Non-Surgical Salvage of Thrombosed Arterio- Venous Fistulae: A Case Series and Review of the Literature Shahriar Moossavi,* John D. Regan,† Eric D. Pierson,* John M. Kasey,* Audrey B. Tuttle,* Tushar J. Vachharajani,* Michael A. Bettmann,† Gregory B. Russell,‡ and Barry I. Freedman* *Departments of Internal Medicine ⁄ Nephrology, †Radiology ⁄ Interventional Radiology, and ‡Division of Public Health Sciences ⁄ Biostatistical Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina ABSTRACT Attempts to salvage thrombosed hemodialysis arterio-venous fistulae (AVF) using interventional techniques are not univer- sally performed. Patients often require temporary dialysis cath- eters pending creation of a new vascular access. We determined the long-term outcome of interventional (non-surgical) repair of completely thrombosed AVF in 49 consecutive accesses (22 radio-cephalic, 1 radio-basilic, 19 brachio-cephalic, and 7 bra- chio-basilic) referred for an intervention within 48 hours of thrombosis. Subjects were 65% male (32), with mean Æ SD age 63.7 Æ 13.5 years (range 33–91), 51% African-American (25), 47% Caucasian (23) and 65% had diabetes (32). Overall, 96% (47 ⁄ 49) of thrombosed AVF were salvaged with compli- cations observed in four cases (two extravasations of contrast; two radial artery emboli), with no serious long-term sequelae. Interventional procedures included 34 venous angioplasties, 11 venous angioplasties with stenting and two combined venous and arterial angioplasties. The primary and secondary patency rates for all salvaged AVF were 50.5 Æ 8.7%, 72.5 Æ 7.8% at 1 year, and 43.3 Æ 10%, 55.4 Æ 12.7% at 2 years, respect- ively. The median estimate to first intervention after the declot procedure was 14.7 months. The median estimate for contin- ued function exceeded 23.1 months. There was no significant statistical difference in the primary (p = 0.73) and secondary patency rates (p = 0.057) for forearm vs. upper arm AVF. We conclude that interventional repairs should routinely be employed to salvage newly thrombosed AVF. The vast major- ity of these individuals can avoid receiving dialysis catheters or placement of a new dialysis vascular access. Maintaining a patent vascular access remains a major challenge in the care of patients on hemodialysis. Forty years after Brescia and Cimino reported the surgically created arterio-venous fistula (AVF), it remains the pre- ferred type of access with the fewest complications and longest function. Supported by the Fistula First pro- gram, there are now intensive efforts to ensure that patients on hemodialysis have an AVF created as pri- mary vascular access. Due to limited number of access sites, efforts should now be extended to maintaining patency in these primary AVF (1–4). Despite the existence of well-established endovascular procedures to declot a thrombosed AVF, attempts to salvage thrombosed AVF are not universally employed. In many cases, temporary or permanent dialysis cathe- ters are placed pending surgical revision of the current access or creation of a new dialysis access. These proce- dures are costly and may increase mortality and morbid- ity (3,5–8). To determine the success of percutaneous interventional treatment of clotted AVF in our patient population, we evaluated the outcome of interventional repair of thrombosed AVF in 49 consecutive cases who were referred for intervention within 48 hours of access failure. We also review the published literature on inter- ventional declotting of thrombosed AVF. Methods Patient Population The study population consisted of 49 hemodialysis patients treated at the Wake Forest University School of Medicine (WFUSM) who were consecutively referred for an interventional evaluation of a clotted AVF between January 1, 2003 and December 31, 2005, allow- ing for a minimum 1 year follow-up. Cases were referred within 48 hours of the detection of the loss of a thrill or bruit in the access. All procedures were performed by interventional radiologists. Data were collected retro- spectively on race, gender, age, date of AVF creation, Address correspondence to: Shahriar Moossavi, Depart- ment of Internal Medicine ⁄ Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boule- vard, Winston-Salem, NC 27157-1053, or e-mail: smoossav@ wfubmc.edu Seminars in Dialysis—Vol 20, No 5 (September–October) 2007 pp. 459–464 DOI: 10.1111/j.1525-139X.2007.00356.x 459