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Objective: Failure is inevitable for all arteriovenous (AV) access procedures. Salvage of an occluded autogenous access (AVF) has been purported to be less successful than that of a prosthetic access (AVG). This study identifies specific factors that impact success for percutaneous thrombectomy.
Methods: The study sample included all percutaneous thrombectomies performed on hemodialysis accesses (AVG and AVFs) in a regional facility during the calendar year 2010. Time between creation of access and initial thrombosis and that between initial thrombosis and rethrombosis were recorded, as were patient demographic and clinical data including age, gender, race, BMI, access anatomy [Brachial-Axillary Graft (BA), Brachial-Cephalic Fistula (BC), Brachial-Basilic (BVT), other], comorbidities, and blood thinners or pacemaker use. Time between creation of access and initial thrombosis was compared in the two groups using the Mann-Whitney U test. The risk of rethrombosis after the initial percutaneous thrombectomy was analyzed as a function of demographic and clinical factors using a Cox proportional hazards regression model.
Results: A total of 415 hemodialysis accesses (75% autogenous) were created during 2010. During the same time period, 52 patients underwent thrombectomy; 20 (38%) AVF and 32 (62%) AVG. Mean time from creation to thrombosis was 597 days for AVF and 380 for AVG (p=0.17, by the Mann-Whitney U test). At a median follow up of 83 days, 25 patients (48%) had rethrombosis after the initial percutaneous thrombectomy. By the Cox model, the AVG group had a marginally higher risk of rethrombosis than the AVF group [Hazard Ratio (HR) = 3.62, p=0.085]. Patients with access anatomy BC, BVT, or other had higher risk of rethrombosis than those with BA, however the difference was only significant for BVT (HR = 8.40, p=0.02).
Conclusion: Percutaneous thrombectomy for AV access failure is a reasonable alternative to open thrombectomy. By multivariate analysis, AVG patients had a marginally higher risk of rethrombosis than those with AVF. However, the risk was significantly higher for patients with BVT than those with a brachial-axillary AVG. Percutaneous thrombectomy can be utilized in patients with autogenous access but those who rely on a BVT for dialysis access require closer follow-up and appropriate education.