Percutaneous Rheolytic Thrombectomy for Thrombosed Autogenous Fistulae and Prosthetic Arteriovenous Grafts: Outcome after Aggressive Surveillance and Endovascular Management

Abstract

Purpose:

To study the outcome of rheolytic thrombectomy for hemodialysis access occlusion.

Methods:

A prospective study was conducted of 187 patients (88 men; median age 63 years, range 21–89) with end-stage renal disease treated with the AngioJet rheolytic thrombectomy catheter followed by angioplasty (± stenting) of the culprit lesions in 285 episodes of at least one successful subsequent hemodialysis session. Graft monitoring and surveillance including clinical and hemodialysis parameters, respectively, to detect a failing/failed access.

Result:

Rheolytic thrombectomy had a technical (immiediate) success rate of 98.2% and a clinical success rate of 95.1%. Technical and clinical success for patients presenting within 2 days of the thrombosis was 99.6%, and 96.6%, respectively, compared to 91.8% (p=0.003, odds ratio 20.8) and 87.8% (p=0.019, odds ratio 4) for later presentation. The number of (4, 3–4) compared to fistulea (2,2–3; p<0.001) and in accesses that had been treated for dysfunction or thrombosis in the past (4, 3–4) compared to accesses that had not (3, 3–4; p=0.07). During follow-up, 95 (36.6%) accesses had no further thrombotic events, 23 (9%) accesses became dysfunction and were treated with endovascular techniques, 137 (52.3%) developed recurren thrombosis for removed for infection. Functional assisted primary patency at 1, 6, 12, and 18 months was 72.4%, 45.1%, 30.3%, and 22.4%, respectively. Reintervention and venous outflow stenosis were associated with better and worse outcomes, respectively; multivariate analysis identified patient age, central vein stenosis, and stenting as additional independent predictors of improved patency.

Conclusion:

Rheolytic thrombectomy is a highly successful procedure, with acceptable long-term assisted primary patency. Early referral for thrombectomy should be encouraged.