Objectives: The management of hemodialysis fistulas and grafts greatly influenced survival and quality of life in patients undergoing hemodialysis. Salvage of vascular access (VA) occlusion can be performed by interventional therapy (IVT) using balloon angioplasty or surgical reconstruction after thrombectomy and angiography. The purpose of this study is to compare the outcomes of each type of salvage procedures in restoring vascular access occlusion.
Methods: Between April 2001 and July 2008, we treated 378 consecutive cases of VA occlusions. The type of dysfunctional hemodialysis fistulas were 111 arteriovenous fistulas (AVF) and 267 arteriovenous grafts (AVG). The thrombectomy (TH)-alone group: 11 AVFs and 48 AVGs were treated with thrombectomy alone using a Fogarty balloon catheter. IVT group: 12 AVFs and 93 AVGs with stenosis predominated in the venous outflow leading to increase venous pressures were treated with balloon angioplasty after thrombectomy. The surgical reconstruction (SR) group consisted of 37 AVFs with stenosis predominately in the anastomotic area, the majority leading to inflow problems, which were reconstructed by proximal anastomosis, and 90 AVGs which could not receive balloon angioplasty were reconstructed by a jump graft to normal vein. The new VA group consisted of 51 new AVFs and 36 new AVGs. We compared the patency rates of each treatment using the Kaplan-Meier method.
Results: The 6- and 12-month patency rates after each treatment for AVF occlusions were respectively as follows: in the TH-alone group (n = 11) they were 66%, 66%, in the IVT group (n = 12) 54%, 46%, in the SR group (n = 37) they were 95%, 83%. In the new VA group (n = 51) they were 69%, 61% (AVF) and 58%, 52% (AVG). The patency rate for AVG occlusions were respectively as follows: in the TH alone group (n = 48) they were 34% and 22%, in the IVT group (n = 93) they were 45% and 28%, in the SR group (n = 90) they were 47% and 35%. In the new VA group (n = 36) they were 50%, 50% (AVF) and 69%, 61% (AVG). In AVF occlusions, the patency rate was significantly better in the SR group (83% at 12 months) than the TH-alone group (66%) and IVT group (46%) (log rank test, p < 0.05). In AVG occlusion cases, there was no statistically significant difference of the patency rate between the SR group (35% at 12 months), the TH alone group (22%) and IVT group (28%).
Conclusion: The patency after surgical reconstruction in AVF occlusions exceeds that observed in AVG. We concluded that it is possible to improve the patency of vascular access to attempt to restore using autogenous fistulae and to avoid AVG as much as possible given their poor outcome.
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