Results of the endovascular treatment system for occluded native arteriovenous fistula

The Delay of Recanalisation of Acutely Thrombosed Dialysis Arteriovenous Access Until the Next Workday has No Negative Impact on Clinical Outcome

PURPOSE

The necessity of providing endovascular recanalization of acutely thrombosed arteriovenous access (AV access) during weekend is questionable, since hemodialysis can alternatively be achieved by temporarily placed non-tunneled central venous catheters (CVC). Interventional therapy of acutely thrombosed AV access is provided only on weekdays in the study center. This study aimed to compare outcomes in patients admitted on weekdays and on the weekend.

METHODS

A total of 355 endovascular procedures for thrombosed AV access performed in a single tertiary center from 2007 to 2017 were retrospectively analyzed for technical and clinical success, complications, rate of CVC and length of hospitalization. Technical success was defined as adequate blood flow with less than 30% residual stenosis, clinical success was defined as at least one successful hemodialysis after recanalization. There were two groups: patients who had to wait at least 2 days for recanalization due to admission at the weekend (n = 59, at-the-weekend group, ATW group) and patients receiving therapy no later than the day after admission (n = 296, on a working day group, OAW group).

RESULTS

The technical/clinical success rate was 96.6%/88.1% in the ATW and 89.1%/84.6% in the OAW group (p > .05). Complications did not differ among groups (p > .05). Despite a higher rate of CVC, no attributed additional adverse events or complications were observed in the ATW group (p > .05).

CONCLUSION

Despite a longer time until treatment and a higher rate of short-term CVC, it seems to be justified to provide recanalization of dialysis shunts only during weekdays.

Arteriovenous Fistula Formation with Adjuvant Endovascular Maturation

INTRODUCTION

The clinical utility of the native arteriovenous fistula (AVF) is limited by a prolonged time to maturation, low overall maturation rate, and subsequent abandonment. Endovascular intervention is increasingly accepted as first line therapy to treat AVF stenosis. The objective of this study was to evaluate AVF formation outcomes when early endovascular intervention was selectively performed to bring about timely AVF maturation.

METHODS

A retrospective study (February 2014- February 2020) was performed on 82 AVF consecutive patients (mean age 62.5±13.5 (17-83); 58 male (70.7%)) with end-stage renal failure who had Vascular Access (VA) construction at a single institution. Four year AVF patency, vascular diameters, haemodialysis parameters, re-intervention rate, and mortality were analysed.

RESULTS

Radiocephalic AVF was the most common fistula constructed (71 patients; 88.6%). Post formation evaluation (46.2+/-56.0 days (5-343)) revealed 33 (40.2%) immature AVFs. Subsequently, 19 patients underwent endovascular procedures consisting of angioplasty/stenting of the juxta-anastomosis, cannulation and/or outflow segments to bring about timely maturation of the AVF. Hence 93.9% of AVFs had reached functional patency (maturation) by 6 months post formation, with a mean time to maturation of 67.8 +/- 65.9 (5-320) days. After reaching maturation, Primary Access Functional Patency was 82 +/- 4.3 % at 6 months, 58+/- 5.5% at 12 months and 34 +/- 6.8% at 48 months. Primary Assisted Access Functional Patency was 95 +/- 2.4% at 6 months, 90 +/-3.3 % at 12 months and 83 % +/- 4.7 % at 48 months. 121 endovascular interventions were performed to maintain patency, equating to an endovascular reintervention rate of .37 procedures/patient year. Mean arterial, venous and brachial flow rates did not change significantly after maturation with a mean fistula (primary assisted functional patency) survival time of 5.9 +/- 0.26 (5.33- 6.36) years from maturation. Only 12 thromboses occurred after the first post formation follow up review, which were all salvaged using endovascular techniques leading to 100% Total secondary functional patency at 4 years. 5 year estimated all-cause mortality was 45.6 +/-12.7%.

CONCLUSION

Arteriovenous fistula maturation rate and time to maturation can be improved when early endovascular intervention is selectively performed post formation. This allows for near universal maturation where, once matured, the use of ongoing endovascular re-intervention allows for a low re-intervention rate and long term patency providing for reliable long term renal vascular access.