Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 50-54

Hybrid and percutaneous salvage of a thrombosed native arteriovenous fistula: 1-year outcomes


Department of Vascular and Endovascular Surgery and Interventional Radiology, CARE Hospitals, Hyderabad, Telangana, India

Date of Submission07-Nov-2020
Date of Acceptance07-Dec-2020
Date of Web Publication30-Aug-2021

Correspondence Address:
Rahul Agarwal
Department of Vascular and Endovascular Surgery and Interventional Radiology, CARE Hospitals, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_154_20

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  Abstract 


Context: Outcomes of salvage procedures for thrombosed native arteriovenous fistulas (AVFs) are studied. Aims: The aim of this study is to assess the short- to mid-term results of percutaneous and hybrid approaches used for salvage of thrombosed native AVF. Settings and Design: This study design was a single-center, descriptive, prospective study. Materials and Methods: All patients undergoing hybrid or percutaneous salvage procedure between July 2018 and September 2019 were included in the study. Patient demographics, clinical, and operative details and follow-up data at 1 year were collected from a prospectively maintained database and subjected to statistical analysis. Salvage procedure selection and techniques were studied. Statistical Analysis: Chi-square test and Fisher's exact test. P < 0.05 was considered statistically significant. Results: Out of 135 patients undergoing salvage procedure during the study period, 85 patients were included in the study based on inclusion and exclusion criteria. The age of the study population ranged from 18 to 75 years with a mean of 53.33. 75.3% (n = 64) were males. Seventy-seven (90.58%) patients were hypertensive, 45 (52.94%) were diabetic, and 22 (25.88%) had coronary artery disease. The mean time to procedure from the failure of AVF was 8.22 days. The most common type of AVF was brachiocephalic (45.88% [n = 39]), followed by radiocephalic (36.47% [n = 31]) and basilic vein transposition (BVT) (17.64% [n = 15]). Stenotic sites were juxta anastomotic in 42 (49.41%), cephalic arch or axillary swing segment (for BVT) in 28 (32.94%), and intervening segment in 54 (63.52%). Sixty patients underwent hybrid salvage and 25 underwent percutaneous salvage procedure. Technical success was 88.23% on table and 83.53% at 24 h. Primary, primary assisted, and secondary patency was 67.86%, 82.14%, and 89.29% at 6 months and 50%, 68.75%, and 83.33% at 12 months. Anastomotic thrombosis was associated with significantly high technical failure (35.7% vs. 12.67%, P = 0.049). Conclusions: A combination of open and endovascular procedures to salvage thrombosed native AVF's is feasible and is associated with good short- and mid-term patency. A thrombosed anastomosis in a failed AVF decreases the success rate of salvage procedures.

Keywords: Arteriovenous fistula, hybrid salvage, percutaneous salvage, native arteriovenous fistula, salvage, thrombosed arteriovenous fistula


How to cite this article:
Agarwal R, Atreyapurapu V, Sharma P, Yerramsetty VK, Burli P, Atturu G, Gupta PC. Hybrid and percutaneous salvage of a thrombosed native arteriovenous fistula: 1-year outcomes. Indian J Vasc Endovasc Surg 2021;8, Suppl S1:50-4

How to cite this URL:
Agarwal R, Atreyapurapu V, Sharma P, Yerramsetty VK, Burli P, Atturu G, Gupta PC. Hybrid and percutaneous salvage of a thrombosed native arteriovenous fistula: 1-year outcomes. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Nov 28];8, Suppl S1:50-4. Available from: https://www.indjvascsurg.org/text.asp?2021/8/5/50/324937




  Introduction Top


An arteriovenous fistula (AVF) is the gold standard for the establishment of primary vascular access and the lifeline for an end-stage renal disease patient and its maturation and adequate function is vital. Several studies have shown that AVFs have high primary failure rate and low 1-year and 2-year patency rates.[1] The maintenance and remediation of a failing or thrombosed arteriovenous (AV) access is important to improve the patency.

When a native AVF is thrombosed, there are various options to salvage the fistula including open surgical techniques such as thrombectomy with patch angioplasty or interposition graft, percutaneous techniques such as thrombolysis, thrombectomy (mechanical or pharmacomechanical), followed by balloon angioplasty for the stenosed segment, and a hybrid technique in which open thrombectomy is combined with percutaneous treatment of the stenotic lesion. The common principle in all these interventions is to effectively remove the thrombus and treat the underlying stenosis.

Availability of hybrid theaters and improvements in endovascular techniques has changed the choice of intervention for thrombosed native AVF from pure surgical or pure endovascular technique to a more of hybrid approach (combination of surgical and endovascular techniques). There are limited data from the Indian subcontinent on the outcomes of such hybrid approaches in the management of thrombosed native AVF. The aim of this study is to assess the short- to mid-term results of percutaneous and hybrid approaches used for salvage of thrombosed native AVF.


  Materials and Methods Top


This is a prospective single-center observational study. Institutional ethical committee approval was received for conducting the study. All patients undergoing salvage procedure for a thrombosed native AVF during the study period (July 2018 to September 2019) were screened for the following inclusion and exclusion criteria.

Inclusion criteria

  • Aged 18 and above
  • Thrombosed native AVF
  • Undergoing either pure endovascular or hybrid salvage procedure for thrombosed AVF of upper limb.


Exclusion criteria

  • Aged below 18 years
  • Patients who underwent any salvage procedure previously on the same AV access site or same limb
  • Open salvage with patch angioplasty or graft interposition or revision of anastomosis.


All eligible patients were recruited into the study and information regarding demographics, past medical history, and current status of the vascular access including the local examination findings, ultrasound, intraoperative findings, procedure details, and follow-up data were collected using a standard pro forma prospectively. One-year follow-up was done in clinic or over the telephone.

Study protocol

All patients presenting with a thrombosed native AVF, underwent clinical and ultrasound examination.

Decision to select the type of salvage procedure was based on the following factors:

  1. Clot burden – hybrid was selected over percutaneous salvage when there was large clot burden (aneurysmal segments and long length thrombosis)
  2. Vein size – Vein size <5 mm and short segment occlusion were subjected to endovascular procedure.


The four main components of salvaging a thrombosed AVF were:

  1. De-clotting of AVF circuit
  2. Identification of lesion
  3. Correction of lesion
  4. Central vein assessment.


Statistical analysis

Data were entered into Microsoft Excel sheet (2010 version) and analyzed using EPI INFO version 3.01 (developed by Centers for Disease Control and Prevention in Atlanta, Georgia, United States). Descriptive statistics such as percentages and proportions were used for categorical data and mean ± standard deviation, and range was used for continuous data. The association between dependent and independent variables was analyzed using Chi-square test and Fisher's Exact test considering P < 0.05 as statistically significant.


  Results Top


Out of 135 vascular access salvages performed during the study period, 85 patients (62.96%) met the inclusion and exclusion criteria and were included in the study. The demographic, clinical, and ultrasound findings are summarized in [Table 1]. The age distribution of study population ranged from 18 to 75 years with a mean of 53.33 years. Majority of patients were males 75.3% (n = 64).
Table 1: Demographic, clinical, and operative details

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Brachiocephalic AVF was the most common type treated, followed by radiocephalic AVF and basilic vein transposition AVF. The mean age of the AVF was 25.55 months, ranging from 2 months to 145 months. The mean duration of failure was 8.22 days, ranging from 2 days to 62 days. Ultrasound examination in the clinic showed that the anastomosis was patent with the thrombus starting beyond the anastomosis in 71 patients (83.53%).

Fifty-one patients had single-site stenosis, and in the remaining 34 patients, there were 2 or more sites of stenosis. In this study, the most common site of stenosis was found to be in the vein segment between the juxta-anastomotic segment and arch or axillary swing segment (63.52%), followed by juxta-anastomotic segment (49.41%) and least common at the arch or swing segment (32.94%). Majority of the patients underwent hybrid salvage (70.58%, n = 60) and under local anesthesia with monitored anesthesia care 85.88% (n = 73).

The salvage procedure was technically successful in 88.23% (n = 75) of patients. There was early failure (<24 h) in four patients (4.7%). As shown in [Table 2], thrombosis at anastomotic site before the procedure was significantly associated with technical and early failure (35.7% vs. 12.67%, P = 0.049). The remaining 71 patients were followed up for 1 year, and the results are summarized in [Figure 1]. At 6-months follow-up, fifty patients had working AVF with a primary patency of 67.86%, primary assisted patency of 82.14%, and secondary patency of 89.29% and 6 had failed. Of the remaining 15 patients, 4 were lost to follow-up, 10 expired, and 1 AVF was closed due to puncture site infection and bleeding. At 1 year, further three patients were lost to follow-up, four were dead, and one had closure of AVF due to pseudoaneurysm. In the remaining 48 patients, the primary patency was 50%, primary assisted patency was 68.75%, and secondary patency was 83.33% and two AVFs had failed.
Table 2: Anastomosis and patency

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Figure 1: Flowchart of the study

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There was one hematoma in hybrid salvage in the postoperative period which was treated by hematoma evacuation and hemostasis and two patients had vein rupture during salvage (1 each in hybrid salvage and percutaneous salvage), and the procedure failed. Hence, the overall complication rate was only 3.53% (one hematoma and two vein ruptures).


  Discussion Top


The results of the study confirm that thrombosed native AVFs can be salvaged with excellent 1-year patency. In each person, there are only limited options for native AVFs. The ability to salvage thrombosed fistulas would help these individuals to continue using an existing fistula and delay the need for a new native AVF or graft.

It is a well-recognized fact that a functioning AVF requires multiple interventions to maintain its patency and function.[1] However, when an native fistula is thrombosed, the question is whether further intervention to salvage the access is worthwhile? This question has been attempted by many researchers with different answers using different techniques.[2],[3],[4],[5],[6],[7],[8],[9],[10]

In the past, some reports and small studies[2] published on the surgical thrombectomy of a failed AVF had poor outcomes, and the belief that the salvage was futile was partly due to inability to evacuate the thrombus completely and high re-thrombosis rate. Unfortunately, these studies did not make any attempt to identify the underlying cause of the thrombosis (site of stenosis) and failure of AVF.

As the endovascular techniques came in vogue, there emerged studies describing the procedures for percutaneous salvage of failed AVF and grafts.[6],[8],[9],[11] These studies were not large, techniques were variable and results incomparable.

In 2002, Liang et al.[8] reported a technical success of 93% with primary and secondary patencies of 70% and 80%, respectively, at 12 months, in a series of 42 thrombosed native AVFs by treating with urokinase and balloon angioplasty. However, the study has only included AVFs with low clot burden.

In 2005, Bittl and Feldman[10] reported a prospective study on 294 thrombosed and failing access (128 fistulas [43.5%] and 166 grafts [56.5%]). They achieved an initial success of 95.6% with percutaneous technique of declotting, dilatation, and selective stenting and an overall 6-month patency of 66%. They measured intraluminal pressure after the procedure and reported it's the inverse relationship with the long-term access patency, but the access patency was not related to the presence of central venous occlusions, graft age, patient age, sex, or diabetes.

With the availability of better and lower profile hardware, endovascular approaches for salvaging thrombosed AVFs increased, and better results were observed with percutaneous intervention.[12]

In 2018, Franco et al.[12] showed that with thrombolysis using Actilyse® and angioplasty for percutaneous salvage in 41 thrombosed AVF and grafts, primary and secondary patencies of 42% and 55%, respectively, could be achieved at 6 months with a technical success of 60%.

In 2011, Hyun et al.[4] and in 2012 Cull et al.[5] described the technical details of hybrid salvage and attained excellent results in their patients. We follow a similar technique of hybrid salvage in our practice.

In 2011, Kim et al.[13] had a technical success of 96.7% for percutaneous thrombectomy and angioplasty with a patency of 96.7% at the end of study with a median follow-up of 62.3 months (2 months to 89 months). None of the patients in endovascular group required a central catheter for dialysis. In the open surgery group who underwent proximal neoanastomosis, patch angioplasty, and interposition graft for stenosed segment, the technical success was 98.9% with patency of 92.2% at the end of the study. Twenty-four patients in this group required a catheter for dialysis. The choice of procedure was based on the length and site of the stenosis. Overall, surgical and endovascular treatment gave high rates of initial success and high patency when the procedure was selected according to the length and site of the stenosis. The author concluded that, when stenosis of a long segment is suspected, endovascular treatment should be the first choice to maintain functioning of the fistula and to avoid the use of a temporary catheter.

In 2017, Gupta et al.[14] reported a technical success of 76% and cumulative patency of 68% at 6 months for the hybrid salvage procedures. Of the 55 patients, 31% had juxta-anastomotic stenosis, 27% had stenosis in the draining vein, and 36% had multiple or diffuse stenosis. The mean age of fistula was 25 ± 17 months and time of presentation was 8.5 ± 5.3 days. Type of AV access included radiocephalic fistula (36%), brachiocephalic fistula (42%), and transposed basilic vein (22%).

Access and procedure-related details and their effect on outcome and patency

In our study, radiocephalic AVF salvage (technical success 74.19% and 6-month patency 90%) is comparable to outcomes of brachiocephalic AVF salvage (technical success 89.74% and 6-month patency 96.15%) and basilic or brachial vein transposition AVF (technical success 86.66% and 6-month patency 70%). These results should be taken in consideration before abandoning a failed radiocephalic AVF in favor of creating a new proximal AVF. Salvage should be attempted in thrombosed radiocephalic AVF to preserve the proximal AVF sites for future use.

In our study, the most common site of stenosis was between the JA and arch or swing segment (63.52%) and 34 patients (40%) had stenosis at more than one site. The findings in our study are different compared to other studies on fistuloplasty and salvage procedures, in which the main area of stenosis reported is the swing segment of the vein like the JA and arch segment.[15],[16],[17] Most of the stenosis were identified during the preoperative ultrasound scan, but in 13 (15.29%) patients, additional lesions were found on the intraoperative fistulogram. Thus, it is imperative that fistulogram should be done to identify all lesions during the salvage procedure.

An interesting finding is that the status of anastomosis, thrombosed versus patent, at the time of salvage procedure significantly affected the outcome of the salvage procedure (P = 0.049). Five (35.71%) out of 14 AVF with thrombosed anastomosis were not salvageable or failed early within 24 h. Only 9 (12.68%) out of 71 AVF, in which anastomosis was patent were not salvageable. Based on these findings, it could be inferred that a failed AVF with a thrombosed anastomosis needs special attention and either proximal revision of AVF or repair of anastomosis with patch should be considered.


  Conclusions Top


A combination of open and endovascular procedures to salvage thrombosed native AVFs is feasible and is associated with good short to mid-term patency. These procedures should be considered before giving up on a thrombosed AVF.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Al-Jaishi AA, Oliver MJ, Thomas SM, Lok CE, Zhang JC, Garg AX, et al. Patency rates of the arteriovenous fistula for hemodialysis: A systematic review and meta-analysis. Am J Kidney Dis 2014;63:464-78.  Back to cited text no. 1
    
2.
Bone GE, Pomajzl MJ. Management of dialysis fistula thrombosis. Am J Surg 1979;138:901-6.  Back to cited text no. 2
    
3.
Palmer RM, Cull DL, Kalbaugh C, Carsten CG, Taylor SM, Snyder BA, et al. Is surgical thrombectomy to salvage failed autogenous arteriovenous fistulae worthwhile? Am Surg 2006;72:1231-3.  Back to cited text no. 3
    
4.
Hyun JH, Lee JH, Park SI. Hybrid surgery versus percutaneous mechanical thrombectomy for the thrombosed hemodialysis autogenous arteriovenous fistulas. J Korean Surg Soc 2011;81:43.  Back to cited text no. 4
    
5.
Cull DL, Washer JD, Carsten CG, Keahey G, Johnson B. Description and outcomes of a simple surgical technique to treat thrombosed autogenous accesses. J Vasc Surg 2012;56:861-5.  Back to cited text no. 5
    
6.
Shatsky JB, Berns JS, Clark TW, Kwak A, Tuite CM, Shlansky-Goldberg RD, et al. Single-center experience with the Arrow-Trerotola Percutaneous Thrombectomy Device in the management of thrombosed native dialysis fistulas. J Vasc Interv Radiol 2005;16:1605-11.  Back to cited text no. 6
    
7.
Zaleski GX, Funaki B, Kenney S, Lorenz JM, Garofalo R. Angioplasty and bolus urokinase infusion for the restoration of function in thrombosed brescia-cimino dialysis fistulas. J Vasc Int Radiol 1999;10:129-36.  Back to cited text no. 7
    
8.
Liang HL, Pan HB, Chung HM, Ger LP, Fang HC, Wu TH, et al. Restoration of thrombosed Brescia-Cimino dialysis fistulas by using percutaneous transluminal angioplasty. Radiology 2002;223:339-44.  Back to cited text no. 8
    
9.
Haage P, Vorwerk D, Wildberger JE, Piroth W, Schürmann K, Günther RW. Percutaneous treatment of thrombosed primary arteriovenous hemodialysis access fistulae. Kidney Int 2000;57:1169-75.  Back to cited text no. 9
    
10.
Bittl JA, Feldman RL. Prospective assessment of hemodialysis access patency after percutaneous intervention: Cox proportional hazards analysis. Catheter Cardiovasc Interv 2005;66:309-15.  Back to cited text no. 10
    
11.
Turmel-Rodrigues L. Application of percutaneous mechanical thrombectomy in autogenous fistulae. Tech Vasc Interv Radiol 2003;6:42-8.  Back to cited text no. 11
    
12.
Franco RP, Chula DC, Alcantara MT, Rebolho EC, Melani AR, Riella MC. Salvage of thrombosed arteriovenous fistulae of patients on hemodialysis: Report on the experience of a Brazilian center. J Bras Nefrol 2018;40:351-9.  Back to cited text no. 12
    
13.
Kim HK, Kwon TW, Cho YP, Moon KM. Outcomes of salvage procedures for occluded autogenous radiocephalic arteriovenous fistula. Ther Apher Dial 2011;15:448-53.  Back to cited text no. 13
    
14.
Gupta PC, Yerramsetty V, Burli P, Sharma P, Nagiredy M, Kulkarni V. FT13. Hybrid salvage for thrombosed autogenous hemodialysis access. J Vasc Surg 2017;65:20S.  Back to cited text no. 14
    
15.
Badero OJ, Salifu MO, Wasse H, Work J. Frequency of swing-segment stenosis in referred dialysis patients with angiographically documented lesions. Am J Kidney Dis 2008;51:93-8.  Back to cited text no. 15
    
16.
Maya ID, Oser R, Saddekni S, Barker J, Allon M. Vascular access stenosis: Comparison of arteriovenous grafts and fistulas. Am J Kidney Dis 2004;44:859-65.  Back to cited text no. 16
    
17.
Quencer KB, Arici M. Arteriovenous fistulas and their characteristic sites of stenosis. AJR Am J Roentgenol 2015;205:726-34.  Back to cited text no. 17
    


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