In access challenged patients, LEAVG and HeRO offer similar rates of secondary patency, infection, and all-cause mortality. The LEAVG required fewer interventions to maintain patency, and the HeRO maintains the benefit of utilizing the upper extremity site of venous drainage. In our practice, we prefer the HeRO to LEAVG, especially in patients with peripheral arterial disease and in the obese population, because it preserves lower extremity access options.

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Background: No independent comparisons, with midterm follow-up, of standard arteriovenous grafts (SAVGs) and immediate-access arteriovenous grafts (IAAVGs) exist. The goal of this study was to compare “real-world” performance of SAVGs and IAAVGs. Methods: Consecutive patients who underwent placement of a hemodialysis graft between November 2014 and April 2016 were retrospectively identified from the electronic medical record and Vascular Quality Initiative database at two tertiary centers. Only primary graft placements were included for analysis. Patients were divided into two groups based on the type of graft implanted. Patients’ comorbidities, graft configuration, operative characteristics, and follow-up were collected and analyzed with respect to primary and secondary patency. Additional outcomes included graft-related complications, time to first cannulation, time to tunneled catheter removal, catheter-related complications, and overall survival. Patency was determined from the time of the index procedure; χ2, Kaplan-Meier, and Cox regression analyses were used, with the P value set as significant at < .05. Results: There were 210 grafts identified, 148 SAVGs and 62 IAAVGs. At baseline, the patients’ characteristics were similar between groups, except for a greater prevalence of preoperative central venous occlusions in the IAAVG group (16.3% vs6.8%; P < .04). Of the IAAVG group, 50 were Acuseal (W. L. Gore & Associates, Flagstaff, Ariz) and 12 were Flixene (Atrium Medical Corporation, Hudson, NH). Primary patency was similar at both 1 year (SAVG, 39.4%; IAAVG, 56.7%; P = .4) and 18 months (SAVG, 29.0%; IAAVG, 43.7%; P = .4). Secondary patency was similar at 1 year (SAVG, 50.7%; IAAVG, 52.1%; P = .73) and 18 months (SAVG, 42.3%; IAAVG, 46.3%; P = .73). Overall survival was 48% at 24 months. IAAVG patients required fewer overall additional procedures to maintain patency (mean number of procedures, 0.99 for SAVGs vs 0.61 for IAAVGs; P = .025). There was no difference in occurrence of steal syndrome (SAVG, 6.8%; IAAVG, 8.1%; P = .74) or graft infection (SAVG, 19.0%; IAAVG, 12.0%; P = .276). Seventy-five percent of all grafts were successfully cannulated, with shorter median time to first cannulation in the IAAVG group (6 days; interquartile range [IQR], 1–19 days) compared with the SAVG group (31 days; IQR, 26–47 days; P < .01). Of all pre-existing catheters, 65.75% were removed, with a shorter median time until catheter removal in the IAAVG cohort at 34 days (IQR, 22–50 days) vs 49 days (IQR, 39–67 days) in the SAVG group (P < .01). Catheter-related complications occurred less frequently in the IAAVG group (16.4% vs 2.9%; P < .045). Conclusions: IAAVGs allow earlier cannulation and tunneled catheter removal, thereby significantly decreasing catheter-related complications. Patency and infection rates were similar between SAVGs and IAAVGs, but fewer secondary procedures were performed in IAAVGs.

Real-world experience with novel arteriovenous access grafts is consistent with results from industry-sponsored studies. Early cannulation of immediate-access grafts can be successfully performed in a wide variety of patients. However, prolonged catheter dwell times persist despite increased rates of successful early-graft cannulation. Further study of methods for promoting catheter removal in this patient population is warranted.

WHAT THIS PAPER ADDS Evidence regarding the management of thrombosed haemodialysis grafts (arteriovenous grafts [AVGs]) is limited to outcomes after open surgery or purely endovascular techniques. Hybrid interventions combining open surgical thrombectomy and endoluminal angioplasty and stenting of the venous anastomotic lesion have been investigated only minimally. This single centre retrospective study aimed to describe outcomes after hybrid treatment of thrombosed AVGs. Technical success and patency were compared with that of open surgery (thrombectomy and revision of venous anastomosis). No differences were identified.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. KaplaneMeier curves were used to analyse time from thrombectomy to first reintervention (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 AE 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 ¼ .71). Secondary patency was 45.1% and 38.5% for open and hybrid treatment, respectively, at 12 months (p ¼ .87). An existing VA stent was predictive of graft abandonment (hazard ratio 4.4, 95% confidence interval 1.2e16.0; p ¼ .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.

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A 66-year-old man was treated for disabling right leg calf claudication with angioplasty and stenting of a chronically occluded superficial femoral artery. During attempted subintimal passage, the guidewire tracked extralumenally, which was not recognized, but it was successfully redirected into the true lumen distal to the occlusion with the use of the Outback (Cordis Endovascular, Miami Lakes, Fla) re-entry device. A bare metal nitinol stent was initially deployed extralumenally in the perivascular soft tissue. The patient returned for reintervention 9 days later complaining of pain and discoloration of the popliteal space. Duplex evaluation of the superficial femoral artery revealed a pseudoaneurysm, and Viabahn stent grafts (W. L. Gore & Assoc, Flagstaff, Ariz) were successfully deployed to produce an endovascular percutaneous prosthetic bypass.

Objectives:The mechanochemical ablation catheter utilizes a liquid sclerosant (sodium tetradecyl sulfate or aethoxysclerol) and a mechanical rotating wire to accomplish occlusion of incompetent GSV or SSV. The procedure does not require tumescence and is performed with local anesthesia at the access site only. It can be characterized as mechanically enhanced sclerotherapy performed in an office setting.Methods: 30 GSVs in 29 patients underwent micropuncture access with local anesthesia only in this first in man study. Through a 5 Fr. micropuncture sheath the MOCA catheter was passed to a position 2 cms. from the saphenofemoral junction. Catheter wire rotation was begun for 3 seconds at 3500 rpm. With the wire rotating, infusion of sclerosant (1.5% sodium tetradecyl sulfate) and catheter pullback (1.5 mm./sec) was begun simultaneously. A total of 12 cc. of sclerosant was used for each GSV. The procedure doesnot require the instillation of tumescent anesthesia.Results: At 1 year 29 of 30 GSV were successfully treated. Primary closure rate 96.7%. At 2 years 24 patients were examined. All 24 remain closed. No DVT, nerve or skin injury occurred. Average total procedure time was 14 minutes. Catheter treatment time was 5 minutes.The MOCA technique has been modified; lower volumes are now used based on diameter and length of vein treated. Catheter placement is closer to SFJ (1 cm.).Conclusions: MOCA is as efficacious at 2 years as current endothermal techniques without the need of tumescent anesthesia and more effective than reported results of foam sclerotherapy of the GSV. It is another alternative modality for most incompetent GSVs and SSVs.