Repeated Endovascular Interventions are Worthwhile, Even After Thrombosis, to Maintain Longterm Use of Autogenous Dialysis Fistulas
Michele N. Richard, MD, Caitlin Dowling, Michael Madatovian, Caitlin Drakeley, Amber Butler, MPH, Dahlia Plummer, MD, Alan M. Dietzek, MD.
Danbury Hospital WCHN, Danbury, CT, USA.
Objective(s): It is well established that autogenous arteriovenous fistulas (aAVF) are the preferred conduit for hemodialysis access. There is no consensus on whether multiple interventions on aAVF, particularly following thrombosis, are worthwhile to extend functional fistula patency (FFP) and minimize use of alternative conduits/catheters. We wanted to evaluate whether our policy of repeated interventions for failing/failed aAVF was effective in prolonging FFP.
Methods: A retrospective chart review was performed of patients with aAVF created 01/2009-12/2014. Data collected included patient demographics, fistula type, number of interventions prior to initiating dialysis (PreDialysis) and after (PostDialysis), intervention type (angioplasty, stent, or TPA thrombolysis), and abandonment causes. Patients were divided into two groups based on PostDialysis interventions to evaluate the effect of more numerous interventions: <2 versus >3. Outcome of aAVF was evaluated for duration of FFP, number of PostDialysis interventions, and time between interventions. Data was analyzed using Chi Square and ANCOVA.
Results: 161 patients met inclusion criteria: 65 had patent fistulas at time of death, 64 continue to have functional fistulas, 15 were lost to followup, only 17 (10.6%) required aAVF abandonment. Average age was 66.9+15 years. Mean FFP was 3.15+1.83 years (0.098-6.88). Mean number of PostDialysis interventions was 1.53+2.11 (0-13). Mean time to abandonment was 1.58+1.38 years (0.15-5.30). Most commonly abandoned fistulas were radiocephalic (47.1%), followed by brachiocephalic (35.3%) and basilic transposition (17.6%). Most common cause for abandonment was thrombosis (47.1%) and infection (23.5%). Of the 129 fistulas that were not abandoned, 8.3% had thrombosis with a mean FFP of 2.12+1.71 years. Overall, patients with BMI>25 were less likely to have their fistulas abandoned (p=0.0128). Female patients (p=0.029) and patients with BMI>25 (p=0.046) were more likely to have increased number of PostDialysis interventions. Although a PreDialysis intervention did not affect FFP (p=0.956), it approached statistical significance with increased number of PostDialysis interventions (p=0.061). Patients with <2 interventions (78.3%) and >3 interventions (21.7%) didn't show any difference in time to abandonment (p=0.366), fistula type (p=0.147), intervention type (p=0.109), or average days between interventions (p=0.121).
Conclusions: These results demonstrate repeated endovascular interventions on aAVF, even after thrombosis, is an effective means to prolong FFP. This is particularly important for those patients that are not candidates for transplantation, have failed transplantation, younger patients and/or those with limited access options.
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