Added Diagnostic Value of Intravascular Ultrasound Over Venography in "High Risk for Dialysis Circuit Vascular Access Failure" ESRD Patients.

Objectives: As a two-dimensional modality, venography has limitations in its capacity to measure lumen caliber and to assess stenotic disease accurately. This has implications in the management of end-stage renal-disease (ESRD) patients "no-option" candidates access for arteriovenous fistula (AVF) or graft (AVG) creation secondary to high risk of vascular access failure. The incremental diagnostic and clinical impact of intravascular ultrasound (IVUS) was quantified in this tunneled dialysis catheter dependent ESRD cohort.

Methods: From January 2024 to February 2025, 14 consecutive "high risk for dialysis circuit vascular access failure" ESRD patients (mean age 56 ± 13 years; 8 male) underwent same-session venography and IVUS. For each interrogated vein, IVUS and venography were compared regarding stenosis grade, venous wall pathology (chronic thrombus, elastic recoil, trabeculae/web formation), and patent central venous outflow. Primary endpoints were IVUS-venography discordance and subsequent change in patient management based on the combined IVUS-venography results. Secondary endpoints included successful surgical vascular access creation, access maturation at 3-6 months, contrast volume, fluoroscopy time, and procedure-related morbidity.

Results: IVUS was discordant with venography in 7/14 patients (50 %): stenosis severity was upgraded in 4 (29 %) and downgraded in 3 (21 %) based on findings in IVUS. IVUS revealed or confirmed appropriate venous outflow for future vascular access creation in 5/14 patients (36 %). Eight of the 14 patients (57 %) ultimately underwent AVF/AVG creation after IVUS-guided central venous mapping. At 6 months, 5/8 accesses (63 %) were functional for dialysis (4 fistulas, 1 graft). Two accesses (25 %) had not been used at the time of analysis, and one fistula (12 %) was ligated secondary to infectious complications. Median contrast volume was 51 mL (range 25-127) and median fluoroscopy time was 7.6 min (range 3.0-20.3). No intraprocedural complications during dedicated central venous mapping occurred, and specifically no complications related to IVUS usage were recorded. Two delayed complications occurred in patients who received vascular access as a result of IVUS assessment, and both were managed successfully with endovascular procedures.

Conclusions: In no-option ESRD patients, IVUS revealed changes in stenosis severity in half of the cases compared to standard two-dimensional venography, resulting in permanent dialysis circuit vascular access creation in more than half of the assessed patients, with 63% of these patients reaching vascular access maturation. Routine incorporation of IVUS into salvage central venous mapping may expand durable vascular access options and reduce dialysis catheter dependency.