The inside-out technique for tunneled dialysis catheter placement with central venous occlusion.

The "inside-out" technique eliminates the need for subclavian or femoral catheter placement by placing a supraclavicular catheter via a percutaneous femoral vein access. Few reports of its use in vascular surgery exist. The purpose of this article is to describe our version of the technique and report results. Between 2016 and 2017, the inside-out technique was performed on eight patients. All patients had more than four prior access sites and bilateral internal jugular vein occlusion. The technical success rates were 100% with no periprocedural complications and success in achieving dialysis access. One patient required catheter replacement within 48 hours, one catheter was used as a bridge to Hemodialysis Reliable Outflow (Hemosphere, a Cryolife Inc Company, Eden Prairie, Minn) graft placement, and one patient died of sepsis unrelated to their catheter. Our data show the inside-out technique to be safe and effective, removes the need for subclavian or femoral catheter placement, and should be a component of treatment algorithms for complex dialysis patients, which is consistent with National Kidney Foundation's Kidney Disease Outcomes Quality Initiative recommendations.

Definitions and End Points for Interventional Studies for Arteriovenous Dialysis Access.

This paper is part of the Clinical Trial Endpoints for Dialysis Vascular Access Project of the American Society of Nephrology Kidney Health Initiative. The purpose of this project is to promote research in vascular access by clarifying trial end points which would be best suited to inform decisions in those situations in which supportive clinical data are required. The focus of a portion of the project is directed toward arteriovenous access. There is a potential for interventional studies to be directed toward any of the events that may be associated with an arteriovenous access' evolution throughout its life cycle, which has been divided into five distinct phases. Each one of these has the potential for relatively unique problems. The first three of these correspond to three distinct stages of arteriovenous access development, each one of which has been characterized by objective direct and/or indirect criteria. These are characterized as: stage 1-patent arteriovenous access, stage 2-physiologically mature arteriovenous access, and stage 3-clinically functional arteriovenous access. Once the requirements of a stage 3-clinically functional arteriovenous access have been met, the fourth phase of its life cycle begins. This is the phase of sustained clinical use from which the arteriovenous access may move back and forth between it and the fifth phase, dysfunction. From this phase of its life cycle, the arteriovenous access requires a maintenance procedure to preserve or restore sustained clinical use. Using these definitions, clinical trial end points appropriate to the various phases that characterize the evolution of the arteriovenous access life cycle have been identified. It is anticipated that by using these definitions and potential end points, clinical trials can be designed that more closely correlate with the goals of the intervention and provide appropriate supportive data for clinical, regulatory, and coverage decisions.

Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedure.

OBJECTIVE: The Kidney Disease Outcome Quality Initiative and Fistula First Breakthrough Initiative call for the indiscriminate creation of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs) without providing patient-specific criteria for vascular access selection. Although the U.S. AVF rate has increased dramatically, several reports have found that this singular focus on increasing AVFs has resulted in increased AVF nonmaturation/early failure and a high prevalence of catheter dependence. The objective of this study was to determine the appropriateness of vascular access procedures in clinical scenarios constructed with combinations of relevant factors potentially influencing outcomes. METHODS: The RAND/UCLA Appropriateness Method was used. Accordingly, a comprehensive literature search was performed and a synthesis of results compiled. The RAND/UCLA Appropriateness Method was applied to 2088 AVF and 1728 AVG clinical scenarios with varying patient characteristics. Eleven international vascular access experts rated the appropriateness of each scenario in two rounds. On the basis of the distribution of the panelists' scores, each scenario was determined to be appropriate, inappropriate, or indeterminate. RESULTS: Panelists achieved agreement in 2964 (77.7%) scenarios; 860 (41%) AVF and 588 (34%) AVG scenarios were scored appropriate, 686 (33%) AVF and 480 (28%) AVG scenarios were scored inappropriate, and 542 (26%) AVF and 660 (38%) AVG scenarios were indeterminate. Younger age, larger outflow vein diameter, normal or obese body mass index (vs morbidly obese), larger inflow artery diameter, and higher patient functional status were associated with appropriateness of AVF creation. Older age, dialysis dependence, and smaller vein size were associated with appropriateness of AVG creation. Gender, diabetes, and coronary artery disease were not associated with AVF or AVG appropriateness. Dialysis status was not associated with AVF appropriateness. Body mass index and functional status were not associated with AVG appropriateness. To simulate the surgeon's decision-making, scenarios were combined to create situations with the same patient characteristics and both AVF and AVG options for access. Of these 864 clinical situations, 311 (36%) were rated appropriate for AVG but inappropriate or indeterminate for AVF. CONCLUSIONS: The results of this study indicate that patient-specific situations exist wherein AVG is as appropriate as or more appropriate than AVF. These results provide patient-specific recommendations for clinicians to optimize vascular access selection criteria, to standardize care, and to inform payers and policy. Indeterminate scenarios will guide future research.

Outcomes of vascular access for hemodialysis: A systematic review and meta-analysis.

BACKGROUND: The decision about the type and location of a hemodialysis vascular access is challenging and can be affected by multiple factors. We explored the effect of several a priori chosen patient characteristics on access outcomes. METHODS: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through November 13, 2014. We included studies that evaluated patency, mortality, access infection, and maturation of vascular access in adults requiring long-term dialysis. Pairs of reviewers working independently selected the studies and extracted the data. Outcomes were pooled across studies using the random-effects model. RESULTS: Two hundred studies met the eligibility criteria reporting on 875,269 vascular accesses. Overall, studies appeared to have provided incidence rates at low to moderate risk of bias. The overall primary patency at 2 years was higher for fistulas than for grafts and catheters (55%, 40%, and 50%, respectively). Patency was lower in individuals with diabetes, coronary artery disease, older individuals, and in women. Mortality at 2 years was highest with catheters, followed by grafts then fistulas (26%, 17%, and 15%, respectively). CONCLUSIONS: The current evidence remains in support of autogenous access as the best approach when feasible. We provide incidence rates in various subgroups to inform shared decision making and facilitate the conversation with patients about access planning.

A Capacitance-Based Sensor for Hemodialysis Cannulation Training: A Proof-of-Concept Study.

In this work, we present a novel capacitance-based sensor for teaching hemodialysis cannulation skills. Initial results from a pilot experiment suggest that data from the sensor could be used to indicate puncture events in tissue-like materials.

Impact of sarcopenia on long-term mortality following endovascular aneurysm repair.

Sarcopenia, also known as a reduction of skeletal muscle mass, is a patient-specific risk factor for vascular and cancer patients. However, there are no data on abdominal aortic aneurysm (AAA) patients treated with endovascular aneurysm repair (EVAR) who have sarcopenia. To determine the impact of sarcopenia on mortality following EVAR, we retrospectively reviewed 200 patients treated with EVAR by estimating muscle mass on abdominal computed tomography (CT) scans. Mortality was analyzed according to its presence (n=25) or absence (n=175). Sarcopenia was more common in women than men (32.0% vs 9.7%; p=0.005). Patients with sarcopenia had an increased risk of mortality compared to those without (76% vs 48%; p=0.016). Of note, the overall mortality rate was 51% with a median follow up of 8.4 years (interquartile range, 5.3-11.7). In conclusion, the presence of sarcopenia on a CT scan is an important predictor of long-term mortality in patients treated for AAA with EVAR. Pending further study, these data suggest that sarcopenia may aid in pre-procedural long-term survival assessment of patients undergoing EVAR.

Prospective multicenter study with a 1-year analysis of a new vascular graft used for early cannulation in patients undergoing hemodialysis.

OBJECTIVE: More than 85% of patients with end-stage renal disease start dialysis through a tunneled dialysis catheter (TDC) for long periods while their arteriovenous fistula or vascular access graft (arteriovenous graft [AVG]) matures. Because TDCs are associated with a high risk of complications, including death and infection, use of an AVG that can be cannulated safely immediately after implantation may reduce morbidity in these patients by allowing earlier TDC removal. We report a prospective multicenter study of a new early-cannulation AVG (Gore ACUSEAL Vascular Graft; W. L. Gore & Associates, Flagstaff, Ariz). METHODS: Patients requiring creation of a prosthetic vascular access for hemodialysis were enrolled between July 2010 and February 2012 and observed for 12 months. Data were collected on the patients' baseline characteristics; location, position, loss of patency, and revisions of prior AVGs; dialysis sessions using the AVG; and major adverse events related to graft implantation or cannulation. Cumulative and primary unassisted graft patency rates were calculated. A subgroup analysis compared outcomes in patients in whom the AVG was first cannulated within 72 hours after implantation with outcomes in patients in whom the initial cannulation was performed >21 days postoperatively. RESULTS: The population of this study was formed by 138 patients who received an ACUSEAL graft. During follow-up, 17 patients died and the AVG was abandoned in 27. The median value for follow-up was 360 days for all patients (variance 15,387). The overall mean time to initial cannulation was 15 days, with 54 grafts (40%) first cannulated within 72 hours after graft implantation and 33 grafts first cannulated >21 days afterward. The reason for late cannulation in some patients was dependent on the implanting surgeon's decision and the surgeon's personal experience with early cannulating grafts. The 1-year overall cumulative patency rate was 79% (95% confidence interval, 71%-85%); the primary unassisted patency rate was 35% (95% confidence interval, 27%-44%). Adverse events included 6 hematomas (two of which were related to cannulation and occurred 107 and 169 days, respectively, after AVG implantation), 15 graft infections, and 15 cases of steal syndrome requiring intervention. Patients in the early- and later-cannulation groups had similar characteristics and no significant differences in rates of cumulative or primary unassisted patency or adverse events. CONCLUSIONS: This study demonstrated that the new, early-cannulation AVG graft can be cannulated soon after implantation without a significant difference in patency and complication rates compared with rates associated with standard cannulation of expanded polytetrafluoroethylene grafts in the literature. This new AVG may allow early removal or avoidance of TDC use in patients undergoing hemodialysis, potentially reducing or eliminating the number of days of catheter-dependent dialysis, but further studies will be needed to demonstrate this potential.

Fistulas in octogenarians: are they beneficial?

BACKGROUND: The incidence of end-stage renal disease is increasing most rapidly in patients aged older than 75 years. Meanwhile, their 5-year survival rate remains the lowest of any dialysis cohort. The purpose of this study was to evaluate the benefit of arteriovenous fistula (AVF) construction in octogenarians, as the data regarding the effects of age on fistula success are conflicting. METHODS: Using our hemodialysis database, we performed a retrospective review of all AVFs placed between 1 November, 2007, and 17 July, 2013, in patients aged 80 years or older. Patient demographics, presence of catheters, time to first fistula use, fistula interventions, fistula patency, and time to patient death were all evaluated. RESULTS: We placed 32 fistulas in 31 patients. Our average patient was 82-year-old, men (75%) and Caucasian (71%). Three patients were excluded, as they never required dialysis. One patient required 2 fistulas; the second fistula was excluded from analysis. Of the remaining 28 patients, 22 (78%) were used for hemodialysis and 19 (68%) required catheter-based dialysis before fistula use. The mean length of catheter use was 166 days, and the median time to first fistula use was 109 days. Primary functional patency was 51% at year 1 and 38% at year 2, respectively. Secondary patency was 75% at year 1 and year 2. Of the 22 patients, 17 (77%) required intervention to achieve or maintain patency. The median time to death was 26 months. CONCLUSIONS: With substantial effort, successful fistula utilization can be achieved in an extremely elderly patient population. Our patients experienced significant catheter utilization and over 3 quarters required secondary interventions to achieve or maintain fistula utilization. Given this group's limited survival and the fact that 21% of their survival time was spent dialyzing with a catheter, the benefit of a functioning fistula to a patient older than 80 years can be questioned.

An early validation of the Society for Vascular Surgery lower extremity threatened limb classification system.

OBJECTIVE: The Society for Vascular Surgery (SVS) recently established the Lower Extremity Threatened Limb Classification System, a staging system using Wound characteristic, Ischemia, and foot Infection (WIfI) to stratify the risk for limb amputation at 1 year. Although intuitive in nature, this new system has not been validated. The purpose of the following study was to determine whether the WIfI system is predictive of limb amputation and wound healing. METHODS: Between 2007 and 2010, we prospectively obtained data related to wound characteristics, extent of infection, and degree of postrevascularization ischemia in 139 patients with foot wounds who presented for lower extremity revascularization (158 revascularization procedures). After adapting those data to the WIfI classifications, we analyzed the influence of wound characteristics, extent of infection, and degree of ischemia on time to wound healing; empirical Kaplan-Meier survival curves were compared with theoretical outcomes predicted by WIfI expert consensus opinion. RESULTS: Of the 158 foot wounds, 125 (79%) healed. The median time to wound healing was 2.7 months (range, 1-18 months). Factors associated with wound healing included presence of diabetes mellitus (P = .013), wound location (P = .049), wound size (P = .007), wound depth (P = .004), and degree of ischemia (P < .001). The WIfI clinical stage was predictive of 1-year limb amputation (stage 1, 3%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and wound nonhealing (stage 1, 8%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and correlated with the theoretical outcome estimated by the SVS expert panel. CONCLUSIONS: The theoretical framework for risk stratification among patients with critical limb ischemia provided by the SVS expert panel appears valid. Further validation of the WIfI classification system with multicenter data is justified.

Platform technologies for decellularization, tunic-specific cell seeding, and in vitro conditioning of extended length, small diameter vascular grafts.

The aim of this study was to generate extended length, small diameter vascular scaffolds that could serve as potential grafts for treatment of acute ischemia. Biological tissues are considered excellent scaffolds, which exhibit adequate biological, mechanical, and handling properties; however, they tend to degenerate, dilate, and calcify after implantation. We hypothesized that chemically stabilized acellular arteries would be ideal scaffolds for development of vascular grafts for peripheral surgery applications. Based on promising historical data from our laboratory and others, we chose to decellularize bovine mammary and femoral arteries and test them as scaffolds for vascular grafting. Decellularization of such long structures required development of a novel "bioprocessing" system and a sequence of detergents and enzymes that generated completely acellular, galactose-(α1,3)-galactose (α-Gal) xenoantigen-free scaffolds with preserved collagen, elastin, and basement membrane components. Acellular arteries exhibited excellent mechanical properties, including burst pressure, suture holding strength, and elastic recoil. To reduce elastin degeneration, we treated the scaffolds with penta-galloyl glucose and then revitalized them in vitro using a tunic-specific cell approach. A novel atraumatic endothelialization protocol using an external stent was also developed for the long grafts and cell-seeded constructs were conditioned in a flow bioreactor. Both decellularization and revitalization are feasible but cell retention in vitro continues to pose challenges. These studies support further efforts toward clinical use of small diameter acellular arteries as vascular grafts.

Radiation safety education in vascular surgery training.

OBJECTIVE: Endovascular volume during vascular surgery training has increased profoundly over recent decades, providing heavy exposure to ionizing radiation. The study purpose was to examine the radiation safety training and practices of current vascular surgery trainees. METHODS: An anonymous survey was distributed to all current U.S. trainees. Responses were compared according to the presence of formal radiation safety training and also the trainees' perception of their attendings' adherence to As Low As Reasonably Achievable (ALARA) strategies. RESULTS: The response rate was 14%. Forty-five percent had no formal radiation safety training, 74% were unaware of the radiation safety policy for pregnant females, 48% did not know their radiation safety officer's contact information, and 43% were unaware of the yearly acceptable levels of radiation exposure. Trained residents knew more basic radiation safety information, and more likely wore their dosimeter badges (P < .05). Trained residents found their radiation safety officer helpful in developing safety habits; untrained residents relied on other residents (P < .05). Trainees who felt their attendings consistently practiced ALARA strategies more likely practiced ALARA themselves (P < .05). CONCLUSIONS: The lack of formal radiation safety training in respondents may reflect an inadequate state of radiation safety education and practices among U.S. vascular surgery residents.

The influence of a Vascular Surgery Hospitalist program on physician and patient satisfaction, resident education, and resource utilization.

A number of surgery practice models have been developed to address general and trauma surgeon workforce shortages and on-call issues and to improve surgeon satisfaction. These include the creation of acute or urgent care surgery services and "surgical hospitalist" programs. To date, no practice models corresponding to those developed for general and trauma surgeons have been proposed to address these same issues among vascular surgeons or other surgical subspecialists. In 2003, our practice established a Vascular Surgery Hospitalist program. Since its inception nearly a decade ago, it has undergone several modifications. We reviewed hospital administrative databases and surveys of faculty, residents, and patients to evaluate the program's impact. Benefits of the Vascular Surgery Hospitalist program include improved surgeon satisfaction, resource utilization, timeliness of patient care, communication among referring physicians and ancillary staff, and resident teaching/supervision. Elements of this program may be applicable to a variety of surgical subspecialty settings.

Comparison of arteriovenous fistulas and arteriovenous grafts in patients with favorable vascular anatomy and equivalent access to health care: is a reappraisal of the Fistula First Initiative indicated?

BACKGROUND: Initiatives to increase arteriovenous fistula (AVF) use are based on studies that show that AVFs require fewer interventions and have better patency than arteriovenous grafts (AVGs). Because patients who receive AVFs typically have more favorable vascular anatomy and are referred earlier for access placement than those who receive AVGs, the advantages of AVF might be overestimated. We compared outcomes for AVFs and AVGs in patients with equivalent vascular anatomy who were on dialysis via catheter at the time of vascular access placement. STUDY DESIGN: The study included patients who underwent placement of a first-time AVF or AVG between 2006 and 2009, who were on dialysis via catheter at the time of access placement, and who had favorable arterial and venous (>3 mm) anatomy. Outcomes for AVF and AVG were compared. RESULTS: Eighty-nine AVF and 59 AVG patients met study inclusion criteria. Similar secondary patency was achieved by AVG and AVF at 12 (72% vs 71%) and 24 months (57% vs 62%), respectively (p = 0.96). The number of interventions required to maintain patency for AVF (n = 1; range 0 to 10) and AVG (n = 1; range 0 to 11) were not different (p = 0.36). However, the number of catheter days to first access use was more than doubled in the AVF group (median 81 days) compared with the AVG group (median 38 days; p < 0.001). CONCLUSIONS: For patients who are receiving dialysis via catheter at the time of access placement, the maturation time, risk of nonmaturation, and interventions required to achieve a functional AVF can negate its benefits over AVG. A fistula first approach might not always apply to patients who are already on dialysis when referred for chronic access placement.

Bariatric surgery is associated with a reduction in major macrovascular and microvascular complications in moderately to severely obese patients with type 2 diabetes mellitus.

BACKGROUND: Bariatric surgery (BAR) has been established as an effective treatment for type 2 diabetes mellitus (T2DM) in obese patients. However, few studies have examined the mid- to long-term outcomes of bariatric surgery in diabetic populations. Specifically, no comparative studies have broadly examined major macrovascular and microvascular complications in bariatric surgical patients vs similar, nonbariatric surgery controls. STUDY DESIGN: We conducted a large, population-based, retrospective cohort study of adult obese patients with T2DM, from 1996 to 2009, using UB-04 administrative data and vital records. Eligible patients undergoing bariatric surgery (BAR [n = 2,580]) were compared with nonbariatric surgery controls (CON [n = 13,371]) for the outcomes of any first major macrovascular event (myocardial infarction, stroke, or all-cause death) or microvascular event (new diagnosis of blindness, laser eye or retinal surgery, nontraumatic amputation, or creation of permanent arteriovenous access for hemodialysis), assessed in combination and separately, as well as other vascular events (carotid, coronary or lower extremity revascularization or new diagnosis of congestive heart failure or angina pectoris). RESULTS: Bariatric surgery was associated with favorable unadjusted 5-year event-free survival estimates for the combined primary outcome (95% ± 1% vs 81% ± 1%, log-rank p < 0.01) and each secondary outcome (log-rank p < 0.01). Multivariate-adjusted and propensity-based relative risk estimates showed BAR to be associated with a 60% to 70% reduction (adjusted hazard ratio [HR] 0.36, 95% CI 0.27 to 0.47) in the combined primary outcome and 60% to 80% risk reductions for each secondary outcome (macrovascular events [adjusted HR 0.39, 95% CI 0.29 to 0.51]; microvascular events [adjusted HR 0.22, 95% CI 0.09 to 0.49]; and other vascular events [adjusted HR 0.25, 95% CI 0.19 to 0.32]). CONCLUSIONS: Bariatric surgery is associated with a 65% reduction in major macrovascular and microvascular events in moderately and severely obese patients with T2DM.

Aortobiiliac bypass to the distal external iliac artery versus aortobifemoral bypass: a matched cohort study.

Vascular bypass has long been the standard surgical treatment for symptomatic aortoiliac occlusive disease (AIOD). Conventional wisdom has been that aortobifemoral bypass (ABF) be performed for AIOD because of the inevitable progression of iliac atherosclerosis leading to bypass thrombosis. However, ABF is prone to significant groin incision complications such as infection and lymphocele. The purpose of this study was to determine if aortobiiliac bypass (ABI) to the distal external iliac artery performs similarly to ABF in cases in which minimal atherosclerosis is present in the distal iliac arteries. Of patients undergoing aortic reconstruction for symptomatic AIOD between July 1998 and December 2008, 37 were found to have minimal atherosclerosis in the distal external iliac arteries and underwent ABI. These were compared with patients undergoing ABF using a retrospective matched cohort design. The indication for ABI was claudication in 86.5 per cent and critical limb ischemia in 13.5 per cent. There was no difference found in overall bypass patency. The 1-, 3-, and, 5-year patencies were 97, 92, and 79 per cent in the ABI group and 93, 85, and 76 per cent in the ABF group, respectively (P = 0.8). The incidence of groin wound complications in the ABF group was 14.6 per cent. ABI to the distal external iliac artery achieves equivalent graft patencies to ABF without added risk of associated groin wound complications. These data suggest that ABI be preferentially considered to ABF in situations when the very distal external iliac arteries are patent and free of significant atherosclerotic disease.

The management of malfunctioning prosthetic arteriovenous accesses by interventional nephrologists and surgeons: a retrospective comparison of long-term outcomes.

PURPOSE: To compare the outcomes of arteriovenous grafts (AVG) managed by interventional nephrologists (IN) to those managed by vascular surgeons (VS). METHODS: Between January 2004 and February 2005, 106 forearm loop AVG were placed. Ten AVG did not meet inclusion criteria and thus were excluded from study. Forty-seven AVG were managed by IN using percutaneous interventional techniques. Vascular surgeons, using surgical techniques, cared for 49 AVG. High-risk AVG in the IN group were surveyed with fistulagrams, whereas AVG in the VS group were not. Outcomes of the IN and VS groups were retrospectively compared. RESULTS: The secondary patency rates at 6 and 18 months were 84% and 69% in the IN group and 79% and 68% in the VS group, respectively (P=.38). Twenty-five (53%) AVG in the IN required at least one surgical procedure to achieve a patency equivalent to that of the VS group. The mean number of AVG interventions to final failure was 4.8 in the IN group and 3.0 in the VS group (P=.03). Infection requiring AVG removal occurred in six patients in the IN group and one patient in the VS group (P=.07). CONCLUSIONS: Surveillance fistulagrams and percutaneous intervention for malfunctioning AVG by IN do not provide superior patency and may require more interventions over the "life" of the graft when compared to no surveillance and surgical intervention by VS. In order to achieve optimal vascular access outcomes, a collaborative relationship between nephrologist and surgeon is essential so as to ensure that the most appropriate intervention is selected and futile interventions are avoided.

A randomized prospective multicenter trial of a novel vascular sealant.

BACKGROUND: Increasing use of anticoagulant medications, particularly antiplatelet therapies, can increase the difficulty in obtaining adequate suture line hemostasis. Multiple vascular sealants have been used as adjuncts to surgical procedures, but none of them have been universally successful. The aim of this study was to evaluate the safety and effectiveness of a new prophylactic vascular sealant in arterial surgery. METHODS: A randomized prospective multi-institutional trial was undertaken comparing ArterX Vascular Sealant (AVS) with Gelfoam Plus during open arterial reconstruction. RESULTS: Three hundred thirty-one anastomotic sites in 217 patients were randomized. One hundred one of 167 (60.5%) anastomotic sites in the AVS group achieved immediate hemostasis compared with 65 of 164 (39.6%) in the control group (P = 0.001). In anastomoses with polytetrafluoroethylene grafts, 105 of 167 (62.5%) in the AVS group achieved immediate hemostasis compared with 56 of 164 (34.0%) in the control group (P < 0.001). No significant differences were noted in morbidity or mortality. Operative time was significantly less in the AVS group compared with the control group (3.2 vs. 3.8 hours, P < 0.01). CONCLUSION: Use of AVS results in superior hemostatic effectiveness compared with Gelfoam Plus, with no difference in safety. Although no cost analysis was performed, cost savings likely resulted from significantly decreased operative time.

Description and outcomes of a simple surgical technique to treat thrombosed autogenous accesses.

OBJECTIVE: Owing to the difficulty of removing acute and chronic thrombus from autogenous accesses (AA) by standard surgical and endovascular techniques, many surgeons consider efforts to salvage a thrombosed AA as being futile. We describe a simple technique to extract acute and chronic thrombus from a failed AA. This technique involves making an incision adjacent to the anastomosis, directly extracting the arterial plug, and manually milking thrombus from the access. This report details the outcomes of a series of thrombosed AAs treated by surgical thrombectomy/intervention using this technique for manual clot extraction. METHODS: A total of 146 surgical thrombectomies/interventions were performed in 102 patients to salvage a thrombosed AA. Mean follow-up was 15.6 months. Office, hospital, and dialysis unit records were reviewed to identify patient demographics, define procedure type, and determine functional patency rates. Kaplan-Meier survival analysis was used to estimate primary and secondary functional patency rates. RESULTS: Complete extraction of thrombus from the AA was achieved in 140 of 146 cases (95%). The studied procedure itself was technically successful in 127 cases (87%). Reasons for failure were the inability to completely extract thrombus from the AA in six, failed angioplasty due to long segment vein stenosis or sclerosis in seven or vein rupture in two, and central vein occlusion in one. Three failures occurred for unknown causes ≤ 3 days of successful thrombectomy. No single factor analyzed (age, sex, race, diabetes status, access type or location) was associated with technical failure. The estimated primary and secondary functional patency rates were 27% ± 5% and 61% ± 6% at 12 months. CONCLUSIONS: The manual clot extraction technique described in this report effectively removed acute and chronic thrombus from failed AAs. Its use, combined with an intervention to treat the underlying cause for AA failure, significantly extended access durability.