Percutaneous rheolytic thrombectomy for thrombosed autogenous fistulae and prosthetic arteriovenous grafts: outcome after aggressive surveillance and endovascular management.

PURPOSE: To study the outcome of rheolytic thrombectomy for hemodialysis access occlusion. METHODS: A prospective study was conducted of 187 patients (88 men; median age 63 years, range 21-89) with end-stage renal disease treated with the AngioJet rheolytic thrombectomy catheter followed by angioplasty (+/- stenting) of the culprit lesions in 285 episodes of arteriovenous graft (n = 261) or fistula (n = 24) thrombosis. Clinical success was defined as at least one successful subsequent hemodialysis session. Graft monitoring and surveillance included clinical and hemodialysis parameters, respectively, to detect a failing/failed access. RESULTS: Rheolytic thrombectomy had a technical (immediate) success rate of 98.2% and a clinical success rate of 95.1%. Technical and clinical success for patients presenting within 2 days of the thrombosis was 99.6% and 96.6%, respectively, compared to 91.8% (p = 0.003, odds ratio 20.8) and 87.8% (p = 0.019, odds ratio 4) for later presentation. The number of stenoses that was managed (median, interquartile range) was significantly higher in grafts (4, 3-4) compared to fistulae (2, 2-3; p<0.001) and in accesses that had been treated for dysfunction or thrombosis in the past (4, 3-4) compared to accesses that had not (3, 3-4; p = 0.07). During follow-up, 95 (36.6%) accesses had no further thrombotic events, 23 (9%) accesses became dysfunctional and were treated with endovascular techniques, 137 (52.3%) developed recurrent thrombosis for which rheolytic thrombectomy was attempted, and 30 (11.5%) were abandoned or removed for infection. Functional assisted primary patency at 1, 6, 12, and 18 months was 72.4%, 45.1%, 30.3%, and 22.4%, respectively. Reintervention and venous outflow stenosis were associated with better and worse outcomes, respectively; multivariate analysis identified patient age, central vein stenosis, and stenting as additional independent predictors of improved patency. CONCLUSION: Rheolytic thrombectomy is a highly successful procedure, with acceptable long-term assisted primary patency. Early referral for thrombectomy should be encouraged.

Effectiveness of a new tunneled catheter in preventing catheter malfunction: a comparative study.

PURPOSE: To compare infection and malfunction rates of two different types of antimicrobial-eluting tunneled cuffed catheters (TCCs) for hemodialysis. MATERIALS AND METHODS: The HemoSplit TCC with BioBloc (silver sulfadiazine) coating (n = 100, control group) and the Tal Palindrome Ruby TCC, which has a novel silver antimicrobial sleeve and a spiral-z tip design (n = 100, study group), were compared in this case-controlled study. The main endpoints were TCC infection and malfunction. RESULTS: Primary-assisted TCC patency was significantly reduced with the BioBloc TCC (71% and 61% at 90 and 180 days, respectively) compared with the Palindrome Ruby TCC (94% at 90 and 180 days, P < .0001). Multivariate analysis identified only the BioBloc TCC and common femoral access site as independent predictors of worse patency. The unadjusted relative risk (95% confidence interval) for TCC dysfunction with the BioBloc compared with the Palindrome Ruby was 6.0 (2.33-15.53, P < .001), and the relative risk adjusted for access site was 3.2 (1.71-11.96, P = .002). The infection-free rates of the two TCC types were similar (P = .36). The reintervention-free rate for infection or malfunction was significantly better with the Palindrome Ruby TCC (76% and 58% at 90 and 180 days, respectively) than with the BioBloc TCC (60% and 45% at 90 and 180 days, respectively; P = .03). CONCLUSIONS: The results support the use of the Palindrome Ruby TCC on the basis of the significantly lower thrombosis and reintervention rate; randomized trials are justified to confirm this finding and to evaluate its role in the prevention of TCC infection.

Equivalent secondary patency rates of upper extremity Vectra Vascular Access Grafts and transposed brachial-basilic fistulas with aggressive access surveillance and endovascular treatment.

OBJECTIVES: The 2006 update of the DOQI guidelines has stated that in patients with end-stage renal disease, autogenous radial-cephalic, or brachial-cephalic fistulas are the preferred access modalities, followed by transposed brachial-basilic (TBB) fistulas and prosthetic arteriovenous (AV) grafts. AV grafts are in general least preferred; however, there is very limited data comparing directly the last two modalities. The aim of the present study is to compare outcomes of the TBB fistula and the Vectra Vascular Access Graft. METHODS: Seventy-six patients had a prosthetic brachial-axillary Vectra graft placed, while in 41 patients brachial-basilic upper arm transposition was performed. Graft surveillance to detect a failing/failed access was followed by endovascular treatment, rheolytic thrombectomy (AngioJet, Possis Medical), and/or angioplasty +/- stenting of the responsible anatomical lesion(s). RESULTS: Use of Vectra grafts and TBB fistulas started after a median (interquartile range) of 14 (7-30) and 70 (52-102) days, respectively (P < .001), as early as the operative day in some patients with grafts. Postoperative complications were more frequent in TBB fistulas and late complications (mainly access thrombosis) in Vectra grafts. Total number of thrombectomy sessions performed for graft or fistula occlusion was 45 and 7, respectively (P = .032); total number of isolated angioplasty sessions, performed for failing graft or fistula was 31 and 45, respectively (P = .004). Although primary patency of the two access modalities was equivalent, primary assisted patency was significantly reduced in Vectra grafts (70% at 12 months and 58% at 18 months), compared with TBB fistulas (82% at 12 months and 78% at 18 months, P = .033); however, as a result of endovascular intervention, secondary patency rates at 12 months (87% vs 88%) and 18 months (87% vs 83%) were equivalent (P = .91). Presence of arterial anastomosis stenosis treated with angioplasty at any stage had a significant negative predictive value on secondary patency rates at 12 and 18 months which were 61%, compared with 96% for Vectra grafts that had any intra-graft, venous outflow, draining or central vein stenosis treated with angioplasty at any stage (P = .010). CONCLUSIONS: Aggressive graft surveillance and endovascular treatment methods can yield equivalent long-term secondary patency rates between Vectra graft and TBB fistulas. The advantage of earlier use of Vectra graft must be balanced against the need for more frequent secondary interventions and the risk of graft infection.