Drug-Eluting Stents vs. Stent-Grafts in Hemodialysis Vascular Access Outflow Interventions

INTRODUCTION: Hemodialysis vascular accesses are susceptible to restenosis, requiring frequent interventions to maintain patency. Stent-grafts (SGs) have been shown to improve patency and are already approved for use in this setting. This study aims to compare the off-label use of drug-eluting stents (DESs) versus SGs in managing hemodialysis vascular access outflow stenosis. MATERIALS AND METHODS: This single-center retrospective study reviewed patients treated with DES or SG for vascular access outflow stenosis. The primary outcome was the comparison of patency rates between DES and SG groups. RESULTS: A total of 156 patients were treated with either DES (n = 60 DES) or SG (n = 106 SG). DES deployment significantly reduced the mean number of target-lesion interventions (TLI) from 2.4 to 0.7 per year (p<0.001) and extended median TLI-free time from 4 to 10 months (p<0.001). Similarly, SG reduced mean TLI from 1.3 to 0.7 per year (p<0.001), increasing TLI-free time from 4 to 13 months (p<0.001). At 12 months, DES primary, assisted primary, and secondary patency rates were 49.9%, 78.2%, and 96.7%, respectively, compared to 58.8% (p=0.198), 72.3% (p=0.264), and 96.9% (p=0.877) for SGs. CONCLUSION: DES and SG significantly reduced TLI rates and prolonged TLI-free intervals compared to plain balloon angioplasty (PBA). No significant differences in overall patency were observed between the devices. These findings support DES as a potential alternative for managing outflow stenosis, particularly in venous confluent sites, where the risk of outflow jailing may compromise future vascular access.Clinical ImpactThis study suggests a potential paradigm shift in managing venous outflow lesions in dialysis access. By demonstrating comparable patency between drug-eluting stents (DES) and stent-grafts (SG), it broadens clinicians' options, particularly in anatomically challenging or recurrent stenoses. The innovation lies in identifying DES as a viable, off-label alternative that preserves future access possibilities by avoiding venous "jailing," a limitation of SGs. For clinicians, this means a more flexible, patient-tailored endovascular strategy that extends time to reintervention, optimizes long-term patency, and supports access preservation-especially valuable in cases requiring future surgical options like brachiobasilic fistula creation.