Surgical salvage of thrombosed native arteriovenous fistulas for hemodialysis by interventional nephrologists.

The purpose of this retrospective clinical study with prospective data collection was to evaluate the outcomes of patients with native arteriovenous fistula (AVF) thrombosis after surgical thrombectomy performed by surgically skilled interventional nephrologists. In 111 hemodialysis patients (66 men [59%], aged 59 +/- 16 [20-87] years), acute thrombosis of the native forearm or arm AVF occurred. The primary patency before thrombosis was 4.0 +/- 4.7 years (range 1.2-28). Thrombectomies were performed as outpatient procedures under local anesthesia (2% lidocaine), using microsurgical instruments and magnifying glasses. The total number of surgical procedures was 128-91 thrombectomies with reanastomosis and 37 thrombectomies alone. In a few cases, angioplasty with stenting and "jump grafts" were used (because of outflow stenosis). The time between thrombosis and surgery was 3.7 +/- 8.6 days (range 0-64), and the number of surgeries to maintain secondary patency was 1.15 +/- 0.47 (range 1-4). The immediate success rate was 93.8% (120/128); 7/8 of failures were in the "thrombectomy alone" group. The post-interventional secondary patency rate at one year was 68%, and in the "thrombectomy with reanastomosis" and "thrombectomy alone" subgroups it was 73% and 54%, respectively. A better outcome with thrombectomy and reanastomosis was achieved in the AVF with perianastomotic stenosis. It seems that intima-media thickening of a new anastomosis was less pronounced because of previous remodeling of the fistula vein. Surgical salvage of a thrombosed AVF performed by an interventional nephrologist was shown to be a safe procedure, significantly prolonging AVF function and avoiding hemodialysis catheter insertion in many cases. Thrombectomy with reanastomosis was more successful than simple thrombectomy.