Outcome of the use of stent grafts to salvage failed arteriovenous accesses.
BACKGROUND
Since elements of the Dialysis Outcome Quality Initiative (K/DOQI) were implemented a decade ago, there has been a reduction in mortality for patients on hemodialysis. As patient longevity has increased, AV access site preservation by salvaging failed arteriovenous (AV) accesses has become increasingly important. However, efforts to salvage an AV access must be balanced against futile and expensive procedures. The Viabahn Endoprosthesis is a self-expandable stent graft (SG) that can be used to treat vein rupture or fibrotic lesions with significant elastic recoil following balloon angioplasty. The literature comprising the outcome of the use of SGs in salvaging failed AV accesses is limited. The purpose of this study is to determine the outcome of failed AV accesses treated with SGs and to identify patient or graft factors predictive of success.


METHODS
The vascular access database and office, hospital, and dialysis unit records were retrospectively reviewed to identify all patients who underwent placement of an SG for the treatment of a thrombosed AV access between September 2004 and December 2007. Mean patient follow-up was 6 months. The K/DOQI goal for patency following a surgical intervention (6 months or later) was used to determine procedure success or failure. Kaplan-Meier life-table analysis was used to determine patency. Patient demographics and graft factors (location, diameter, length) were analyzed to identify predictors of success.


RESULTS
Fifty-five SGs were placed in 48 patients (males, 29%; mean age, 61 years; diabetes mellitus, 47%) with a failed AV access. The indications were to treat significant elastic recoil or vein rupture following balloon angioplasty (47 patients) and to treat an AV graft seroma (1 patient). Cost for the VE ranged from $2337 to $3367 per patient. The procedure was deemed successful (patent at 6 months) in 29 + or - 7% of cases. Procedure success was not influenced by AV access location, endoprosthesis size (diameter or length), or patient demographic factors (p > 0.05).


CONCLUSIONS
Use of the SG to salvage AV accesses falls short of the current K/DOQI clinical outcome goals for successful surgical intervention in the majority of cases. Given these results and the cost of the SG, its use is indicated in cases where AV access salvage will have an impact on long-term survival such as for patients in whom there are few options for new access placement. Further studies are needed to compare the SG to less costly options, such as angioplasty alone or angioplasty with the use of bare metal stents.
Webb
Keith M
KM
Academic Department of Surgery, Greenville Hospital System University Medical Center, University of South Carolina School of Medicine, Greenville, SC 29605, USA.
Cull
David L
DL
Carsten
Christopher G
CG
Johnson
Brent L
BL
Taylor
Spence M
SM
D000368:Aged; D000800:Angioplasty, Balloon / Q000009:adverse effects* / Q000191:economics; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects* / Q000191:economics; D001807:Blood Vessel Prosthesis / Q000191:economics; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation*; D003362:Cost-Benefit Analysis; D005260:Female; D006083:Graft Occlusion, Vascular / Q000191:economics / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D017048:Health Care Costs; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012042:Registries; D006435:Renal Dialysis / Q000191:economics; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents / Q000191:economics; D013927:Thrombosis / Q000191:economics / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency