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Results Of Rheolytic Thrombectomy Of 285 Arteriovenous Vascular Access Grafts And Fistulas Followed By Aggressive Surveillance And Endovascular Management

Stavros K Kakkos, Georges K Haddad, Joseph Haddad, Martha M Scully, Daniel J Reddy
Henry Ford Hospital, Detroit, MI

OBJECTIVES: To study the technical and clinical success rates of AV graft or fistula rheolytic thrombectomy and also its long term primary assisted patency.

METHODS: 285 thrombosed vascular access grafts (n=261) and fistulas (n=24) were managed with rheolytic thrombectomy, using the AngioJet device (Possis Medical Inc, Minneapolis, MN) and a specially designed catheter, followed by angioplasty (± stenting) of the anatomical lesion(s) (arterial anastomosis, graft or fistula body, venous outflow, draining or central veins) responsible for the thrombotic event. In 7 additional cases the procedure was aborted because graft/fistula or anastomosis access was not possible. Clinical success was defined as at least one successful subsequent hemodialysis session. Graft surveillance was continued and included clinical and hemodialysis parameters to detect a failing/failed access.

RESULTS: Rheolytic thrombectomy was technically successful in 280 cases (98.2%) and clinically successful in 271 cases (95.1%). Technical and clinical success for patients presented within 2 days of the thrombosis was 99.6% and 96.6%, respectively, compared to 91.8% (P= .003, OR 20.8) and 87.8% (P= .019, OR 4) for later presentation. Clinical success was also better in patients older than 62 years (98% vs 91.9%, P= .18, OR 4.28). During follow-up, 95 accesses (36.6%) had no further thrombotic events, 137 (52.3%) developed recurrent thrombosis and rheolytic thrombectomy was attempted, while 30 of (11.5%) were abandoned or removed for infection (n=1). Functional primary assisted patency at 30 days, 6 months, 12 months and 18 months was 72.4%, 45.1%, 30.3% and 22.4%, respectively. Clinical parameters, including access type, configuration and thrombus age had no effect on patency rates, while venous outflow stenosis has an adverse predictive role on patency using Log-rank test (Figure). Multivariate analysis (Cox regression) identified patient age, venous outflow and central vein angioplasty and also stenting as independent predictors of patency (Table).

CONCLUSIONS: Rheolytic thrombectomy is a highly successful procedure with acceptable long term primary assisted patency results. Early referral for thrombectomy should be encouraged. Further research to prevent development or recurrence of venous outflow stenoses is justified.