Secondary patency of thrombosed prosthetic vascular access grafts with aggressive surveillance, monitoring and endovascular management.

BACKGROUND To study the long-term patency of thrombosed prosthetic vascular access grafts treated with percutaneous mechanical thrombectomy (PMT) followed by aggressive surveillance and monitoring and repeated endovascular interventions. STUDY DESIGN Two hundred seven vascular access grafts presented with first-time thrombosis were treated with PMT using the AngioJet device (n=185) or the Arrow-Trerotola percutaneous thrombolytic device (n=22) followed by angioplasty (+/- stenting) of the anatomical lesion responsible for the thrombotic event. Clinical success was considered at least one successful subsequent hemodialysis session. Graft surveillance/monitoring included clinical and hemodialysis parameters to detect a failing or thrombosed graft. RESULTS PMT was technically successful in 202 cases (97.6%) and clinically successful in 193 cases (93.2%). During follow-up, 149 got thrombosed and either abandoned (n=33) or underwent at least once repeat thrombectomy (n=116); finally 100 grafts were abandoned (n=90), ligated (n=5) or removed (n=5). Endovascular management (0.54 procedures per 100 graft-days, thrombectomy, n=307 sessions and angioplasty, n=162 sessions) increased significantly functional assisted-primary patency rates from 29% and 14% at 1 and 2 years to a secondary patency of 62% and 47%, respectively. Secondary patency was worse in loop grafts (P=.02) and intermediate graft thrombosis (occurred between 31-182 days after graft placement, P<.001) and better when renal failure was due to hypertension or diabetes (compared to other or cryptogenic causes, P=.048) or isolated angioplasty for graft dysfunction during follow-up had been performed (P<.001). Multivariate analysis identified intermediate graft thrombosis and isolated angioplasty as independent predictors of secondary patency (P<.001, relative risk 2.77 and P<.001, relative risk 0.28, respectively). CONCLUSIONS PMT is a highly successful procedure with acceptable long-term secondary patency results, provided that aggressive endovascular management of subsequent thrombotic or dysfunction episode is performed. Further research to identify the causes of intermediate graft thrombosis is justified.