Surgical versus endovascular management of thrombosed autogenous arteriovenous fistulae.

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was: In patients undergoing haemodialysis with thrombosed autogenous arteriovenous fistulae, does surgical management as compared to endovascular management improve clinical outcomes? A total of 130 papers were identified using the search protocol described, of which four represented the best evidence available to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Three of the four studies demonstrated no significant difference between the initial success rates of surgical or endovascular management. However, one study illustrated that hybrid surgery (a combination of endovascular and surgical techniques) significantly improved initial success rates, shortened hospital stays and decreased total monetary costs. Furthermore, three studies showed that subsequent fistula patency rates were significantly higher when surgical management was instigated. Nevertheless, one study suggested that surgery worsened subsequent patency rates and that in fact surgical patients were more likely to require temporary dialysis catheters than endovascular patients. Therefore, the clinical bottom line is that with careful patient and fistula selection, surgery provides a number of benefits over endovascular management of thrombosed autogenous arteriovenous fistulae, particularly in the medium to long term. However, further appropriately powered and randomised Level 1 studies are necessary to clarifying this important issue.