title: Acute arteriovenous access failure: long-term outcomes of endovascular salvage and assessment of co-variates affecting patency.
abstract: OBJECTIVE
  This study reports long-term outcomes after endovascular salvage (EVS) for acute dialysis fistula/graft dysfunction.
  
  
  METHODS
  All patients presenting with acute fistula or graft dysfunction, excluding primary failures, referred for endovascular salvage were included in this single-centre prospective study.
  
  
  RESULTS
  Altogether, 410 procedures were carried out in 232 patients. Overall, the incidence of thrombosis/occlusion (per patient-year) was 0.12 for fistulae and 0.9 for grafts. The anatomical success rate for EVS was 94% for fistulae and 92% for grafts. Primary patency rates for fistulae at 1, 6, 12, 24 and 36 months were 82, 64, 44, 34 and 26%, respectively, whereas secondary patency rates were 88, 84, 74, 69 and 61%, respectively. Primary patency rates for grafts at 1, 6 and 12 months were 50, 14 and 8%. The overall rate of complications was 6% with no incidence of symptomatic pulmonary embolism. In a Cox regression model, upper-arm location of fistula (HR 1.9, p = 0.04, n = 144) was associated with lower primary patency, whereas the presence of thrombosis was associated lower primary (HR 1.9, p = 0.004, n = 144) and secondary patency (HR 3.7, p < 0.001, n = 144). Aspirin therapy was associated with longer primary patency (HR 0.6, p = 0.02, n = 144) and secondary patency (HR 0.58, p = 0.08, n = 144).
  
  
  CONCLUSIONS
  EVS is effective but longer-term outcomes are poor. Presence of thrombosis portends poor fistula survival and strategies for prevention need attention. Balloon maceration, our preferred declotting technique, is safe and the most cost-effective method. Aspirin therapy for patients presenting with failure of fistulae deserves further investigation.
authors.affiliation: Department of Renal Medicine, Manchester Royal Infirmary, Manchester, UK.
authors.forename: Milind D
authors.initials: MD
authors.lastname: Nikam
authors.forename: James
authors.initials: J
authors.lastname: Ritchie
authors.forename: Anu
authors.initials: A
authors.lastname: Jayanti
authors.forename: Ondina A
authors.initials: OA
authors.lastname: Bernstein
authors.forename: Leonard
authors.initials: L
authors.lastname: Ebah
authors.forename: Paul
authors.initials: P
authors.lastname: Brenchley
authors.forename: Alastair
authors.initials: A
authors.lastname: Hutchison
authors.forename: Nicholas
authors.initials: N
authors.lastname: Chalmers
authors.forename: Sandip
authors.initials: S
authors.lastname: Mitra
mesh_terms: D000368:Aged; D001163:Arteriovenous Anastomosis / Q000473:pathology; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005542:Forearm / Q000098:blood supply; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D006435:Renal Dialysis / Q000379:methods; D016879:Salvage Therapy / Q000379:methods*; D017131:Thrombectomy; D013927:Thrombosis / Q000209:etiology / Q000628:therapy; D017211:Treatment Failure; D016896:Treatment Outcome; D062666:Vascular Access Devices / Q000009:adverse effects*