Drug Coated Balloon Angioplasty in Failing AV Fistulas: A Randomized Controlled Trial

Abstract

Background: Restenosis remains a problem in hemodialysis access interventions. Paclitaxel-coated balloons have shown promise in reducing access-related restenosis in small trials. The primary hypotheses for our multicenter trial were superior effectiveness at 180 days and noninferior safety at 30 days of a drug-coated balloon compared with conventional angioplasty for treatment of dysfunctional arteriovenous fistulas.

Design, setting, participants, & measurements: This randomized trial enrolled 285 patients with dysfunctional arteriovenous fistulas at 23 centers. Grafts, central venous stenoses, thrombosed fistulas, and immature fistulas were excluded. All patients received angioplasty of the lesion responsible for access dysfunction. After successful angioplasty (≤30% residual stenosis), lesions were treated with either a paclitaxel-coated balloon or an uncoated control balloon of similar design to the drug-coated balloon. Access function during follow-up was determined per centers' usual protocols; reintervention was clinically driven. The primary efficacy outcome assessment was done at 6 months, and the safety assessment was done within 30 days of the procedure. Prespecified secondary end points included assessment of postintervention target lesion primary patency and access circuit primary patency at 6 months.

Results: The 180-day end point was not met with target lesion primary patency (71%±4% for the drug-coated balloon and 63%±4% for control; P=0.06), representing a difference of 8%±6% (95% confidence interval, -3% to 20%). Access circuit primary patency did not differ between groups. Interventions to maintain target lesion patency were fewer for the drug-coated balloon at 6 months (0.31 versus 0.44 per patient; P=0.03). The primary safety noninferiority end point was met and did not differ between groups (P=0.002).

Conclusions: Paclitaxel-coated balloon-assisted angioplasty did not meet the primary effectiveness end point at 180 days compared with conventional angioplasty. Both arms showed equivalent safety (ClinicalTrials.gov number NCT02440022).

Keywords: Angioplasty, Balloon; Angioplasty, Balloon, Coronary; Constriction, Pathologic; dialysis access; paclitaxel; randomized controlled trials; restenosis.

Copyright © 2018 by the American Society of Nephrology.

Figures

Graphical abstract

Figure 1.

Consolidated Standards of Reporting Trials diagram for study accrual. *Not enrolled/not randomized.

Figure 2.

Survival curves for target lesion primary patency show no significant difference at 180 days, but a significant improvement in patency for the DCB at 210 days (exploratory analysis). 95% CI, 95% confidence interval; SE, SEM.

Figure 3.

Survival curves for access circuit primary patency show no difference between DCB and control. 95% CI, 95% confidence interval; SE, SEM.

Figure 4.

Survival curves for safety show no difference between DCB and control, meeting the non-inferiority endpoint. Note that the P value is for the Kaplan–Meier analysis and is not for the primary safety analysis, which was binary and P=0.002. 95% CI, 95% confidence interval; SE, SEM.