ABSTRACT
The 1994 report of the U.S. Renal Data System (USRDS) has shown a progressive annual increase in the number of newly treated end-stage renal disease (ESRD) patients in this country, with an 8.76% annual growth since 1982 (1). Among the three main treatment modalities-hemodialysis, renal transplantation, and peritoneal dialysis-hemodialysis is instituted in approximately two-thirds of these patients. For the 200,000 hemodialysis patients in the United States, it is imperative to establish an effective arteriovenous (AV) fistula with a reasonable long-term patency rate, even with the required three-time weekly needle punctures at the access site. In spite of our best efforts, most if not all of these vascular accesses will eventually thrombose and require either a revision or the creation of a new fistula or graft at a different site. Over the course of an ESRD patient’s dialysis lifetime, complications related to the establishment or
maintenance of vascular access is the most common reason for admission to a health care facility (2). The limited number of easily accessible sites and the good results obtained after revision of failed dialysis access grafts have led vascular access surgeons to attempt revision prior to constructing a new AV fistula elsewhere. For autogenous fistulae, Kinnaert et al. (3) and Rohr et al. (4) report secondary patency rates of 88 and 65% at 1 year and 88 and 55% at 2 years, respectively. For prosthetic arteriovenous grafts, similar secondary patency rates of 75 and 95% at 1 year and 61 and 81% at 2 years have been achieved in the respective series reported by Kherlakian et al. (5) and Puckett and Lindsay (6). Moreover, Palder et al. (7) have shown that successfully revised fistulae, either autogenous or prosthetic, maintain a patency survival similar to that of unrevised fistulae. The purpose of this chapter is to review the surgical approaches to throm-
bectomy and revision for the most commonly encountered failures of AV dialysis access (Tables 7.1 and 7.2) (8).
