Hemodialysis Arteriovenous Fistula Dysfunction: Retrospective Comparison of Post-thrombotic Percutaneous Endovascular Interventions with Pre-emptive Angioplasty

Abstract

We aimed to compare the clinical outcomes of pre-emptive angioplasty versus post-thrombotic percutaneous endovascular restoration of dysfunctional arteriovenous fistula (AVF). This retrospective study reviewed the data from 80 patients who underwent 114 endovascular interventions for a malfunctioning AVF from July 2016 to August 2019. Stenotic AVFs were treated with pre-emptive angioplasty. Thrombosed AVFs were treated with percutaneous pharmacomechanical fibrinolysis with urokinase used only during the operation or continuously infused. The differences in patency rates were evaluated using the Kaplan-Meier method. In addition, univariate and multivariate regression Cox models were used to determine influential factors on the postintervention primary patency. Post-thrombotic interventions and pre-emptive angioplasty yielded statistically similar rates in clinical success (100 vs. 100%), anatomic success (94 vs. 89%; P=0.52), complication (4 vs. 11%; P=0.29), as well as postintervention primary, assisted primary and secondary patency (P=0.80; 0.57; 0.57). The use of pre-emptive angioplasty was associated with reduced total cost (¥25,108 vs. ¥30,833, P<0.001). The patients who used urokinase only during the operation prolonged both the primary and assisted primary patency (P=0.02; 0.002), while those with continuous infusion of urokinase had worst patency rates and high costs (¥39,275 vs. ¥25,108 vs. ¥27,140, P<0.001). Compared with the other locations, dysfunction in the anastomotic or juxta-anastomotic segment (HR=0.41, P=0.001) was associated with prolonged postintervention primary patency. No clinical outcome differences were found between the post-thrombotic percutaneous endovascular interventions and pre-emptive angioplasty. However, pre-emptive angioplasty decreased access expenditure.