title: Percutaneous therapy to maintain dialysis access successfully prolongs functional duration after primary failure.
abstract: The role of endovascular therapy for thrombosed dialysis access has grown despite the paucity of data on its viability. The purpose of this study was to characterize the outcomes of a universal endovascular dialysis declot policy at a tertiary medical center. A database of patients undergoing endovascular treatment of thrombosed dialysis access between 1997 and 2003 was maintained. A two-puncture, combined percutaneous mechanical and pharmacologic thrombectomy technique was used. Data were collected on the success rate, complication rate, long-term patency, and presence and location of stenosis. Fistulograms were reviewed in all cases to assess lesion characteristics and pre- and postprocedure results. Results were standardized to current Society of International Radiology and Society for Vascular Surgery criteria. Failure was considered as either an anatomic defect requiring therapy or loss of functionality of the fistula. Life-table analyses were performed to assess time-dependent outcomes. Cox's proportional hazard analyses were performed to identify factors associated with outcomes. Values are the mean +/- standard error of the mean. There were 114 patients (50% male; average age 58 years, range 21-78) who presented with 174 thrombosed grafts. Therapy was performed for 237 thrombotic events (median 2, range 1-5 thrombotic events per hemodialysis access). After successful declot, anastomotic venous stenoses were encountered in 72% and central venous stenoses in 18% of cases; no cause was found in 10%. All stenoses were treated with balloon angioplasty. The technical failure rate was 4.6%. The 30-day all-cause mortality rate was 1.7%, and major morbidity rate was 2.4%. There were 413 interventions (236 percutaneous transluminal angioplasty and/or 183 declot) performed to maintain patency, which amounted to 2.3 interventions per patient. Average primary functional dialysis life span was 6.7 months up to the primary thrombotic event. Aggressive endoluminal therapy added a further average of 12 months of functionality (defined as continued dialysis access). A universal policy of endovascular therapy for occluded dialysis access results in reestablishment of function in the majority of patients and will triple functional longevity. Furthermore, while this approach remains procedure-intensive, it carries low morbidity and mortality and preserves future sites of access.
authors.affiliation: Department of Surgery, Center for Vascular Disease, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642, USA.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Bakken
authors.forename: Irfan I
authors.initials: II
authors.lastname: Galaria
authors.forename: Cara
authors.initials: C
authors.lastname: Agerstrand
authors.forename: Wael E
authors.initials: WE
authors.lastname: Saad
authors.forename: Scott M
authors.initials: SM
authors.lastname: Surowiec
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Singh
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Rhodes
authors.forename: David
authors.initials: D
authors.lastname: Lee
authors.forename: Nikhil C
authors.initials: NC
authors.lastname: Patel
authors.forename: Karl A
authors.initials: KA
authors.lastname: Illig
authors.forename: David L
authors.initials: DL
authors.lastname: Waldman
authors.forename: Mark G
authors.initials: MG
authors.lastname: Davies
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D015897:Comorbidity; D003928:Diabetic Nephropathies / Q000453:epidemiology; D005260:Female; D006083:Graft Occlusion, Vascular / Q000628:therapy*; D006333:Heart Failure / Q000453:epidemiology; D006801:Humans; D007037:Hypothyroidism / Q000453:epidemiology; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000628:therapy; D015993:Life Tables; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D017131:Thrombectomy / Q000379:methods*; D019851:Thrombophilia / Q000453:epidemiology; D016896:Treatment Outcome; D014654:Vascular Patency