TITLE: Comparable Patency of Open and Hybrid Treatment of Venous Anastomotic Lesions in Thrombosed Haemodialysis Grafts.

OBJECTIVE: Arteriovenous graft (AVG) failures are typically associated with venous anastomotic (VA) stenosis. Current evidence regarding AVG thrombosis management compares surgical with purely endovascular techniques; few studies have investigated the "hybrid" intervention that combines surgical balloon thrombectomy and endovascular angioplasty and/or stenting to address VA obstruction. This study aimed to describe outcomes after hybrid intervention compared with open revision (patch venoplasty or jump bypass) of the VA in thrombosed AVGs.

METHODS: Retrospective cohort study. Consecutive patients with a thrombosed AVG who underwent thrombectomy between January 2014 and July 2018 were divided into open and hybrid groups based on VA intervention; patients who underwent purely endovascular thrombectomy were excluded. Patient demographics, previous access history, central vein patency, AVG anatomy, type of intervention, and follow up data were recorded. Kaplan-Meier curves were used to analyse time from thrombectomy to first re-intervention (primary patency) and time to abandonment (secondary patency). Cox regression analysis was performed to evaluate predictors of failure.

RESULTS: This study included 97 patients (54 females) with 39 forearm, 47 upper arm, and 11 lower extremity AVGs. There were 34 open revisions (25 patches, nine jump bypasses) and 63 hybrid interventions, which included balloon angioplasty ± adjunctive procedures (15 stents, five cutting balloons). Technique selection was based on physician preference. Primary patency for the open and hybrid groups was 27.8% and 34.2%, respectively, at six months and 17.5% and 12.9%, respectively, at 12 months (p = .71). Secondary patency was 45.1% and 38.5% for open and hybrid treatment, respectively, at 12 months (p = .87). An existing VA stent was predictive of graft abandonment (hazard ratio 4.4, 95% confidence interval 1.2-16.0; p = .024). Open vs. hybrid intervention was not predictive of failure or abandonment.

CONCLUSION: Hybrid interventions for thrombosed AVGs are not associated with worse patency at six and 12 months compared with open revision.

SOURCE: Go C, Kulkarni R, Wagner JK, et al. Comparable Patency of Open and Hybrid Treatment of Venous Anastomotic Lesions in Thrombosed Haemodialysis Grafts[J]. Eur J Vasc Endovasc Surg, 2020, 60(6):897-903. DOI: 10.1016/j.ejvs.2020.08.012. 

目的：动静脉移植物（AVG）衰竭通常与静脉吻合（VA）狭窄相关。目前AVG血栓管理证据主要集中于外科手术与单纯血管内技术的比较。很少有研究讨论将外科球囊取栓术与血管内血管成形术和/或支架置入术相结合以解决VA梗阻的“混合型”干预措施。这项研究的目的是描述混合干预后与血栓形成的AVG中VA的开放翻修（修补静脉成形术或跳跃旁路术）相比的结果。

方法：回顾性队列研究。连续性纳入在2014年1月至2018年7月间接受血栓切除术的血栓形成性的AVG患者，根据VA干预分为开放组和混合组；单纯进行血管内取栓术的患者被排除在外。记录患者的人口统计资料，既往通路史，中心静脉通畅性，AVG解剖结构，干预类型和随访数据。 Kaplan-Meier曲线用于分析从取栓术到第一次再次介入的时间（一期通畅率）和到放弃通路的时间（二期通畅率）。进行Cox回归分析以评估功能丧失的预测因素。

结果：该研究包括97例患者（54例女性），其中39例前臂，47例上臂和11例下肢AVGs。共有34个开放修复（25个修补，9个跳转旁路）和63个混合干预，其中包括球囊血管成形术+附加技术（15个支架，5个切开球囊）。技术选择基于医生的偏好。开放和混合组在六个月时的一期通畅率分别为27.8％和34.2％，在12个月时分别为17.5％和12.9％（p = .71）。开放和混合治疗在12个月时的二期通畅率分别为45.1％和38.5％（p = .87）。现有的VA支架可预测移植物的放弃（危险比4.4，95％置信区间1.2-16.0； p = .024）。开放与混合干预不能预测失败或被放弃。

结论：与开放翻修相比，混合治疗血栓性AVGs在6个月和12个月时的通畅性并不差。

启发：人工血管静脉吻合口病变严重影响人工血管的整体通畅率，不论何种解决方案，通畅率差异并无统计学意义。我们仍需个体化解决该类问题。