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OBJECTIVES: Tapered grafts are used for hemodialysis access with the goal of reducing ischemic complications. Currently, most AV graft thromboses are treated with percutaneous interventions at outpatient access centers. These interventions are often associated with angioplasty of the arterial anastomosis and arterial end of the graft to diameters greater than 6 mm. Dilatation of the proximal 4 mm. taper will produce at least an elimination of the taper and potentially rupture, pseudoaneurysm or steal syndrome. We performed this retrospective study to determine the fate of tapered AV grafts after percutaneous intervention.
METHODS: We retrospectively reviewed the outcomes of eighty 4-7 mm tapered PTFE grafts placed for hemodialysis access in 74 patients. Percutaneous interventions for graft complications were performed at one of two outpatient access centers. The type and location of the interventions were analyzed with a focus on those grafts which underwent interventions on the inflow artery, arterial anastomosis and proximal grafts segments. Primary and secondary patency rates and the frequency of complications of rupture, pseudoaneurysm and steal were calculated for this subgroup.
RESULTS: Thirty three of eighty grafts had a total of 63 interventions of the inflow artery, arterial anastomosis or proximal graft. Angioplasty was performed with balloons ranging from 5 to 10 mm. with 79% of interventions utilizing balloons 6 mm. in diameter or greater. In these 33 grafts, seven ruptures or pseudoaneurysms of the arterial anastomosis or proximal graft (24.2%) were treated with four covered stents and three surgical revisions. Four limbs (12%) developed steal syndrome, two of which required open surgical revision. One patient had two complications, making the overall complication rate 30.3% (10/33). Primary and secondary patency rates for this subgroup were 21.8% and 68.7% respectively at 6 months and 12.5% and 53.1% at one year.
CONCLUSIONS: The majority of tapered AV grafts in this series required secondary interventions within 12 months of placement. Most patients required inflow intervention and dilatation of the artery, anastomosis and proximal graft to 6 mm. or greater was common. This eliminates the benefit of the taper and resulted in rupture, pseudoaneurysm or steal syndrome in over 30% of patients in this series. This study raises questions about the benefits of tapered AV grafts for dialysis access with current endovascular strategies utilized for graft thrombosis.