Endovascular treatment of swing-segment stenosis in vascular access: current status and future directions

Swing-segment lesions are a fairly common reason for access failure and predispose to repeated interventions. The pathophysiology, hemodynamic circumstances and the primary intervention might all play a role in early recurrence. Mainly, percutaneous transluminal angioplasty (PTA), bare metal stenting and stent graft implantation have been performed to prolong lesion patency and access circuit patency. The available data on endovascular treatment of swing-segment lesions are scarce, heterogeneous and of poor quality. Moreover, with the continuous evolution of endovascular techniques and introduction of new devices there is a risk of increasing device-specific investigations. In the meantime, PTA is easily discarded in favor of novel stents and stent grafts. However, PTA might still have an important position in the overall treatment strategy to postpone loss of the vascular access site. However, without optimal post-interventional imaging, true PTA results remain obscure and indications for additional stent (graft) implantation unclear. Currently, it seems that different devices are utilized to prolong lesion patency rather than access circuit patency. Obviously, more randomized controlled trials and well-structured multicenter registries may be capable of determining a superior treatment modality for a specific lesion. However, it might be more accurate to identify the optimal sequence of interventions by which the lifespan of the access site is maintained as long as possible.