Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Multidisciplinary Management of Morbidly Adherent Placenta.

BACKGROUND: Morbidly adherent placentation (MAP) increases the risk for obstetric hemorrhage. Cesarean hysterectomy is the prevalent perioperative approach. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive and relatively simple endovascular procedure to temporarily occlude the aorta and control below diaphragm bleeding in trauma. It has been effectively used to reduce obstetric hemorrhage. OBJECTIVES: To evaluate whether REBOA during cesarean delivery (CD) in women with morbidly adherent placentation is a safe and effective treatment modality. METHODS: We introduced REBOA for CD with antepartum diagnosis of MAP in 2019 and compared these patients (RG) to a standard approach group (SAG) treated in our center over the preceding year, as a control. All relevant data were collected from patient electronic files. RESULTS: Estimated blood loss and transfusion rates were significantly higher in SAG; 54.5% of SAG patients received four RBC units or more vs. one administered in RG. No fresh frozen plasma, cryoprecipitate, or platelets were administered in RG vs. mean 3.63, 6, and 3.62 units, respectively in SAG. Ten SAG patients (90.9%) underwent hysterectomy vs. 3 RG patients (30%). Five SAG patients (45%) required post-surgical intensive care unit (ICU) admission vs. no RG patients. Bladder injury occurred in five SAG cases (45%) vs. 2 RG (20%). One RG patient had a thromboembolic event. Perioperative lactate levels were significantly higher in SAG patients. CONCLUSIONS: Use of REBOA during CD in women with MAP is safe and effective in preventing massive bleeding, reducing the rate of hysterectomy, and improving patient outcome.

Superior Mesenteric Vein Injury During Oncologic Right Colectomy: Current Vascular Repair Modalities.

PURPOSE: To review the different vascular repair options of superior mesenteric vein (SMV) damage during oncologic right colectomy. METHODS: This is a retrospective chart review of 5 cases in which severe damage to the SMV occurred during oncological right colectomy in an academic medical center. RESULTS: During a 10-year study period, we encountered 5 cases in which severe damage to the SMV and its tributaries occurred. Two of the patients underwent primary venous repair for partial lacerations. The other 3 underwent interposition graft repair using a great saphenous vein (GSV) graft. Two of the grafts remained patent, while the third required replacement with a bovine pericardial patch. CONCLUSIONS: The SMV injury during oncologic right colectomy is a technically challenging injury. Based on our own experience and review of the literature, we formulated the following set of recommendations: (1) Venous ligation should be avoided, and revascularization should be attempted whenever feasible. (2) Primary venorrhaphy in cases of partial lacerations is the preferred treatment option. (3) End-to-end anastomosis is an efficient but seldom available repair option in the setting of complete SMV transection without segmental loss. (4) Autologous vein graft using the GSV is the preferred mode of repair during SMV injury with tissue loss. (5) Use of polytetrafluoroethylene (PTFE) graft should be avoided if possible due to greater risk of graft contamination. (6) A low threshold for reexploration depending on laboratory and imaging findings is advisable.

General, regional or local anesthesia for successful radial cephalic arteriovenous fistula.

Autogenous fistulas and in particular radiocephalic fistulas are recommended as the first vascular access for hemodialysis. Unfortunately, the rates of early failure and non-maturation are very high. For more than a decade, brachial plexus block has been proposed as the anesthesia of choice for fistula creation due to its beneficial sympathectomy-like effect, causing vasodilation and attenuation of spasm. Until recently, there was not a single randomized clinical study supporting this proposition. Because performing regional anesthesia is time-consuming and requires expertise, many surgeons prefer local or general anesthesia for vascular access surgery. However, in August 2016 a randomized clinical trial was published showing that regional anesthesia significantly reduces early failure and improves primary and functional patency at 3 months compared to local anesthesia. The aging of the dialysis population, with their attendant morbidity and increased risk for general anesthesia, makes it clear that regional anesthesia is the recommended approach for fistula creation. The excess time required for this approach will decrease with increasing expertise along the learning curve, and will be compensated by a reduction in time that would otherwise be needed for new access construction due to failure of fistulas constructed under local anesthesia.

Stent grafts for treatment of cannulation zone stenosis and arteriovenous graft venous anastomosis.

Stent grafts (SGs) are widely used for treatment of failing vascular accesses, fistulas and grafts. The mechanical barrier of the covered stent prevents in-stent stenosis and can be used to effectively correct ruptured vein and aneurysms. Treatment of cannulation zone stenosis with SG can be justified when its use is obligatory, in order to prevent total access loss. Although there are worrying complications attendant on SG insertion and cannulation, including jeopardizing future access creation, most studies report no complications of SG in cannulation zone stenosis. SGs for treatment of arteriovenous graft venous anastomosis stenosis is controversial. Two large randomized trials conclusively demonstrate improved primary patency with SGs at the venous anastomosis of arteriovenous graft at up to two years when compared with percutaneous transluminal angioplasty, sustained for up to 2 years and reducing the number of interventions per patient year. However, the ultimate goal of SG treatment of venous anastomosis stenosis is preventing thrombosis and increasing graft longevity, which was unfortunately not fully achieved.

Phase Ib Safety, Two-Dose Study of MultiGeneAngio in Patients with Chronic Critical Limb Ischemia.

Critical limb ischemia (CLI) is the most severe presentation of peripheral arterial disease. We developed cell-based therapy entailing intra-arterial injection of autologous venous endothelial cells (ECs) modified to express angiopoietin 1, combined with autologous venous smooth muscle cells (SMCs) modified to express vascular endothelial growth factor. This combination promoted arteriogenesis in animal models and was safe in patients with limiting claudication. In an open-label, phase Ib study, we assessed the safety and efficacy of this therapy in CLI patients who failed or were unsuitable for surgery or intravascular intervention. Of 23 patients enrolled, 18 with rest pain or non-healing ulcers (Rutherford categories 4 and 5) were treated according to protocol, and 5 with significant tissue loss (Rutherford 6) were treated under compassionate treatment. Patients were assigned randomly to receive 1 × 107 or 5 × 107 (EC-to-SMC ratio, 1:1) of the cell combination. One-year amputation-free survival rate was 72% (13/18) for Rutherford 4 and 5 patients; all 5 patients with Rutherford 6 underwent amputation. Of the 12 with unhealing ulcers at dosing, 6 had complete healing and 2 others had >66% reduction in ulcer size. Outcomes did not differ between the dose groups. No severe adverse events were observed related to the therapy.

Heparin-bonded expanded polytetrafluorethylene grafts in hemodialysis access.

When options for autologous arteriovenous (AV) fistulas have been fully exhausted, AV grafts continue to play an important role in access creation for hemodialysis, offering long-term hemodialysis access that is a better alternative to central vein catheters. The drawbacks of AV grafts are their poor patency, infection and higher cost. Their main advantages are that they are widely available, are easy to create, and mature early. In the context of the "Fistula First" initiative, many patients with low quality veins suffer from fistula failure and non-maturation resulting in prolonged catheter days that would otherwise be prevented by initial creation of an AV graft. Endeavors to improve graft patency include administration of pharmacological agents, changing graft configuration, altering graft biology, and altering the graft surface. In this review, the current status of heparin-bonded AV grafts for hemodialysis is discussed.

Validity and reliability of an instrument for assessing case analyses in bioengineering ethics education.

Assessment in ethics education faces a challenge. From the perspectives of teachers, students, and third-party evaluators like the Accreditation Board for Engineering and Technology and the National Institutes of Health, assessment of student performance is essential. Because of the complexity of ethical case analysis, however, it is difficult to formulate assessment criteria, and to recognize when students fulfill them. Improvement in students' moral reasoning skills can serve as the focus of assessment. In previous work, Rosa Lynn Pinkus and Claire Gloeckner developed a novel instrument for assessing moral reasoning skills in bioengineering ethics. In this paper, we compare that approach to existing assessment techniques, and evaluate its validity and reliability. We find that it is sensitive to knowledge gain and that independent coders agree on how to apply it.

Upper limb grafts for hemodialysis access.

Arteriovenous (AV) grafts are required for hemodialysis access when options for native fistulas have been fully exhausted, where they continue to play an important role in hemodialysis patients, offering a better alternative to central vein catheters. When planning autogenous accesses using Doppler ultrasound, adequate arterial inflow and venous outflow must be consciously preserved for future access creation with grafts. Efforts to improve graft patency include changing graft configuration, graft biology and hemodynamics. Industry offers early cannulation grafts to reduce central catheter use and a bioengineered graft is undergoing clinical studies. Although the outcome of AV grafts is inferior to fistulas, grafts can provide long-term hemodialysis access that is a better alternative to central venous catheters. AV grafts have significant drawbacks, mainly poor patency, infection and cost but also have some advantages: early maturation, ease of creation and needling and widespread availability. The outcome of AV graft surgery is variable from center to center. The primary patency rate for AV grafts is 58% at 6 months and the secondary patency rate is 76% at 6 months and 55% at 18 months. There are centers of excellence that report a 1 year secondary patency rate of up to 91%. In this review of the use of AV grafts for hemodialysis access in the upper extremities, technical issues involved in planning the access and performing the surgery in its different configurations are discussed and the role of surveillance and maintenance with their attendant surgical and radiological interventions is described.

Patient safety: the doctor's perspective.

Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Beyond their economic cost and their cost in human lives, errors cause loss of trust in the healthcare system by patients and diminished satisfaction by both patients and health professionals. There are many evidence-based safety-oriented behaviours and interventions that are easily implemented, such as ultrasound-guided central venous catheter insertion, prevention of catheter-related bloodstream infection and more. In vascular access, the development of research in patient safety has raised a variety of issues requiring study in order to provide the optimal patient safety approach. Patients are major contributors to their own safety, and as such, physicians should develop a new approach to involve them in the cycle of decision making through every step of their treatment. There are many opportunities along this path for the patient to be engaged in safety behaviours and for the access team to ensure such behaviours by employing simple strategies. The advent of the access centre, based on multidisciplinary teamwork, has enhanced the potential to improve patient safety by prevention of errors in planning and performing access surgery, avoiding delay in treatment of access malfunction and improving communication between the team members. However, a significant effort in research is still needed in order to implement intervention by evidence-based data focused on patient safety.

A prospective randomized study of heparin-bonded graft (Propaten) versus standard graft in prosthetic arteriovenous access.

OBJECTIVE: Prosthetic grafts continue to be required for hemodialysis access when the options for native fistulas have been exhausted. The inferior long-term patency of grafts makes the possibility of preventing occlusion with heparin-bonded grafts an attractive alternative. We carried out a prospective randomized study to compare the patency of standard grafts with heparin-bonded grafts. METHODS: Patients with end-stage renal failure requiring a prosthetic access were randomized to receive either a standard expanded polytetrafluorethylene (ePTFE) graft or a heparin-bonded ePTFE graft. Patients were enrolled from June 2007 until November 2011 and were followed up until July 2013, when the study concluded. RESULTS: In this study, 160 patients were randomized and followed up for a median of 23.5 months. No patient was lost to follow-up. Primary patency was 35% and 14% for heparin-bonded grafts and 29% and 12% for standard ePTFE grafts at 6 and 12 months, respectively (P = .48). Assisted primary patency was 54%, 41%, and 27% for heparin-bonded grafts and 41%, 30%, and 23% for standard grafts at 12, 24, and 36 months, respectively (P = .12). Secondary patency was 83%, 83%, and 81% for heparin-bonded grafts and 81%, 73%, and 68% for standard grafts at 12, 24, and 36 months, respectively (P = .33). There were significantly fewer thromboses in heparin-bonded grafts during the first 5 months (P = .020). Of 80 standard grafts, 24 were eventually abandoned vs 17 heparin-bonded grafts (P = .188). Bleeding complications, infections, and intervention rates were similar in both groups. CONCLUSIONS: Heparin-bonded grafts demonstrated a trend to improved patency, but the difference was not statistically significant. Heparin-bonded grafts had a significantly lower early thrombosis rate that was sustained only for the first 5 months of follow-up.

The patient's role in patient safety and the importance of a dedicated vascular access team.

The role of dialysis patients in ensuring their own safety throughout the process of vascular access construction should be far from negligible. Patients can make important contributions to their safety starting in the predialysis stage, via vascular access construction and through the experience of chronic hemodialysis. Currently, patients assume a passive role and their empowerment requires both patients and caregivers to overcome many personal and cultural barriers, thus encouraging safety-related behavior. There are many opportunities for end-stage renal failure patients to be involved in every stage of their disease. In this chapter, we discuss how hemodialysis patients can participate in patient safety, including some of the main opportunities for involvement along the care pathway from the point at which the decision is made that the patient requires vascular access surgery.

Vascular access in hemodialysis patients older than 80 years.

OBJECTIVE: There is a worldwide surge in numbers of elderly people requiring hemodialysis accompanying the prevailing increase in longevity. There is a trend for central venous catheters to be preferentially placed in elderly patients, whereas others recommend routine use of grafts for surgical access. In our center, age has not been a consideration in deciding to construct arteriovenous access for hemodialysis. We reviewed our experience with arteriovenous access surgery in all hemodialysis patients aged 80 years and older to determine if this approach is justified in terms of patency and life expectancy. METHODS: A retrospective study was made of all patients aged 80 years and older who had surgery from January 2005 to December 2009 at our national vascular access referral center. All patients had preoperative mapping and had fistula construction if the vein size was at least 3 mm. Otherwise they had brachiobasilic or brachioaxillary grafts. All patients had routine access surveillance by Doppler ultrasound (duplex) and physical examination at regular intervals, and interventions were carried out according to the findings. Type of access, success rate, maturation, primary and secondary patency, and patient survival in the age group older than 80 years were noted. RESULTS: During the study period, 134 patients had 146 new accesses. There were 128 autogenous accesses (30 forearm, 91 upper arm, and seven transposed basilic veins) and 18 prosthetic accesses. Overall primary patency was 39%, 33%, and 23% at 12, 24, and 36 months. Secondary patency was 92%, 83%, and 77% at 12, 24, and 36 months. There was no significant difference in patency between the different types of accesses and between diabetic and nondiabetic patients. Eleven upper arm and four forearm fistulas had delayed maturation or nonmaturation. The relative risk for delayed maturation or nonmaturation of forearm fistulas (13.3%) compared with brachial-cephalic fistula (12.1%) was 1.1030 (95% confidence interval, 0.3973-3.204; P = .8571). Median patient survival was 38 months, with 49 dying during follow-up. CONCLUSIONS: Contrary to recent recommendations favoring grafts for hemodialysis in patients older than 80 years, most elderly patients in this study were found to have vasculature that was suitable for autogenous access construction, with patency rates similar to those of their younger counterparts when adequate preoperative planning and postoperative maintenance were carried out. Age alone should not disqualify patients older than 80 years from access surgery for hemodialysis, nor should age disqualify these patients from the Fistula First Initiative.

Anesthesia for vascular access surgery.

The type of anesthesia chosen is an integral part of the decision-making process for arteriovenous access construction. We discuss the different types of anesthesia used, with emphasis on brachial plexus block, which is potentially safer than general anesthesia in this fragile patient population with end-stage renal disease. Brachial plexus block is superior to local anesthesia and enables the use of a tourniquet to minimize potential damage to the blood vessels during anastomosis using microsurgery techniques, and does not lead to the vasospasm that may be seen with local anesthesia. Regional anesthesia has a beneficial sympathectomy-like effect that causes vasodilation with increased blood flow during surgery and in the fistula postoperatively that may prevent early thrombosis and potentially improve outcome.

Stent grafts for central venous occlusive disease in patients with ipsilateral hemodialysis access.

PURPOSE: To assess long-term outcomes of stent grafts in patients with symptomatic central venous stenoses and occlusions ipsilateral to hemodialysis grafts or fistulas. MATERIALS AND METHODS: The study included 52 of 55 consecutive patients with symptomatic stenoses of the central veins draining upper limb dialysis access grafts or fistulas treated with stent grafts. Indications for stent grafts were poor angioplasty results, rapid recurrence, or total occlusion. Endpoints were lesion patency and access patency following intervention. Mean follow-up was 25 months with a median of 24 months and 1.25 additional procedures per patient year. Patency rates were calculated using Kaplan-Meier analysis. RESULTS: All stent grafts were successfully deployed. The lesion patency rates at 6, 12, 24, and 36 months after intervention were 60%, 40%, 28%, and 28%. The access patency rates at 6, 12, 24, and 36 months after intervention were 96%, 94%, 85%, and 72%. There was one major complication and no minor complications. In 40 patients (77%), the internal jugular vein confluence was covered by the stent graft. In five patients, the dialysis circuits became occluded, with no clinical sequelae in four; one patient was lost to follow-up. The contralateral brachiocephalic vein was covered in three patients (6%), preventing contralateral access construction in one patient. CONCLUSIONS: Central vein stent graft placement in patients with hemodialysis access is associated with prolonged access patency. Coverage of major vein confluences, which occurred in 83% of the patients in this series, can compromise future access and should be avoided whenever possible by careful technique.

Ipsilateral hemodialysis access after axillary dissection for breast cancer.

Breast cancer survivors who have had axillary lymph node dissection (ALND) and who later develop end-stage renal failure may eventually require hemodialysis access. If veins available for access in the contralateral arm have been exhausted, especially after chemotherapy, the ipsilateral arm will have to be considered for access construction. There are no evidence-based guidelines for lymphedema prevention, but there are sweeping recommendations to avoid physical injury to the ipsilateral limb, including needle puncture, after ALND with or without radiotherapy. Three studies have shown little or no effect of hand surgery in producing or exacerbating lymphedema after ALND. Dialysis access guidelines recommend the use of autogenous accesses over synthetic grafts whenever possible. Three patients after ALND were referred for hemodialysis access construction in our center. Pre-operative duplex ultrasound confirmed that patent veins appropriate for autogenous access construction were only present in the ipsilateral arm. Autogenous arteriovenous fistulas were constructed in the ipsilateral arm in the three patients. All the three entered our access surveillance program and were regularly examined. All had more than 20 lymph nodes removed. One had axillary radiotherapy and anthracycline-based chemotherapy, one had anthracycline-based chemotherapy without axillary radiotherapy and one had neither treatment. The access was established 4-10 years after ALND. No patient developed significant lymphedema at two, 20 and 76 months respectively after access construction, with cannulation for dialysis occurring three times a week. Autogenous hemodialysis access construction does not seem to contribute to lymphedema development after ALND. Physicians and other medical personnel caring for patients with breast cancer should not oppose the use of the ipsilateral arm if it is the only arm with vasculature suitable for autogenous access construction. Recommendations for lymphedema prevention may exaggerate the extent of risk attributable to interventions in the ipsilateral arm.

Stent graft treatment for hemodialysis access aneurysms.

BACKGROUND: Aneurysms that develop in arteriovenous accesses as a result of repeated punctures are sometimes complicated by infection or ischemia causing sloughing of the overlying skin, which may endanger the access and risk major bleeding and other complications. Surgical revision may necessitate the temporary use of a central venous catheter until dialysis can be resumed via the access. We used stent grafts in selected patients for the exclusion of access aneurysms. METHODS: Twenty of 63 patients requiring access revision for complication of an aneurysm from February 2005 to December 2009 underwent ambulatory endovascular stent graft deployment. Indications included signs of impending rupture, questionable viability of overlying skin, pain, infection, and limitation of cannulation sites by the size or number of the aneurysms. Endovascular treatment always included angioplasty of associated outflow or central vein stenoses at the same ambulatory session. RESULTS: Twenty patients with complicated access aneurysms were treated by endovascular stent graft exclusion at an average of 4.8 ± 4.3 years (range, 0.2 to 16.1 years) after access construction: nine graft pseudoaneurysms, nine native vein aneurysms, and two acute iatrogenic pseudoaneurysms. Six patients had skin erosion over the aneurysm, and 12 had painful aneurysms and clinical signs of compromised blood supply to the skin. Another two patients with an acute giant false aneurysm occurring during endovascular procedures were treated in the same interventional session by the stenting technique to control bleeding. All the aneurysms underwent endovascular exclusion without complications. Only one infected puncture site failed to heal within 2 months of stenting and was closed surgically 10 months later due to persistent localized graft infection, but with no further bleeding episodes. Only one aneurysm did not reabsorb within 3 months. Patients with painful skin ischemia had immediate pain relief. All patients also had stenosis in the draining veins necessitating additional percutaneous transluminal angioplasty. Only one patient required hospitalization (for intravenous antibiotic treatment of staphylococcal sepsis). No patients required a central catheter for hemodialysis. One access occluded due to cephalic arch stenosis in a noncompliant patient. Functional patency was 87% at 12 months, with a median follow-up of 15 months (range, 6.3 to 55.5 months). CONCLUSION: Endovascular treatment with stent grafts in complicated access aneurysms is a simple, safe and rapid ambulatory procedure that enables treatment of both the aneurysm and its accompanying draining vein stenosis. It enables continued cannulation of the existing access and avoids the use of central catheters.

Banding between dialysis puncture sites to treat severe ischemic steal syndrome in low flow autogenous arteriovenous access.

Dialysis-associated steal syndrome with rest pain and ischemic nonhealing ulcers dictates prompt surgical intervention. Distal revascularization with interval ligation is extensive surgery for frail patients in whom calcified distal arteries make anastomosis difficult. Simple banding is appropriate in high-flow fistulas. In low-flow accesses, further flow reduction by simple banding may result in inadequate dialysis and cause thrombosis. However, banding between puncture sites maintains a pressure gradient between the arterial and venous puncture sites that enables adequate flow with effective hemodialysis that would not be possible with banding at the anastomosis. This new technique is a good solution for maintaining access patency and increasing digital pressure while avoiding complicated surgical revisions in high-risk patients.

Angioplasty with stent graft versus bare stent for recurrent cephalic arch stenosis in autogenous arteriovenous access for hemodialysis: a prospective randomized clinical trial.

BACKGROUND: Early recurrent stenosis of the cephalic arch in autogenous arteriovenous access for hemodialysis is a common problem that requires stenting to prevent thrombosis. Because the results of stenting are unsatisfactory, we compared the efficacy of stent grafts with bare stents in these patients. METHODS: All patients who presented with recurrent cephalic arch stenosis >50% within 3 months of successful balloon angioplasty were randomized to have angioplasty and stenting with either a bare nitinol stent or a stent graft. Outcome was assessed by angiography 3 months later. Restenosis was defined as >50% narrowing of the stent lumen or of the vessel margin up to 0.5 cm adjacent to the stent. There were no exclusions. RESULTS: This report includes data on the outcome of 25 consecutive patients with recurrent cephalic arch stenosis who were treated from April to August 2006. At 3 months, three patients had died and one had undergone a renal transplant. The 21 patients who had angiography at 3 months had patent stents. Restenosis rates were seven of 10 (70%) in the bare stent group and two of 11 (18%) in the stent graft group (P = .024). Life-table analysis at 3 and 6 months showed that primary patency was 82% in the stent graft group and 39% in the bare stent group. One-year primary patency was 32% in the stent graft group and 0% in the bare stent group (P = .0023). During a mean follow-up of 13.7 months, nine patients died, four in the bare stent group and five in the stent graft group. Two patients in the stent graft group had received a renal transplant. The number of interventions per patient-year was 1.9 in the bare stent group and 0.9 in the stent graft group (P = .02). CONCLUSIONS: The use of stent grafts in angioplasty for recurrent cephalic arch stenosis significantly improved short-term restenosis rates and long-term patency compared with the use of bare stents. The significant improvement that emerged during the study caused accrual of patients to be halted for ethical reasons. This study altered our usage of stents for venous stenoses in arteriovenous accesses by eliminating bare nitinol stents in favor of stent grafts.

Thrombolysis for early failure of prosthetic arteriovenous access.

BACKGROUND: Early failure (within 6 weeks of construction) of prosthetic arteriovenous access (AVA) is traditionally treated by surgical revision rather than endovascular intervention because it is assumed to be related to technical factors related to the surgery. This premise is not evidence based and our results for surgical thrombectomy have been poor. Based on our previous experience with angiography and thrombolysis in newly constructed autogenous AVAs, we changed our approach to perform endovascular thrombolysis initially, instead of proceeding directly to surgical revision. METHODS: We prospectively studied all patients who had an early failure of new prosthetic AVA from January 2000 to June 2004 to determine the cause of and treat the occlusions by endovascular means. Thrombolysis took place at least 7 days after surgery, allowing sufficient tissue incorporation to prevent puncture site bleeding. No patients were excluded from the study. RESULTS: During the 54 months of the study, 269 prosthetic AVAs were constructed at our center. Twenty patients had early occlusion. The mean time from creation of the prosthetic AVA to occlusion was 15.8 +/- 10.9 (median 13, range 3-41) days and the mean time to intervention was 25.0 +/- 11.6 (median 21, range 9-54) days. Of the 20 patients, 17 underwent successful endovascular thrombolysis. The only patient of the 20 found to have a technical problem related to surgery had this resolved angiographically. There was one complication in a patient with failed endovascular thrombolysis, who had extravasation from the arterial anastomosis that halted the procedure. This patient later had surgical revision in keeping with the angiographic findings. Cumulative patency rates at 6 months and 1 year were 75% and 68%, respectively. CONCLUSIONS: Endovascular thrombolysis for early occlusion of prosthetic AVAs is feasible, safe, and is associated with a good patency rate. It appears to be a better initial approach than surgical revision in these patients because technical-surgical problems related to AVA construction are rare.