Thrombolysis for early failure of prosthetic arteriovenous access

Early failure (within 6 weeks of construction) of prosthetic arteriovenous access (AVA) is traditionally treated by surgical revision rather than endovascular intervention because it is assumed to be related to technical factors related to the surgery. This premise is not evidence based and our results for surgical thrombectomy have been poor. Based on our previous experience with angiography and thrombolysis in newly constructed autogenous AVAs, we changed our approach to perform endovascular thrombolysis initially, instead of proceeding directly to surgical revision.

We prospectively studied all patients who had an early failure of new prosthetic AVA from January 2000 to June 2004 to determine the cause of and treat the occlusions by endovascular means. Thrombolysis took place at least 7 days after surgery, allowing sufficient tissue incorporation to prevent puncture site bleeding. No patients were excluded from the study.

During the 54 months of the study, 269 prosthetic AVAs were constructed at our center. Twenty patients had early occlusion. The mean time from creation of the prosthetic AVA to occlusion was 15.8 +/- 10.9 (median 13, range 3-41) days and the mean time to intervention was 25.0 +/- 11.6 (median 21, range 9-54) days. Of the 20 patients, 17 underwent successful endovascular thrombolysis. The only patient of the 20 found to have a technical problem related to surgery had this resolved angiographically. There was one complication in a patient with failed endovascular thrombolysis, who had extravasation from the arterial anastomosis that halted the procedure. This patient later had surgical revision in keeping with the angiographic findings. Cumulative patency rates at 6 months and 1 year were 75% and 68%, respectively.

Endovascular thrombolysis for early occlusion of prosthetic AVAs is feasible, safe, and is associated with a good patency rate. It appears to be a better initial approach than surgical revision in these patients because technical-surgical problems related to AVA construction are rare.