Percutaneous Salvage of Thrombosed Immature Arteriovenous Fistulas

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Abstract
Thrombosed immature fistulas have historically been considered unsalvageable. However, advances in procedure and balloon catheter technologies have expanded the scope of endovascular treatments. This study investigates the efficacy, functionality, and cost associated with the use of percutaneous techniques for the salvage of thrombosed immature fistulas. Over a 2‐year period and from a population of 18,000 patients on hemodialysis, 140 consecutive patients with thrombosed immature fistulas underwent attempts at salvage via thrombectomy procedures. All fistulas had thrombosed following access creation and had never been used for hemodialysis. Multiple approaches were utilized to gain access to the fistula, including trans‐fistula cannulation, distal arterial puncture, and proximal retrograde venous access. Thrombectomy was performed via balloon maceration and aspiration. Accelerated maturation was achieved through sequential angioplasty of diffusely stenotic veins and elimination of competing branch vessels. Primary access, primary assisted, and secondary access patencies were calculated at 3, 6, 12, and 24 months. A cost analysis was performed based on procedure statistics and the 2009 Medicare reimbursement schedule and compared with data from the 2009 United States Renal Data Survey. Thrombectomy was successful in 119 (85%) immature clotted fistulas, and hemodialysis adequacy was achieved in 111 (79%) fistulas. The average maturation time from thrombectomy to cannulation for dialysis was 46.4 days, with an average of 2.64 interventions per patient. There were 5 (3.5%) cases of angioplasty‐induced rupture, all of which were treated with stent placement. Clinically significant pseudoaneurysm formation occurred in 4 (2.8%) patients. At 12 months, secondary access patency of salvaged accesses was 90%. Based on 2009 Medicare outpatient billing rates per patient per initial access‐year and the maturation times observed in the New York area, percutaneous salvage of thrombosed immature fistulas costs $4881 to $14,998 less than access abandonment and new access creation. Endovascular techniques can be used for the salvage of thrombosed nonmaturing fistulas. When analyzed within the initial access‐year, this approach yields significant cost savings over access abandonment.

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