Salvage of a failing dialysis graft by percutaneous creation of a jump bypass graft

Percutaneous salvage of failing arteriovenous grafts with diffuse disease or occlusion in the venous outflow remains an issue with no ideal solution. The present report describes a method of percutaneous creation of vascular bypasses in a patient with a failing graft. The patient had a long-segment stenosis in the venous outflow of a brachial-cephalic dialysis graft, and the graft was salvaged by conversion to a brachial-basilic graft. Notably, this method allowed the bypass to safely traverse a long distance (20 cm), and at 8 months, the graft remained functional and free of complications. In principle, this approach can be applied to different situations in which superficial bypass conduits are desired.     

Percutaneous treatment of complications occurring during hemodialysis graft recanalization

INTRODUCTION/OBJECTIVE: To describe and evaluate percutaneous treatment methods of complications occurring during recanalization of thrombosed hemodialysis access grafts. METHODS AND MATERIALS: A retrospective review of 579 thrombosed hemodialysis access grafts revealed 48 complications occurring during urokinase thrombolysis (512) or mechanical thrombectomy (67). These include 12 venous or venous anastomotic ruptures not controlled by balloon tamponade, eight arterial emboli, 12 graft extravasations, seven small hematomas, four intragraft pseudointimal 'dissections', two incidents of pulmonary edema, one episode of intestinal angina, one procedural death, and one distant hematoma. RESULTS: Twelve cases of post angioplasty ruptures were treated with uncovered stents of which 10 resulted in graft salvage allowing successful hemodialysis. All arterial emboli were retrieved by Fogarty or embolectomy balloons. The 10/12 graft extravasations were successfully treated by digital compression while the procedure was completed and the graft flow was restored. Dissections were treated with prolonged Percutaneous Trasluminal Angioplasty (PTA) balloon inflation. Overall technical success was 39/48 (81%). Kaplan-Meier Primary and secondary patency rates were 72 and 78% at 30, 62 and 73% at 90 and 36 and 67% at 180 days, respectively. Secondary patency rates remained over 50% at 1 year. There were no additional complications caused by these maneuvers. DISCUSSIONS AND CONCLUSION: The majority of complications occurring during percutaneous thrombolysis/thrombectomy of thrombosed access grafts, can be treated at the same sitting allowing completion of the recanalization procedure and usage of the same access for hemodialysis.     

Chest wall arteriovenous graft for dialysis: A case report

Upper extremity access sites are the preferred access sites for hemodialysis. With the improvement of the survival in dialysis population, most patients outlive the dialysis access lifespan. As such, some patients exhaust the vascular access options of the upper extremities, which necessitates the search for new access sites. While lower extremity grafts and hemodialysis reliable outflow devices are potential alternatives, these access sites are plagued with recurrent lesions at the venous anastomosis and subsequent thrombosis leading to poor access survival. Within this framework, the axillary-based dialysis access was developed to address these challenges. In this report, we describe a 70-year-old woman who exhausted her upper extremity access sites and eventually underwent a chest wall arteriovenous graft (AVG) that connected the right axillary artery to the right axillary vein. This chest wall AVG remained functional without any intervention for more than 3 years. In conclusion, chest wall AVG access can be a viable option for hemodialysis patients who have exhausted the access sites of the upper extremities, while potentially minimizing complications seen in other methods of vascular access.     

Streptokinase and transluminal angioplasty in the treatment of acutely thrombosed hemodialysis access fistulas

Streptokinase was selectively infused into nine thrombosed hemodialysis access fistulas in eight patients. Lysis occurred in all but one case. Of the eight infusions producing lysis, seven resulted in some clinical benefit. Three grafts functioned adequately for 2 to 6 months after streptokinase infusion alone. A fourth patient had good function for over 11 months after streptokinase treatment and transluminal angioplasty. In a fifth patient, graft function was partially restored, but a persistent arterial defect led to elective graft replacement. Moderate fibrinolysis in the sixth case was of no clinical benefit; rethrombosis developed promptly after SK was discontinued because of bleeding from a recent puncture site. In cases 7 and 8, fibrinolysis restored arterial inflow to the graft, but surgery was needed to revise partially obstructed venous outflow. It is concluded that selective streptokinase infusion, with or without transluminal angioplasty and operation, is often effective in the treatment of acutely thrombosed vascular access fistulas.     

Endovascular management of thrombosed axillary artery to right atrium hemodialysis graft

PurposeTo describe the salvage of a left axillary artery to right atrium hemodialysis graft using endovascular techniques.Case reportA 54-year-old man with multiple arteriovenous graft failures presented with a thrombosed left axillary artery to right atrium Gore-tex hemodialysis graft. The graft was salvaged using rheolytic catheter thrombectomy, mechanical thrombectomy, balloon angioplasty, and stenting.ConclusionsThis single case report suggests that when axillary to right atrium grafts fail, various endovascular techniques can be employed to salvage the graft and maintain dialysis access.     

Use of the peripheral cutting balloon to treat hemodialysis-related stenoses

PURPOSE: To compare the effectiveness and safety of use of the peripheral cutting balloon (PCB) versus standard percutaneous transluminal angioplasty (PTA) for the treatment of hemodialysis-related stenoses. MATERIALS AND METHODS: This prospective, randomized multicenter clinical trial included 340 patients with stenotic or thrombosed hemodialysis grafts who were randomized to receive treatment with the PCB or PTA for venous outflow stenosis. One hundred seventy-three patients underwent treatment with the PCB, 101 with stenotic grafts and 72 with thrombosed grafts. PTA was used to treat 167 patients, 94 patients with stenotic grafts and 73 with thrombosed grafts. The follow-up period extended for 6 months. RESULTS: The procedural success rates were 80.8% and 75.4% for the PCB and PTA groups, respectively (P = .24). With use of the PCB, the primary patency rates of the target lesions were 84.3%, 65.8%, and 47.9% at 1 month, 3 months, and 6 months, respectively. With PTA, the primary patency rates of the target lesions were 77.7%, 63.4%, and 40.5% at 1 month, 3 months, and 6 months, respectively. The primary patency rates of the entire vascular access circuit were 82.6%, 61.0%, and 43.3% at 1 month, 3 months, and 6 months, respectively, with use of the PCB. For patients who were treated with PTA, the primary patency rates of the vascular access circuit were 75.9%, 61.0%, and 36.3% at 1 month, 3 months, and 6 months, respectively. When comparing the PCB and PTA, there was no difference in the 6-month primary patency rates in the target lesion (P = .373) or the entire vascular access circuit (P = .531). There were nine device-related complications in the PCB group (5.2%): five venous ruptures (2.9%), three venous dissections (1.7%), and one case of thrombosis (0.6%). There were no device-related complications in the PTA group. CONCLUSION: This prospective, randomized trial comparing use of the PCB versus standard PTA for treatment of hemodialysis-related venous stenoses demonstrated that the PCB provides equivalent 6-month patency to PTA for stenotic and thrombosed grafts.     

Loop arteriovenous graft of the chest wall as a viable option for dialysis

The search for a reliable, complication-free vascular access is crucial among dialysis patients. The creation of a long-term access site for hemodialysis is dependent on several factors that mandate forming a life-plan for dialysis access, with upper extremity vascular access being the preferred route. However, complications including poor maturation, venous anastomosis lesions, and thrombosis are all associated with poor survival of these accesses. As a result, numerous patients within the dialysis population have exhausted access sites in the upper and lower extremities, requiring the search for other access options including chest wall arteriovenous graft (AVG). However, limited data is available about the outcomes of these chest wall grafts. Here, we describe two 62-year-old female dialysis patients who exhausted other dialysis access sites and subsequently underwent arteriovenous loop graft of the chest wall that connected the axillary artery with the ipsilateral axillary vein. These AVGs remained functional during the follow up period. This report highlights the viability of chest wall AVG access in the unique subset of hemodialysis patients who exhausted all other access sites.     

The radiological management of the thrombosed arteriovenous dialysis fistula

Patent vascular access is a prerequisite for adequate haemodialysis, and is a major determinant of quality of life and long-term survival of patients with end-stage renal disease. Autogenous haemodialysis fistulas (AVFs) have demonstrated superior clinical outcome when compared to synthetic grafts, but both types of access remain susceptible to venous stenoses, and consequent thrombotic occlusion. Recent publications have reported primary patency rates of up to 100% following percutaneous de-clotting of AVFs incorporating techniques such as pharmacological thrombolysis, mechanical thrombectomy, and thrombo-aspiration. Endovascular management also provides information regarding the underlying cause of access thrombosis, with option to treat. Consequently, there has been a paradigm shift in the management of fistula thrombosis, with interventional radiology assuming a lead role in initial salvage procedures. This article will attempt to provide the reader with an insight into the multiple radiological techniques that can be employed to salvage a thrombosed AVF based on current published literature.     

Percutaneous thrombectomy: a review

Percutaneous thrombectomy (PT) is an established technique for the removal of acute thrombus in occluded arteries, veins and vascular grafts. Percutaneous thrombectomy can be used as an adjunctive treatment to other methods of thrombus removal such as thrombolysis or as sole therapy. The two main methods are percutaneous aspiration thrombectomy in which thrombus is removed by suction with the aid of wide-bore catheters, and mechanical thrombectomy using a variety of automated devices to fragment or remove thrombus. Aspiration thrombectomy is often used as an adjunct to thrombolysis in acute arterial occlusion, or as salvage therapy to remove distal emboli following iliac or femoropopliteal angioplasty. Mechanical thrombectomy is useful for the treatment of thrombosed dialysis grafts and is being increasingly used for the treatment of massive pulmonary emboli and ileofemoral or ileocaval deep venous thromboses.     

Increased expression of a disintegrin and metalloproteinase thrombospondin 1 in thrombosed hemodialysis grafts

PURPOSE: To use proteomic analysis to identify upregulated and downregulated proteins in thrombosed hemodialysis graft specimens. One of these significantly upregulated proteins was a disintegrin and metalloproteinase thrombospondin-1 (ADAMTS-1), and its expression and activity were determined in thrombosed hemodialysis grafts. MATERIALS AND METHODS: Hemodialysis vascular access samples (thrombosed veins, n = 8; control veins, n = 6) were obtained from patients who required surgical revision. Proteomic analysis was performed with isotope-coded affinity tag labeling with multidimensional liquid chromatography followed by tandem mass spectrometry on four thrombosed hemodialysis graft specimens with control veins. Expression of ADAMTS-1 was confirmed by performing immunoprecipitation followed by Western blot analysis. Finally, immunohistochemistry was used to localize expression in a separate group of patients with thrombosed grafts. RESULTS: Thirty-nine unique proteins were common to all four patients. ADAMTS-1 was one of the only significantly upregulated protein (>38 fold). ADAMTS-1 expression was confirmed by performing immunoprecipitation and Western blot analysis and was significantly increased. ADAMTS-1 expression was localized to adventitial macrophages and neutrophils of thrombosed grafts. CONCLUSIONS: ADAMTS-1 was significantly upregulated in thrombosed hemodialysis grafts by mass spectrometric analysis and Western blot analysis. Expression was localized to adventitial macrophages and leukocytes. It is hypothesized that ADAMTS-1 may be related to intimal hyperplasia in hemodialysis vascular access grafts. Future work is planned on inhibiting ADAMTS-1 expression and determining the effect on intimal hyperplasia in hemodialysis grafts.     

Diagnostic imaging of and radiologic intervention for bovine ureter grafts used as a novel conduit for hemodialysis fistulas

OBJECTIVE: The objectives of our study were to review the appearances on diagnostic imaging and amenability to imaging-guided intervention of a novel bovine ureter graft (Syner-Graft 100 [SG 100]) for use as a conduit for hemodialysis fistulas. CONCLUSION: The SG 100 shows initial promise as a conduit for hemodialysis fistulas in patients with difficult vascular access. The SG 100 has characteristic appearances on diagnostic imaging and is prone to similar pathologic processes that affect autogenous venous and synthetic grafts. These grafts are readily amenable to imaging-guided percutaneous intervention, which plays a major role in prolonging graft function.     

Direct graft puncture with use of a crossed catheter technique for thrombolysis of peripheral bypass grafts

PURPOSE: To determine the efficacy and safety of direct graft puncture of peripheral arterial bypass grafts with placement of retrograde and antegrade catheters within the graft for thrombolytic therapy. This study also evaluated potential clinical benefit to patients. MATERIALS AND METHODS: A retrospective study was performed on 19 patients with 24 peripheral bypass grafts and lower extremity ischemia of less than 1 month duration. Thrombolysis was performed with a continuous high-dose infusion of urokinase. Successful lysis was defined as greater than 95% clot dissolution with antegrade flow within the graft. RESULTS: Technical success was achieved in 17 of 19 patients (89%). The complexity of operative intervention was diminished in 12 of 19 patients (63%). The major complication rate (16%) was significantly higher and, therefore, this technique has a role for patients in whom traditional access is not optimal, such as in those in whom access cannot be achieved or in those with long bypass grafts. CONCLUSION: Direct graft puncture with placement of catheters across the proximal and distal anastomoses of bypass grafts is a safe method of access, with a major complication rate similar to conventional access techniques. This mode of graft access demonstrates efficacious thrombolysis and acts as a conduit for ancillary procedures.     

Thrombolysis of clotted hemodialysis grafts with tissue-type plasminogen activator

PURPOSE: To evaluate prospectively the efficacy of treating thrombosed hemodialysis arteriovenous polytetrafluoroethylene (PTFE) grafts using tissue-type plasminogen activator (tPA) and percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: Forty-two sequential thrombosed PTFE dialysis grafts in 33 patients presented for declotting. All 42 grafts were treated with a modified lysis and PTA technique with use of 2 mg tPA and 3,000-5,000 U heparin in a total volume of 5 mL, administered into the graft via an angiocatheter. The elapsed time from tPA injection until completion was recorded. Prospective data collection included demographic information, technical details of the procedure, immediate outcomes, complications, and patency rates. RESULTS: Technical success, defined as complete graft recanalization with a palpable thrill after treatment plus successful hemodialysis, was achieved in all cases, except five. These five cases were deliberate graft closures due to inadequacy of the outflow veins to support an arteriovenous graft after successful lysis. Mean lysis time was 40.8 minutes and mean room procedure time after the lysis period was 65.4 minutes. Eight procedure-related complications occurred (two major and six minor). The follow-up period was 4-241 days, with an estimated mean of 157 days. The 30-day and 90-day primary patency rates were 57% and 50%, respectively. CONCLUSIONS: Treatment of thrombosed PTFE dialysis grafts with use of 2 mg tPA and 3,000 U of heparin is safe and effective. Use of this modified lysis and PTA technique allows an expeditious procedure in the angiography suite. However, this technique precludes imaging of the outflow veins before treatment, so that grafts entering diffusely diseased veins may need to be closed after successful lysis.     

Mechanical Thrombectomy of Occluded Hemodialysis Native Fistulas and Grafts Using a Hydrodynamic Thrombectomy Catheter: Preliminary Experience

The purpose of this study was to evaluate the efficacy and safety of a new hydrodynamic percutaneous thrombectomy catheter in the treatment of thrombosed hemodialysis fistulas and grafts. Twenty-two patients (median age: 47 years; range: 31–79 years) underwent mechanical thrombectomy for thrombosed hemodialysis fistulas or polytetrafluoroethylene (PTFE) grafts. In all cases, an Oasis hydrodynamic catheter was used. Five patients had native fistulas and 17 had PTFE grafts. Six patients required repeat procedures. All patients with native fistulas and 15 of the 17 with PTFE grafts also underwent angioplasty of the venous limb following the thrombectomy. Major outcome measures included technical success, clinical success, primary and secondary patency, and complication rates. Twenty-eight procedures were performed in total. The technical success rate was 100% and 90% and clinical success was 86% and 76% for native fistulas and grafts, respectively. The primary patency at 6 months was 50% and 59% for fistulas and grafts, respectively, and the secondary patency at 6 months was 75% and 70% for fistulas and grafts, respectively. Two patients died of unrelated causes during the follow-up period. The Oasis catheter is an effective mechanical device for the percutaneous treatment of thrombosed hemodialysis access. Our initial success rate showed that the technique is safe in the treatment of both native fistulas and grafts.     

Radiation hand exposure during restoration of flow to the thrombosed dialysis access graft

PURPOSE: To determine radiation dose to the hands of interventional radiologists during restoration of flow to thrombosed dialysis access grafts. MATERIALS AND METHODS: Sixty-two procedures were performed in 54 patients with thrombosed synthetic arteriovenous hemodialysis access grafts. For each procedure, five staff interventional radiologists wore thermoluminescent ring dosimeters on each hand. Overall hand doses were obtained, and patient and graft factors as well as technical factors were analyzed to determine the effects on hand exposure. RESULTS: The mean right hand and left hand exposures were 0.78 mSv and 0.55 mSv (78 and 55 mrem), respectively, and there was a significant difference between the two (P = .01). There was a significant difference among the interventionalists, mostly based on the lower doses associated with a single operator (P < .01). Not unexpectedly, fluoroscopy times (P < .01) and, to a lesser degree, the number of angiographic runs (P = .05) were significant factors influencing hand radiation dose. Patient sex, age and location of the graft, previous thrombosis, the number of previous interventions, and success or failure of the procedure were not significant factors in hand dose. CONCLUSIONS: Hand exposure during the restoration of flow to thrombosed dialysis access grafts is relatively high and is greater for the right hand than for the left. The exposures are dependent on technical factors, most notably fluoroscopy times, not on patient- or graft-related factors.     

Original report. Pulse-spray thrombolysis of thrombosed hemodialysis grafts with tissue plasminogen activator

OBJECTIVE: The purpose of this study was to evaluate pulse-spray pharmacomechanical thrombolysis with the use of tissue plasminogen activator in the recanalization of thrombosed hemodialysis access grafts. CONCLUSION: Pulse-spray pharmacomechanical thrombolysis with tissue plasminogen activator is an effective method for percutaneous recanalization of thrombosed hemodialysis access grafts with results similar to other percutaneous techniques.     

The role of interventional radiology in management of patients with end-stage renal disease

The aim of the paper is to review the role of interventional radiology in the management of hemodialysis vascular access and complications in renal transplantation. The evaluation of patients with hemodialysis vascular access is complex. It includes the radiology/ultrasound (US) evaluation of the peripheral veins of the upper extremities with venous mapping and the evaluation of the central vein prior to the access placement and radiological detection and treatment of the stenosis and thrombosis in misfunctional dialysis fistulas. Preoperative screening enables the identification of a suitable vessel to create a hemodynamically-sound dialysis fistula. Clinical and radiological detection of the hemodynamically significant stenosis or occlusion demands fistulography and endovascular treatment. Endovascular prophylactic dilatation of stenosis greater than 50% with associated clinical abnormalities such as flow-rate reduction is warranted to prolong access patency. The technical success rates are over 90% for dilatation. One-year primary patency rate in forearm fistula is 51%, versus graft 40%. Stents are placed only in selected cases; routinely in central vein after dilatation, in ruptured vein and elastic recoil. Thrombosed fistula and grafts can be declotted by purely mechanical methods or in combination with a lytic drug. The success rate of the technique is 89-90%. Primary patency rate is 8-26% per year and secondary 75% per year. The most frequently radiologically evaluated and treated complications in renal transplantation are perirenal and renal fluid collection and abnormalities of the vasculature and collecting system. US is often the method of choice for the diagnostic evaluation and management of the percutaneous therapeutic procedures in early and late transplantation complications. Computed tomography and magnetic resonance are valuable alternatives when US is inconclusive. Renal and perirenal fluid collection are usually treated successfully with percutaneous drainage. Doppler US, magnetic resonance angiography and digital subtraction angiography have a principle role in the evaluation of vascular complications of renal transplantation and management of the endovascular therapy. Stenosis, the most common vascular complication, occurs in 1-12% of transplanted renal arteries and represents a potentially curable cause of hypertension following transplantation and/or renal dysfunction. Treatment with percutaneous transluminal renal angioplasty (PTRA) or PTRA with stent has been technically successful in 82-92% of the cases, and graft salvage rate has ranged from 80 to 100%. Restenosis occurs in up to 20% of cases, but are usually amenable to repeated PTRA. Complications such as arterial and vein thrombosis are uncommon. Intrarenal A/V fistulas and pseudoaneurysms are occasionally seen after biopsy, the treatment requires superselective embolisation. Urologic complications are relatively uncommon, predominantly they consist of the urinary leaks and urethral obstruction. Interventional treatment consists of percutaneous nephrostomy, balloon dilation, insertion of the double J stents, metallic stent placement and external drainage of the extrarenal collections.     

Modified use of the arrow-trerotola percutaneous thrombolytic device for the treatment of thrombosed hemodialysis access grafts.

PURPOSE: To assess the safety and efficacy of using the Arrow-Trerotola percutaneous thrombolytic device (PTD) as the sole means of mechanical thrombolysis in hemodialysis access grafts, including in situ treatment of the arterial plug. PATIENTS AND METHODS: Fifty consecutive patients (22 women, 28 men; mean age, 58 years; mean graft age, 29 months), in whom mechanical thrombolysis of a thrombosed hemodialysis access graft using the PTD was planned, were included in the study. In all patients, the PTD was used to treat the arterial plug in situ at the arterial anastomosis, instead of using a Fogarty catheter to reposition the plug, as indicated in the PTD product labeling. Prospective data collection included demographic information, technical details of the procedure, immediate outcomes, and complications. Patients were followed for 3 months using definitions and data forms that were identical to those used in the original clinical trial of the PTD. A sample of procedures drawn from the PTD clinical trial database (n = 54) served as control. RESULTS: Immediate technical patency was 100%. Complications included arterial embolization (6% versus 2% control; P = NS; all successfully treated with backbleeding); venous rupture (6% versus 2% control; P = NS); and sepsis (n = 1), probably due to occult graft infection. Adjunctive therapy with an Adherent Clot catheter was needed in two procedures (4%). Three month patency using life-table analysis was 42% (versus 39% control; P = NS). The number of subsequent interventions (surgical/percutaneous) to the arterial limb of the graft did not differ from the PTD trial, and no native arterial stenoses were detected during the follow-up period. CONCLUSIONS: The PTD is safe and effective when used as the sole means of mechanical thrombolysis of hemodialysis grafts. Treating the arterial plug in situ with the PTD eliminates the need for a Fogarty or Adherent Clot catheter in 96% of procedures. A slight increase in arterial embolic complications was observed but these were easily treated with backbleeding.     

Creation of a transrenal arteriovenous dialysis shunt: feasibility study in a swine model.

PURPOSE: To investigate the feasibility of percutaneous renal artery and vein access for the creation of a transrenal arteriovenous hemodialysis graft. MATERIALS AND METHODS: Renal-artery-to-ipsilateral-renal-vein conduits were constructed with use of entirely percutaneous techniques in seven swine. Renal artery and vein access was performed in six animals with use of a retrograde (inside-out) technique and in one animal with use of an antegrade (outside-in) technique. Modified 8-F sheaths were used in the first three animals and Wallgrafts were used in the final four animals to form the arterial and venous limbs of each shunt. The arterial and venous limbs were joined together by a subcutaneous segment of 6-mm reinforced polytetrafluoroethylene (PTFE) in five animals and by external conduits in two animals. Wallgrafts were deployed from the renal artery and vein into the segments of PTFE. The free ends of each conduit were tunneled and joined together to close the arteriovenous circuit. Post-shunt angiography was used in all animals to document successful shunt creation and demonstrate rapid arteriovenous shunting as a determinant of technical feasibility. Two of the seven animals received additional anticoagulation therapy and/or antiplatelet therapy to prevent shunt thrombosis during the follow-up period. The three initial animals were killed within 2 hours of shunt creation, and two of the remaining four animals returned for angiographic follow-up, one on day 2 and one on day 9. All animals underwent a complete necropsy to assess for potential complications including hemorrhage and vascular or bowel injury. RESULTS: Retrograde renal arterial and venous access was successful in all six animals in which it was attempted. Five of six arterial accesses and four of six venous accesses traversed the peritoneum with two arterial accesses and one venous access penetrating a loop of large bowel. Antegrade access was performed and successfully accomplished in the final animal. Brisk arteriovenous shunting was demonstrated on completion angiography in all animals. Graft occlusion was present in the two animals that returned for follow-up and two animals died before follow-up as a result of graft leakage and subsequent hemorrhage. Minimal perinephric and intrarenal hemorrhage was demonstrated at necropsy after shunt insertion in the remaining five animals. Renal infarction was present in all kidneys used for transrenal access. CONCLUSION: The transrenal approach for the creation of a percutaneous arteriovenous shunt is feasible after renal artery and vein access by either the retrograde or antegrade technique. Additional technical refinements of the procedure and the devices used will be necessary before follow-up studies are conducted.     

Forearm loop, upper arm straight, and brachial-internal jugular vein dialysis grafts: a comparison study of graft survival utilizing a combined percutaneous endovascular and surgical maintenance approach.

PURPOSE: To determine rates and duration of patency achievable in forearm loop, upper arm straight, and brachial-internal jugular (IJ) vein hemodialysis grafts utilizing a combined percutaneous endovascular and surgical maintenance approach. MATERIALS AND METHODS: A retrospective analysis of 74 hemodialysis grafts (forearm loop, n = 22; upper arm straight, n = 34; and brachial-IJ vein, n = 18) in 50 patients with end-stage renal disease was conducted. Operative notes, interventional procedural reports, and hospital records were used to construct a history for each of these grafts from the time of surgical placement until the time the graft was abandoned for an alternative method of dialysis. All procedures performed to maintain and/or restore patency during the usable lifetime of the grafts were documented. RESULTS: Survival analysis using the Kaplan-Meier method demonstrated the following probabilities of primary patency at 6, 12, and 16 months, respectively: forearm loop graft = .46, .26, and .26; upper arm straight graft = .39, .22, and .16; and brachial-IJ vein graft = .19, .06, and .06 (forearm loop vs upper arm straight grafts, P > .05; forearm loop and upper arm straight vs brachial-IJ grafts, P < .001, P < .001, respectively). The probabilities of secondary patency at 12, 24, and 48 months, respectively, were: forearm loop graft = .89, .30, and NA; upper arm straight graft = .52, .35, and .17; and brachial-IJ vein graft = .54, .42, and .21 (P < .05 for all three comparisons: forearm loop > brachial-IJ > upper arm straight). Six percutaneous and two surgical procedures were compared and no significant differences in utilization were determined among the three graft types (ANOVA, P range, .38-.88). CONCLUSION: Kaplan-Meier analysis determined the probability of primary patency for forearm loop grafts to be similar to that for upper arm straight grafts, and both were significantly greater than for brachial-IJ vein grafts. The secondary patency rates for forearm loop grafts are greater than for upper arm and brachial-IJ vein grafts, while that for the brachial-IJ vein graft is greater than the upper arm straight graft. Utilization of interventional and surgical resources required to maintain patency do not significantly differ among the three types of upper extremity hemodialysis grafts.