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Results of Repeat Percutaneous Interventions on Failing Arteriovenous Fistulas and Grafts and Factors Affecting Outcomes
Kimberly T. LeBlanc, MD, PhD, Alex Csizinscky, MD, Julie Flahive, Francesco Aiello, MD, Jessica P. Simons, MD, Andres Schanzer, MD, Louis M. Messina, MD, William P. Robinson, MD.
University of Massachusetts, Worcester, MA, USA.
Objectives: Repeat percutaneous interventions on failing arteriovenous fistulas (AVF) and grafts (AVG) for hemodialysis are common but the outcomes are not known. We sought to determine the results of second-time percutaneous intervention on AVGs and AVFs and identify factors associated with failure.
Methods: We reviewed second-time percutaneous interventions on failing AVFs and AVGs at a single institution between 2007 and 2013. Patient comorbidities, graft or fistula configuration, lesion characteristics, and procedural characteristics of the intervention performed were analyzed with respect to technical success, primary, primary assisted, and secondary patency.
Results: 96 second-time percutaneous interventions were performed on 52 AVFs and 44 AVGs. Patients included 56% men at a mean age of 64 (SD=17) years. Lesions were primarily located along the accessed portion of the outflow in AVFs and within the length of the graft and at the venous anastomosis in AVGs. Transluminal angioplasty alone was performed in 79 patients and uncovered or covered stents were placed in 15. Pharmacomechanical thrombectomy was performed in 32 patients (34%) and was more commonly performed in AVGs compared to AVFs (53% vs. 17%, p=0.0002). Technical success was achieved in 90 procedures (97%). Median follow-up was 2.5 years. One-year primary patency, assisted primary patency, and secondary patency were 35%, 85%, and 85%, respectively. Primary patency did not differ between AVFs and AVGs but five-year secondary patency was lower for AVG in comparison to AVF (49% vs 90%, P=0.04). On multivariable analysis, only the need for pharmacomechanical thrombectomy significantly predicted failure of primary patency (HR 2.62, 95% CI: 1.59-4.32, p=0.0002). The presence of an AVG compared to AVF independently predicted failure of secondary patency (HR 2.86, CI: 1.00-8.15, p=0.05).
Conclusions: Second-time percutaneous interventions on AVFs and AVGs are associated with excellent technical success but poor primary patency at one year. Pharmacomechanical thrombectomy frequently necessitates additional percutaneous interventions within 1 year to maintain patency. Additional interventions result in acceptable secondary patency with AVG performance inferior to that of AVF. The cost-effectiveness of repeat percutaneous interventions required to maintain AVG and AVF patency as well as optimal surveillance strategies need further investigation.
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