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.

Gluteal fascial advancement: an innovative, effective method for treating pilonidal disease.

The ideal elective surgical procedure for pilonidal disease is debated. Simple excision and closure is commonly performed but is associated with a high incidence of wound complications and recurrence. We developed a simple modification of primary closure, which involves the elevation, mobilization, and closure of the gluteal fascia. The purpose of this study is to compare outcomes of this gluteal fascial advancement technique with standard primary closure for the treatment of pilonidal disease. We retrospectively reviewed our surgical database to include all patients who underwent surgery for pilonidal disease from 2004 to 2007. Patients who underwent primary closure (n = 66) were compared with patients who underwent gluteal fascial advancement (n = 17). Demographic data as well as recurrence and the incidence of wound complications were examined. There was a significant difference in incidence of wound breakdown (0 vs 21%), recurrence (0 vs 20%), and early wound drainage (6 vs 32%). Overall there was an 80 per cent reduction in wound complications after gluteal fascial advancement compared with primary closure. Gluteal fascial advancement is a simple modification of standard primary closure and is associated with fewer wound complications and recurrences.