Management of dialysis fistula thrombosis

Abstract

The results of 74 operations for fistula thrombosis were analyzed by life table methods to identify aspects of operative management that were important in restoring long-term patency. Fistula patency was restored by simple thrombectomy in 14 of 15 (93 per cent) arteriovenous fistulas between the radial artery and cephalic vein and in 20 of 26 (77 per cent) bovine heterograft fistulas. However, early reocclusion was common after thrombectomy, resulting in cumulative 6 month patency rates of only 22 per cent for radiocephalic fistulas and 41 per cent for bovine heterograft fistulas. A protocol including routine intraoperative angiography and revision of identified fistula defects was employed in 33 operations (12 radiocephalic fistulas and 21 bovine heterograft fistulas). Significant defects were detected in 21 (64 per cent) and were revised concurrent with thrombectomy. Eleven lesions (52 per cent) were unsuspected and would have been undetected without routine angiographic assessment. Revision or demonstration of normal post-thrombectomy angiograms resulted in cumulative 6 month patency rates of 70 per cent for radiocephalic fistulas and 72 per cent for bovine heterograft fistulas, which are significantly better (p <0.05) than the results of thrombectomy alone. Revised defects included stenotic venous outflow intimal fibroplasia (14 instances), pseudoaneurysms (3), and anastomotic technical imperfections (4). A variety of remediable vascular lesions may contribute to recurrent dialysis fistula thrombosis. Correction of these defects is rewarded by improved maintenance of vascular access patency.