Hybrid surgical approach in treatment of vascular access graft thrombosis

The aim of this study was to evaluate the efficacy of a hybrid surgical approach in treatment of vascular access graft thrombosis, which consist of open thrombectomy to remove clots and endovascular balloon angioplasty to treat stenotic lesions. Material and methods: 9 patients were included, primary and primary-assisted patency at 1, 3, and 6 months were evaluated. Six were females and three were males. The patient median age was 50±12 years. The median time on hemodialysis (HD) treatment was 77 months. There were 6 upper arm grafts and 3 lower leg grafts. Ten hybrid thrombectomies were performed on 9 patients. All procedures were done under local anesthesia. No central venous catheters for acute HD were implanted. Ultrasound Dopplerography (USDG) was performed at 6 months follow up period. Results: primary vascular access graft patency rates at 12, 24 and 36 months were 66%, 44% and 11%, respectively, with 100% success. Primary-assisted vascular access graft patency rates at 1, 3, and 6 months were 100%, 88% and 77%, respectively. 1/9 (11%) stent-graft was implanted at the venous graft anastomosis due to inappropriate result of balloon angioplasty (recoil >50%). No sights of clinically significant pulmonary embolism, local wound infection, and puncture zone were detected. Conclusion: hybrid surgical approach could provide good early and late outcomes as a treatment modality of vascular access graft thrombosis. Usage of ultra-high pressure balloons provides good clinical and angiography results. Use of stent-graft could provide a good clinical result concerning the patency rate after failed balloon angioplasty.

гибридная хирургия, балонная ангиопалстика, протезный артериовенозный доступ, синтетический протез, стент-графт, тромбоз, тромбэктомия, anastomotic stenosis, hybrid surgery, vascular access graft thrombosis, thrombectomy

1. Андрусев А.М., Томилина Н.А., Перегудова Н.Г. и соавт. Заместительная терапия терминальной хронической почечной недостаточности в Российской Федерации 2014-2018 гг. Отчет по данным Общероссийского Регистра заместительной почечной терапии Российского диализного общества Нефрология и диализ. 2020. 22(1): 1-71. DOI: 10.28996/2618-9801-2020-1

2. Roy-Chaudhury P., Arend L., Zhang J. et al. Neointimal hyperplasia in early arteriovenous fistula failure. Am J Kidney Dis. 2007 Nov; 50(5):782-90. DOI: 10.1053/j.ajkd.2007.07.019

3. Quencer K.B., Friedman T. Declotting the Thrombosed Access. Tech Vasc Interv Radiol. 2017 Mar; 20(1):38-47. DOI: 10.1053/j.tvir.2016.11.007

4. Feldman H.I., Held P.J., Hutchinson J.T. et al. Hemodialysis vascular access morbidity in the United States. Kidney Int 1993; 43: 1091-1096.) DOI: 10.1038/ki.1993.153

5. Fluck R., Kumwenda M. Renal association clinical practice guideline on vascular access for haemodialysis. Nephron Clin Pract 2011; 118: c225-c240 DOI: 10.1159/000328071

6. Osman O.O., El-Magzoub A.R., Elamin S. Prevalence and risk factors of central venous stenosis among prevalent hemodialysis patients, a single center experience. Arab J Nephrol Transplant. 2014; 7:45-47.

7. Agarwal A.K. Central vein stenosis. Am J Kidney Dis. 2013; Jun;61(6):1001-15. DOI: 10.1053/j.ajkd.2012.10.024

8. Dariushnia S.R. et al. Quality improvement guidelines for percutaneous image-guided management of the thrombosed or dysfunctional dialysis circuit. J Vasc Interv Radiol. 2016;27(10):1518-30 DOI: 10.1016/j.jvir.2016.07.015

9. Valji K., Bookstein J.J., Roberts A.C. et al. Pharmacomechanical thrombolysis and angioplasty in the management of clotted hemodialysis grafts: Early and late clinical results. Radiology. 1991; 178:243-247. DOI: 10.1148/radiology.178.1.1824582

10. Turmel-Rodrigues L., Sapoval M., Pengloan J. et al. Manual thromboaspiration and dilation of thrombosed dialysis access: Mid-term results of a simple concept. J Vasc Interv Radiol. 1997; 8:813-824. DOI: 10.1016/s1051-0443(97)70666-3

11. Cynamon J., Lakritz P.S., Wahl S.I. et al. Hemodialysis graft declotting: Description of the “lyse and wait” technique. J Vasc Interv Radiol. 1997; 8:825-829. DOI: 10.1016/s1051-0443(97)70667-5

12. Kitrou P.M., Papadimatos P., Spiliopoulos S., Christeas N. Lysis-Assisted Balloon (LAB) Thrombectomy. A Declotting Technique for the Treatment of Thrombosed Arteriovenous Dialysis Grafts. 5-Year Experience of 241 Endovascular Procedures. Cardiovasc Intervent Radiol. 2018 Feb;41(2):245-252. DOI: 10.1007/s00270-017-1813-z

13. Trerotola S.O., et al. Treatment of thrombosed hemodialysis access grafts: Arrow-Trerotola percutaneous thrombolytic device versus pulse-spray thrombolysis. Arrow-Trerotola percutaneous thrombolytic device clinical trial. Radiology. 1998;206(2):403-14. DOI: 10.1148/radiology.206.2.9457193

14. Bermudez P., et al. Endovascular revascularization of hemodialysis thrombosed grafts with the hydrodynamic thrombectomy catheter. our 7-year experience. Cardiovasc Intervent Radiol. 2017;40(2):252-9. DOI: 10.1007/s00270-016-1488-x

15. KDOQI clinical practice guidelines foe vascular access. Am J Kidney Dis. 2006;48:S176-S247. DOI: 10.1053/j.ajkd.2006.04.029

16. MarstonW.A., Criado E., Jaques P.F. Prospective randomized comparison of surgical versus endovascular management of thrombosed dialysis access grafts. J Vasc Surg. 1997 Sep;26(3):373-80. DOI: 10.1016/s0741-5214(97)70030-2

17. Bakran A., McWilliams R.G. Arteriovenous Graft Stenosis: An Overview of Treatment Alternatives. J Endovasc Ther. 2001 Apr;8(2):173-6. DOI: 10.1177/152660280100800212.

18. Kitrou P.M., Katsanos K., Papadimatos P. A survival guide for endovascular declotting in dialysis access: procedures, devices, and a statistical analysis of 3,000 cases. Expert Rev Med Devices. 2018 Apr;15(4):283-291. DOI: 10.1080/17434440.2018.1454311.

19. Koukounas V., et al. Incidence of arterial micro-embolization during percutaneous AngioJet thrombectomy of hemodialysis grafts. Cardiovasc Intervent Radiol. 2014;37(2):405-11. DOI: 10.1007/s00270-013-0663-6

20. Koukounas V., et al. Incidence of arterial micro-embolization during percutaneous AngioJet thrombectomy of hemodialysis grafts. Cardiovasc Intervent Radiol. 2014;37(2):405-11. DOI: 10.1007/s00270-013-0663-6

21. Chan N., Wee I., Tse Kiat Soong et al. A Systematic Review and Meta-Analysis of Surgical Versus Endovascular Thrombectomy of Thrombosed Arteriovenous Grafts in Hemodialysis Patients. J Vasc Surg. 2019 Jun;69(6):1976-1988.e7. doi: 10.1016/j.jvs.2018.10.102

22. Davoodi M., Farsavian H., Farsavian A.A. Hybrid Therapy Using a Surgical Thrombectomy with a Balloon Angioplasty to Regain Thrombosed Dialysis Vascular Access-Clinical Case Series. Surgery Curr Res, 2016. 7: 283. doi: 10.4172/2161-1076.1000283

23. Catherina Go. Society for Vascular Surgery (SVS) Vascular Annual Meeting (VAM; 2019, 12-15 June, National Harbor, USA.

24. Troisi1 N., Chisci E., Frosini1 P. Et al. Hybrid simultaneous treatment of thrombosed prosthetic grafts for hemodialysis. J Vasc Access 2014;15 (5): 396-400. DOI: 10.5301/jva.5000218