Middleton JP, McDermott VG, Schumm DG, Schwab SJ
Surgical thrombectomy and revision improves survival of
hemodialysis vascular access
Am Soc Nephrol
J Am Soc Nephrol (abstract)
(Sep) 7:1414 1996
Vascular access remains the most frustrating problem in ESRD
management. Various surgical and radiologic procedures are in use to
salvage thrombosed or at-risk accesses.
This prospective study of 50 patients examines the outcome of a
treatment algorithm consisting of [radiologic] outpatient thrombolysis
with venous outflow obstruction angioplasty. 32 of these 50 patients
re-thrombosed; of these, 19 underwent inpatient surgical thrombectomy
and revision. Despite an 88% initial success with outpatient
thrombolysis/angioplasty, a 64% rethrombosis rate compared unfavorably
with a 16% rate for surgical revision. The authors conclude that
surgical revision, though costlier, may be better and ultimately
reduce costs.
Comment: Although done prospectively, the abstract does not
clarify how patients were selected for surgical salvage vs. repeat
thrombolysis, and the conclusion would have been stronger had there
been a randomization earlier on in the algorithm. I am also not clear
as to why graft revision would require in-patient status, absent some
other complication of access failure. Presumably, the revision was
done based upon the venographic findings at the entry angioplasty. The
use of the term AV fistula for what appear to be PTFE interposition
grafts is also confusing. A prospective study of clotted grafts,
starting with venography then randomizing to angioplasty versus
surgical revision, is needed. (James A. Sondheimer MD, Wayne
State University, Detroit, MI)
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Am Soc Nephrol
Basic hemodialysis :
Vascular Access: graft/fistula