Abstract
Backround. The use of artificial vascular grafts (arteriovenous graft, AVG) is indicated in patients in hemodialysis programs if the subcutaneous venous bed is exhausted or unsuitable for arteriovenous fistula (AVF) creation. The native fistula should be the hemodialysis access of first choice: AVF has better results in terms of function and potential complications. However, the use of AVG is necessary in some patients. In these patients, extensive clinical examination, color duplex sonography and angiography should be performed prior to indication. The technique of graft implantation requires respect for geometric relations for the graft anastomoses to minimize the formation of intimal hyperplasia mainly on the venous anastomosis. The main complications of AVG are stenosis on the venous anastomosis (VAG), causing closure of graft and graft infection. The cumulative function of AVG is 59-90% in the first year and 50-82% in the second year. Arteriovenous graft stenosis leading to thrombosis is a major cause of complications in patients undergoing hemodialysis. The purpose of this review is to summarise current knowledge of the diagnostics and treatment of graft thrombosis and discuss the issue in combination with relevant publications via Pubmed database. The most frequent cause of failure of AVG for hemodialysis is stenosis and closure by VAG. AVG closure can be addressed surgically, endovascularly (amenable to thrombectomy by radiological or surgical means) and by hybrid performance.
Highlights
A well-functioning vascular access is essential for efficient hemodialysis treatment
Venous anastomosis was checked by intraoperative angiography, surgical thrombectomy was treated surgically and in endovascular treatment balloon angioplasty of the venous stenosis was performed
An innovative view on the treatment of clotted arteriovenous graft (AVG) with stenosis of venous anastomosis of the graft (VAG) was provided by experience with the stent graft insertion in the functional stenotic VAG
Summary
A well-functioning vascular access is essential for efficient hemodialysis treatment. VAG stenosis should be treated surgically or endovascularly in the case that parameters for angioplasty of venous stenosis are present – 50% stenosis is noted and only when associated with one of several indicators of graft dysfunction-abnormal physical findings, decreased access flow rate below 600 mL/min and elevated static intraluminal pressure[3]. The underlying graft outlet stricture requires direct surgical revision or balloon angioplasty during surgery or intervention in the angiography suite to ensure long-term patency of the graft[30]. The data collected by Uflacker et al provided a prospective comparison of mechanical thrombectomy (Amplatz thrombectomy device) and surgical thrombembolectomy (declot) performance in thrombosed AVG For both techniques, venous anastomosis was checked by intraoperative angiography, surgical thrombectomy was treated surgically (patch angioplasty, reeanastomosis) and in endovascular treatment balloon angioplasty of the venous stenosis was performed. The results of VAG stenosis balloon angioplasty are comparable to that of surgical revision[3]
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