Salvage of thrombosed dialysis access grafts with venous anastomosis stents

BACKGROUND: Thrombosis of arteriovenous (AV) grafts caused by stenosis at the venous anastomosis is a well-described problem. Surgical thrombectomy and conventional angioplasty with mechanical thrombectomy have provided good success rates in achieving immediate graft patency but with generally dismal graft survival rates in the range of 11% to 36% at 6 months' follow-up. The role of intravascular stents in patients who have failed angioplasty or surgical revision at the venous anastomosis has not been fully elucidated, particularly in older grafts that have previously undergone multiple procedures. METHODS: In this series, 34 patients had self-expanding nitinol stents placed at the venous anastomosis following graft thrombectomy and angioplasty procedures. Patients were selected for stent placement if conventional angioplasty alone was unsuccessful due to immediate elastic recoil or residual stenosis. All patients were followed after stent placement and evaluated for duration of graft patency and need for repeated endovascular procedures. RESULTS: The average graft age at the time of stent placement was 17.9 months. Eight-eight percent of grafts were functioning at 6 months' follow-up, and 63% of the entire group had survived without the need for additional procedures. Among those with need for repeat interventions, 81% had new lesions outside of the stent, and 57% had new lesions within the stent. In 38% of cases, new stenoses were located both outside and within the stent. Among grafts no longer being used, only 19% of the time was it due to disease recurring within the stent. CONCLUSION: Polytetrafluoroethylene (PTFE) graft longevity is improved when venous anastomosis stenoses are treated with stents in selected cases of older grafts that would have normally undergone abandonment or surgical revision.