Treatment of stenosis and thrombosis in haemodialysis fistulas and grafts by interventional radiology

Background. There are no large series reporting the long-term results after radiological treatment of both stenosis and thrombosis in native fistulas (AVFs) and prosthetic grafts. Methods. Between 1987 and 1999, 726 dilations, 135 stent placements and 257 declotting procedures were performed in 209 consecutive forearm AVFs, 74 upper arm AVFs and 156 prosthetic grafts. The stents used were the Wallstent*, the Craggstent*, and the Passager*. Declotting was performed by manual catheter-directed thromboaspiration, with or without previous urokinase infusion. Results. The initial success rates ranged from 78 to 98%. The rate of significant complications was 2%. Primary patency rates at 1 year were twice as good for forearm AVFs (50%) than for grafts (25%) (P < 0.05), and were 34% for upper arm AVFs. Secondary patency rates were similar in the 3 groups at 1 year (80-86%) and at 2 years(68-80%). Reintervention was necessary every 18 months in forearm AVFs compared to every 9 months in grafts (P < 0.05). Thrombosed grafts fared worse than failing grafts. Accesses of less than 1 year's duration needed more reinterventions than older accesses (every 16 months vel sus 30 in forearm AVFs, every 7 months versus 13 in grafts, P < 0.05). Conclusions. The percutaneous treatment of stenosis and thrombosis in haemodialysis access achieves patency rates similar to those reported in the surgical literature and confirms that grafts must be avoided as much as possible given their poorer outcome, especially after the first thrombosis. Poorer outcome is also demonstrated in accesses of less than 1 year's duration.