LAUSR

Dear Editors, We read with interest the article entitled ‘‘First Clinical Results of the Merit WRAPSODY Cell-Impermeable Endoprosthesis for Treatment of Access Circuit Stenosis in Haemodialysis Patients’’ published by Gilbert et al. [1]. The WRAPSODY Endoprosthesis is a self-expanding, cellimpermeable stent-graft designed for the treatment arteriovenous access stenoses. Despite this study being funded by the manufacturer, we are encouraged that this new configuration may show promise in access preservation for hemodialysis patients. However, the proper use of any endovascular device is paramount to ensuring maximal efficacy: to that end, we were disheartened by the clinical example provided in Fig. 3. These images demonstrate stent-graft deployment in the cephalic vein, extending to the mid-subclavian vein and, thus, jailing the axillary venous confluence. While this is a known complication of stent graft use in the cephalic vein [2], there are sufficient techniques described for the experienced interventionalist to mitigate this risk [3, 4]. In the case illustration provided in this article, although the stent-graft resolved the stenosis and the final images demonstrated inline flow from the cephalic vein to the right atrium, exclusion of the axillary vein by a covered stent obstructs the basilic and brachial venous inflow. While this may result in a positive shortterm clinical result, this remains a poor example of vein preservation for the lifetime of this patient. If the cephalic arteriovenous access fails, not only will the patient be left with limited options for future access, but there is also risk of symptomatic venous outflow obstruction due to the stent-graft position. Long-term access options must be considered in every patient, in keeping with the recent K-DOQI guidelines’ Kidney Life Plan [5]. This patient has had an intervention that is not in accordance with that goal, and we implore the authors and readers of this journal to consider this when treating such lesions.