Paclitaxel for the Treatment of Upper-Extremity Arteriovenous Access Fistula Stenosis

The Use of Intravascular Paclitaxel for the Treatment of Upper-Extremity Arteriovenous Access Fistula Stenosis: A Randomized Study

The objective of this study is to evaluate the safety and effectiveness of the use of intravascular paclitaxel, in addition to standard therapy, for the treatment of arteriovenous dialysis access fistula stenosis.

A fistulogram will be performed in standard fashion. The diagnostic component will include evaluation of the inflow artery, arterial anastomosis and full length of the fistula vein or graft, plus venous return up to the heart. The location, vessel size, lesion diameter and percent stenosis for each lesion will be recorded. Enrollment and randomization will occur at this point.

All patients will then receive standard therapy for their stenosis. This will include intravenous heparin administered in a standard dose of 70 units/kg. Lesions that respond poorly to angioplasty (>30% residual stenosis after angioplasty treatment with 2 inflations) will be stented. Stent selection will be based on clinical setting. Initial stent treatment will utilize an uncovered nitinol stent. Treatment of in-stent restenosis will include initial balloon angioplasty, and use of a covered stent (Viabahn, GORE, or Fluency, Bard). Documentation of location and type of treatment for each lesion treated will be recorded.

Once standard treatment is completed, the operating surgeon will be informed of the patient randomization: treatment (paclitaxel) or control. For subjects assigned to treatment, Paclitaxel solution treatment of each lesion encountered from proximal to distal will be attempted until the 20 mg Paclitaxel dose limit is met.

A TAPAS infusion catheter will be used for all paclitaxel dose administrations. The TAPAS infusion catheter will be positioned to reduce the presence of branches which permit the loss of paclitaxel from the treatment zone. After the full outflow vein segment is treated, the fistulogram is completed in the standard fashion. Prior to removal of the sheath, a final angiographic study of all areas treated is performed to document patency and lesion appearance.

For the control group, instead of paclitaxel administration, a sham treatment period of 10 minutes is allowed to elapse followed by the performance of the final completion angiogram. Any additional lesions identified with this study are then treated appropriately following standard technique.

All patients will follow the same follow up evaluation schedule.

Inclusion Criteria:

1. Age 18 years or older
2. Patient or guardian able to provide a signed witnessed informed consent
3. Stenosis greater than or equal to 50% treated satisfactorily (less than 20% residual stenosis) with balloon angioplasty alone or balloon angioplasty and stent placement
4. Either gender

Exclusion Criteria:

1. Women who are pregnant or who are expected to or might become pregnant
2. Women of child-bearing potential who do not use contraception
3. Life expectancy less than 12 months
4. Known allergy to paclitaxel
5. Known allergy to contrast media not previously demonstrated to be controllable with premedication on a prior study using contrast
6. Known allergy to the pre-medications (dexamethasone, famotidine, diphenhydramine)
7. Pre-fistulogram thrombosis of the fistula or graft
8. Thrombectomy of the fistula or graft within 14 days of the procedure
9. Patient receiving chemotherapy
10. Patients with an immunodeficiency disease or condition
11. Documented hypercoagulable state
12. White Blood Count < 2000/mm3
13. Platelet count less than 100,000/mm3
14. Chronic hepatitis or jaundice (total bilirubin > 2x upper limit of normal)
15. Simultaneous enrollment in another investigational device or drug study