Balloon angioplasty versus surgical revision for thrombosed dialysis graft outlet stenosis after graft thrombectomy.
ABSTRACT It is important to correct underlying graft outlet stenosis after thrombectomy of dialysis grafts. This study retrospectively reviewed patients who received dialysis graft thrombectomy at this institution to compare the effectiveness of 2 different methods.
A total of 289 dialysis graft thrombectomy procedures performed during 2001-2003 were retrospectively reviewed. The results of 163 cases in balloon angioplasty group were compared with those of 129 patients who underwent outlet revision. Patient characteristics between the 2 groups were similar with regard to demographic characteristics and comorbidities (P > .05). The mean primary patency of balloon and revision groups are 7.23 +/- 7.38 and 8.35 +/- 9.53 (months), respectively. Survival curves for each group were calculated by Kaplan-Meier method. There was no difference between 2 groups regarding graft patency.
The result of dialysis graft outlet balloon angioplasty was comparable to that of surgical revision. Considering the invasiveness, balloon angioplasty should be considered when treating thrombosed dialysis grafts.
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ABSTRACT: The increasing number of patients requiring hemodialysis and the limited number of access sites have resulted in an increase in multiple graft revisions to maintain access for hemodialysis. Venous outflow or anastomotic stenoses in vascular grafts tend to recur and contribute to the difficulty in maintaining a functioning graft. Thus, extending the life of a failed graft becomes an important objective of this study, which was to assess the use of covered nitinol stents to salvage expanded polytetrafluoroethylene (ePTFE) grafts with venous anastomotic or outflow stenosis that have failed after multiple revisions. This is a review of 8 failed non-autogenous ePTFE grafts with isolated venous anastomotic or proximal outflow stenoses that had undergone multiple previous revisions, had failed percutaneous transluminal angioplasty (PTA), and required placement of a covered nitinol stent. Graft locations were forearm (2), upper arm (4), and femoral (2). The mean number of interventions per patient before stent placement was 5.87 thrombectomies (range 2-28) and 3.38 balloon angioplasties (range 2-19). Five patients had 0.62 interposition grafting and 3 had patch angioplasty. All 8 patients (100%) underwent successful dialysis after thrombectomy and stenting. The primary and secondary patency rates after stent placement were 50% and 75%, and 25% and 75%, at 3 and 6 months, respectively. Percutaneous thrombectomy, balloon angioplasty, and concomitant covered nitinol stent placement extend the function of hemodialysis access grafts that have previously failed multiple times.Vascular and Endovascular Surgery 01/2006; 40(4):275-9. · 0.88 Impact Factor
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ABSTRACT: To identify best clinical practice for the management of occluded haemodialysis access. Surgery or percutaneous thrombolysis with or without angioplasty, has been used for the management of clotted haemodialysis access, with variable reported success rates. Concerns over high morbidity rates and delays in achieving satisfactory patent arterio-venous (AV) access, led to a retrospective audit of all patients with occluded haemodialysis vascular access between 1 June 1995 and 30 June 2001. Data recorded included type of access, procedure used, outcome, complications and hospital stay. There were 45 episodes occurring in 17 patients. 33 of the 45 episodes occurred in synthetic grafts. Eleven of the 17 patients had multiple episodes (range 2 to 11), nine of whom had synthetic grafts. Forty three of the 45 episodes initially underwent DSA on presentation. There was a low success rate with thrombolysis, with only 20 cases effective in re-establishing dialysis. Surgery revision was required to re-establish effective dialysis in 25 of the 45 episodes. Six of 43 thrombolysis procedures experienced a major complication related to excessive bleeding. Primary patency was slightly better for surgery compared with thrombolysis (4.9 months versus 3.8 months). Temporary catheters were inserted for dialysis in 19 of 45 episodes and remained for a mean of 5.8 days. Four patients had a major episode of catheter-related sepsis. Two patients required admission to the Intensive Care Unit (ICU) for management of their sepsis. Patients who failed thrombolysis and required surgery had a prolonged stay, averaging 8.2 days. This was associated with a marked increase in hospital costs. The average cost for successful thrombolysis was $1976, compared with $5348 where surgery was subsequently required. Costing of surgical intervention alone was similar to that of thrombolysis. Surgery with dedicated vascular surgeons remains the safest, most rapid and most effective approach to treating occluded dialysis AV fistulae and grafts.The New Zealand medical journal 12/2002; 115(1166):U258.
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ABSTRACT: Although autogenous arteriovenous fistulae are the optimal route for dialysis access, extended polytetrafluoroethylene (ePTFE) grafts continue to be the preferred access for patients without suitable superficial veins. Among the common complications related to dialysis grafts, thrombosis due to graft outlet stenosis is the most frequently encountered clinical problem. A cuffed graft was designed to eliminate the outflow turbulence to reduce outlet stenosis and to enhance the clinical patency of ePTFE grafts. We conducted a prospective, randomized study to compare the clinical outcomes of cuffed ePTFE grafts and noncuffed grafts in dialysis access. Between November 2004 and October 2005, 89 ePTFE grafts were implanted for hemodialysis access in the upper extremities of end-stage renal patients. Graft selection was randomized, with patients receiving a cuffed graft (Venaflo) or a regular noncuffed graft (Stretch Gore-Tex). All patients were monitored for signs of thrombosis or other complications. Primary and secondary graft patency was analyzed by using a life-table analysis, and the log-rank test was applied to compare graft patencies. Demographic data for both groups were similar without statistical difference. The primary patency rates and secondary patency rates at 12 months after implantation were 56% and 91% for cuffed grafts, and 41% and 78% for noncuffed grafts, respectively. The cuffed group outperforms the noncuffed group regarding primary and secondary patencies statistically. However, the incidence of other complications that required further surgery was similar in both groups. This investigation revealed that the cuffed ePTFE graft, which was designed to decrease graft outlet stenosis, may enhance the clinical patency rates of dialysis grafts.World Journal of Surgery 02/2009; 33(4):846-51. · 2.23 Impact Factor