Balloon angioplasty for arteriovenous graft stenosis

Purpose: To retrospectively review the long-term outcome as well as the cos t effectiveness of thrombolytic therapy and balloon angioplasty (TBA) versu s surgical thrombectomy and balloon angioplasty (SBA) in the treatment of p rosthetic dialysis access grafts. Methods: Between February 1996 and February 1999, 63 hemodialysis patients (35 women; mean age 62.2 years) were treated for 105 thromboses in 6-mm pol ytetrafluoroethylene straight or loop bridge arteriovenous grafts. Choice o f treatment was at the discretion of the surgeon or interventional radiolog ist: either Fogarty balloon thrombectomy followed by balloon dilation of th e venous anastomotic stenosis or urokinase thrombolysis followed by angiopl asty. Results: Forty-eight SBAs and 55 TBAs were performed in 63 patients without complications. The primary patency rates in the entire cohort were 34%, 29 %, and 17% at 1, 2, and 3 months, respectively. Primary patency after TEA w as 29%, 18%, and 11%, and that for SEA, 45%, 45%, and 33% over the same tim e intervals. The mean graft survival was 10 days for TEA versus 31 days for SEA. Repeat angioplasty performed in 23 grafts produced secondary patency rates of 52% at 1 month, 34% at 3 months, and 5% at 5 months. The Medicare reimbursement for both treatments was identical ($1638 for TEA and $1670 fo r SEA). Conclusions: The poor patency rate and high cost of TEA and SEA suggests th at these procedures should not be routinely used for salvage of thrombosed arteriovenous grafts with outflow stenosis. Patch angioplasty or creation o f simultaneous temporary and new permanent accesses may be a more cost-effe ctive approach in these patients.