A metaanalysis comparing surgical thrombectomy, mechanical thrombectomy, and pharmacomechanical thrombolysis for thrombosed dialysis grafts

Background. The achievement and maintenance of access sites for hemodialysis is a persistent challenge for both the vascular surgeon and the clinical nephrologist. The advent of improved interventional, endovascular, and pharmacomechanical techniques for the treatment of thrombosis has raised questions as to whether surgical thrombectomy is the most effective treatment. Objective: The purpose of this study was to determine the role of surgical thrombectomy as the standard of care for the patient with end-stage renal disease and a thrombosed/stenosed arteriovenous graft (AVG). Design and methods: The study was designed as a metaanalysis. All publications that directly or indirectly described randomized controlled trials for the treatment of thrombosed dialysis grafts in patients with end-stage renal disease and AVG were searched. Relative risk (RR) and risk difference were used as the measure of effect for each dichotomous outcome. All of the studies that met the inclusion criteria were limited to prosthetic AVGs. Results: The overall results suggested a clear superiority of surgery over endovascular procedures at 30 days, 60 days, 90 days, and 1 year. The RRs (95% CI) at these time points were 1.32 (1.07, 1.60), 1.34 (1.13, 1.58), 1.22 (1.05, 1.40), and 1.22 (1.07, 140), respectively, and favored surgery in all cases (30 days, P=.010; 60 days, P=.0007; 90 days, P=.007; and 1 year P=.003). The number needed to treat to prevent one endovascular occlusion after thrombectomy was 8 at 30 days, 6 at 60 days, 8 at 90 days, and 7 at 1 year. The rates of technical failure were significantly greater in the endovascular group compared with the surgical group (RR, 1.90; 95% CI, 1.32, 2.73; P=.0005), which generated an absolute risk reduction of 16% (P=.0002). No significant difference was seen in the complication rates between the two groups. Conclusion: The analysis of all currently available randomized controlled trials clearly supports the use of surgical thrombectomy for the treatment of thrombosed prosthetic vascular access grafts. The use of endovascular techniques has been found to be inferior to surgery in terms of both primary patency and technical failure rates.