title: Percutaneous rheolytic thrombectomy for thrombosed autogenous fistulae and prosthetic arteriovenous grafts: outcome after aggressive surveillance and endovascular management.
abstract: OBJECTIVE
  To study the outcome of rheolytic thrombectomy for hemodialysis access occlusion.
  
  
  METHODS
  A prospective study was conducted of 187 patients (88 men; median age 63 years, range 21-89) with end-stage renal disease treated with the AngioJet rheolytic thrombectomy catheter followed by angioplasty (+/- stenting) of the culprit lesions in 285 episodes of arteriovenous graft (n = 261) or fistula (n = 24) thrombosis. Clinical success was defined as at least one successful subsequent hemodialysis session. Graft monitoring and surveillance included clinical and hemodialysis parameters, respectively, to detect a failing/failed access.
  
  
  RESULTS
  Rheolytic thrombectomy had a technical (immediate) success rate of 98.2% and a clinical success rate of 95.1%. Technical and clinical success for patients presenting within 2 days of the thrombosis was 99.6% and 96.6%, respectively, compared to 91.8% (p = 0.003, odds ratio 20.8) and 87.8% (p = 0.019, odds ratio 4) for later presentation. The number of stenoses that was managed (median, interquartile range) was significantly higher in grafts (4, 3-4) compared to fistulae (2, 2-3; p<0.001) and in accesses that had been treated for dysfunction or thrombosis in the past (4, 3-4) compared to accesses that had not (3, 3-4; p = 0.07). During follow-up, 95 (36.6%) accesses had no further thrombotic events, 23 (9%) accesses became dysfunctional and were treated with endovascular techniques, 137 (52.3%) developed recurrent thrombosis for which rheolytic thrombectomy was attempted, and 30 (11.5%) were abandoned or removed for infection. Functional assisted primary patency at 1, 6, 12, and 18 months was 72.4%, 45.1%, 30.3%, and 22.4%, respectively. Reintervention and venous outflow stenosis were associated with better and worse outcomes, respectively; multivariate analysis identified patient age, central vein stenosis, and stenting as additional independent predictors of improved patency.
  
  
  CONCLUSIONS
  Rheolytic thrombectomy is a highly successful procedure, with acceptable long-term assisted primary patency. Early referral for thrombectomy should be encouraged.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, MI 48202, USA.
authors.forename: Stavros K
authors.initials: SK
authors.lastname: Kakkos
authors.forename: Georges K
authors.initials: GK
authors.lastname: Haddad
authors.forename: Joseph
authors.initials: J
authors.lastname: Haddad
authors.forename: Martha M
authors.initials: MM
authors.lastname: Scully
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon; D001166:Arteriovenous Shunt, Surgical; D016009:Chi-Square Distribution; D005260:Female; D005471:Fluoroscopy; D006083:Graft Occlusion, Vascular / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D006435:Renal Dialysis; D015607:Stents; D017131:Thrombectomy / Q000379:methods*; D013927:Thrombosis / Q000209:etiology / Q000628:therapy*; D016896:Treatment Outcome; D014654:Vascular Patency