Description and outcomes of a simple surgical technique to treat thrombosed autogenous accesses.
OBJECTIVE
Owing to the difficulty of removing acute and chronic thrombus from autogenous accesses (AA) by standard surgical and endovascular techniques, many surgeons consider efforts to salvage a thrombosed AA as being futile. We describe a simple technique to extract acute and chronic thrombus from a failed AA. This technique involves making an incision adjacent to the anastomosis, directly extracting the arterial plug, and manually milking thrombus from the access. This report details the outcomes of a series of thrombosed AAs treated by surgical thrombectomy/intervention using this technique for manual clot extraction.


METHODS
A total of 146 surgical thrombectomies/interventions were performed in 102 patients to salvage a thrombosed AA. Mean follow-up was 15.6 months. Office, hospital, and dialysis unit records were reviewed to identify patient demographics, define procedure type, and determine functional patency rates. Kaplan-Meier survival analysis was used to estimate primary and secondary functional patency rates.


RESULTS
Complete extraction of thrombus from the AA was achieved in 140 of 146 cases (95%). The studied procedure itself was technically successful in 127 cases (87%). Reasons for failure were the inability to completely extract thrombus from the AA in six, failed angioplasty due to long segment vein stenosis or sclerosis in seven or vein rupture in two, and central vein occlusion in one. Three failures occurred for unknown causes ≤ 3 days of successful thrombectomy. No single factor analyzed (age, sex, race, diabetes status, access type or location) was associated with technical failure. The estimated primary and secondary functional patency rates were 27% ± 5% and 61% ± 6% at 12 months.


CONCLUSIONS
The manual clot extraction technique described in this report effectively removed acute and chronic thrombus from failed AAs. Its use, combined with an intervention to treat the underlying cause for AA failure, significantly extended access durability.
Department of Surgery, Greenville Hospital System/University Medical Center, University of South Carolina School of Medicine-Greenville, Greenville, SC 29605, USA. dcull@ghs.org
David L
DL
Cull
Joshua D
JD
Washer
Christopher G
CG
Carsten
Gail
G
Keahey
Brent
B
Johnson
D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009657:North Carolina; D006435:Renal Dialysis; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D017131:Thrombectomy / Q000009:adverse effects / Q000379:methods*; D013927:Thrombosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D017211:Treatment Failure; D014654:Vascular Patency