title: Equivalent secondary patency rates of upper extremity Vectra Vascular Access Grafts and transposed brachial-basilic fistulas with aggressive access surveillance and endovascular treatment.
abstract: OBJECTIVE
  The 2006 update of the DOQI guidelines has stated that in patients with end-stage renal disease, autogenous radial-cephalic, or brachial-cephalic fistulas are the preferred access modalities, followed by transposed brachial-basilic (TBB) fistulas and prosthetic arteriovenous (AV) grafts. AV grafts are in general least preferred; however, there is very limited data comparing directly the last two modalities. The aim of the present study is to compare outcomes of the TBB fistula and the Vectra Vascular Access Graft.
  
  
  METHODS
  Seventy-six patients had a prosthetic brachial-axillary Vectra graft placed, while in 41 patients brachial-basilic upper arm transposition was performed. Graft surveillance to detect a failing/failed access was followed by endovascular treatment, rheolytic thrombectomy (AngioJet, Possis Medical), and/or angioplasty +/- stenting of the responsible anatomical lesion(s).
  
  
  RESULTS
  Use of Vectra grafts and TBB fistulas started after a median (interquartile range) of 14 (7-30) and 70 (52-102) days, respectively (P < .001), as early as the operative day in some patients with grafts. Postoperative complications were more frequent in TBB fistulas and late complications (mainly access thrombosis) in Vectra grafts. Total number of thrombectomy sessions performed for graft or fistula occlusion was 45 and 7, respectively (P = .032); total number of isolated angioplasty sessions, performed for failing graft or fistula was 31 and 45, respectively (P = .004). Although primary patency of the two access modalities was equivalent, primary assisted patency was significantly reduced in Vectra grafts (70% at 12 months and 58% at 18 months), compared with TBB fistulas (82% at 12 months and 78% at 18 months, P = .033); however, as a result of endovascular intervention, secondary patency rates at 12 months (87% vs 88%) and 18 months (87% vs 83%) were equivalent (P = .91). Presence of arterial anastomosis stenosis treated with angioplasty at any stage had a significant negative predictive value on secondary patency rates at 12 and 18 months which were 61%, compared with 96% for Vectra grafts that had any intra-graft, venous outflow, draining or central vein stenosis treated with angioplasty at any stage (P = .010).
  
  
  CONCLUSIONS
  Aggressive graft surveillance and endovascular treatment methods can yield equivalent long-term secondary patency rates between Vectra graft and TBB fistulas. The advantage of earlier use of Vectra graft must be balanced against the need for more frequent secondary interventions and the risk of graft infection.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI 48202, USA.
authors.forename: Stavros K
authors.initials: SK
authors.lastname: Kakkos
authors.forename: Tanja
authors.initials: T
authors.lastname: Andrzejewski
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Haddad
authors.forename: Georges K
authors.initials: GK
authors.lastname: Haddad
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Reddy
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Nypaver
authors.forename: Martha M
authors.initials: MM
authors.lastname: Scully
authors.forename: Donna L
authors.initials: DL
authors.lastname: Schmid
mesh_terms: D000328:Adult; D000368:Aged; D017130:Angioplasty / Q000295:instrumentation*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D001916:Brachial Artery / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011140:Polyurethanes; D011474:Prosthesis Design; D006435:Renal Dialysis; D015607:Stents; D017131:Thrombectomy; D013997:Time Factors; D017211:Treatment Failure; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply*; D014654:Vascular Patency; D014680:Veins / Q000503:physiopathology / Q000601:surgery
chemical_list: D011140:Polyurethanes; C044690:polyetherurethane urea