovenous fistulas (AVF) and grafts (AVG). Patients who underwent image-guided ligation for dysfunctional dialysis access from December 2014-September 2015 were included. Interventional radiologists performed all ligations. Stenotic lesions that were identified during the procedure were treated with angioplasty. Hemodynamically significant collateral veins were ligated using an 18G Hawkins needle and a 0-silk suture under ultrasound guidance. Usable fistula is defined as successful dialysis treatment via fistula for 4 weeks. A total of 27 image-guided ligations were performed in 23 patients. Fistula collateral vein ligations were performed in 18 patients referred for failure to mature. The average time between access creation date and fistulogram was 157 days. 6 patients (33%) had no venous outflow stenosis (VOS). 5 patients (28%) had juxta-anastomotic stenosis (JAS) alone. 6 patients (33%) had VOS and 1 patient (6%) had both JAS and VOS. 9 patients had 1 collateral vein (CV) ligated, while 2 CV ligation was performed in 8 patients, and one patient had three CVs ligated. Fistula was mature and usable in 9 patients with a mean time of 27 days after ligation. 1 patient developed steal syndrome after IRANI procedure leading to fistula ligation. 8 other patients still need follow-up. Mean follow-up time for usable fistulas was 101 days. IRANI procedure was also performed in four patients who were referred for high recirculation (n=2), difficulty cannulation (n=1), and fistula infiltration (n=1). All these resolved after angioplasty and CV ligation. IRANI procedure was also used to perform AVF ligation (n=3) and AVG ligation (n=2) with 100% success rate. The IRANI procedure offers a minimally invasive approach for collateral vein ligation, performed under complete image-guidance. This technique is cost-effective and can be extended to other dialysis access interventions including access banding and access ligation successfully.