Geographic miss and stent graft restenosis in hemodialysis access

Stent grafts are widely used to treat dysfunctional hemodialysis vascular access, yet restenosis remains common and its predictors are incompletely understood. We analyzed 203 unique patients who underwent stent graft implantation between 2018 and 2022 from a prospectively maintained database. Geographic miss was defined as inadequate lesion coverage or suboptimal stent sizing; longitudinal geographic miss (LGM) was defined as residual stenosis >30% within 5 mm of either stent edge. The outcomes were loss of stent graft patency and access primary patency, assessed using Kaplan-Meier analysis and Cox regression models. Among 203 patients, 81% had arteriovenous grafts and 19% had arteriovenous fistulas. One-year stent graft patency and access primary patency were 63.1% and 22.7%, respectively. In the primary exploratory multivariable model, LGM was associated with both loss of stent graft patency (HR 2.62, 95% CI 1.34-5.12) and loss of access primary patency (HR 2.76, 95% CI 1.50-5.05). Other factors associated with patency outcomes included diabetes mellitus, thrombosis presentation, vessel rupture or dissection, smaller stent diameter, and stent graft length. LGM remained associated with both outcomes in an additional clinically adjusted model. These findings suggest that LGM may represent a potentially modifiable procedural target, although prospective studies with standardized imaging follow-up and prospective validation are needed.