Results of Aggressive Graft Surveillance and Endovascular Treatment on Secondary Patency Rates of Vectra Vascular Access Grafts

Stavros K. Kakkos, Roger Haddad and Georges Haddad
Vascular surgery, Henry Ford Hospital, Detroit, MI

Objective: The aim of the present study was to determine the effect of an aggressive graft surveillance and endovascular treatment protocol on secondary patency rates of a polyetherurethaneurea vascular access graft, specially designed to provide early access and rapid hemostasis.
Methods: One hundred and ninety Vectra^® Vascular Access Grafts (C. R. Bard, Inc., Murray Hill, NJ) were placed in 176 patients (78 females and 98 males, mean age 61.7 years). There were 41 forearm grafts, 145 upper arm grafts and 4 thigh grafts. Graft surveillance was performed by using clinical and hemodialysis parameters to detect a failing/failed graft and followed by endovascular treatment, rheolytic thrombectomy (AngioJet, Possis Medical Inc., Minneapolis, MN) and/or angioplasty ± stenting of the anatomical lesion (outflow, draining or central veins).
Results: Hemodialysis started after a median of 15.5 days, as soon as from the day of the operation in some cases. Bleeding complications occurred in 6 patients (3.2%), venous hypertension in 7 (3.7%), steal syndrome in 2 (1.1%), neurological complications in 2 (1.1%), while late infection (range 2.7-14.6 months) was seen in 6 patients (3.2%). Thrombectomy and angioplasty (median number of sessions 1, interquartile range 1-2) was performed in 43 grafts. Isolated angioplasty, not associated with thrombosis (median number of sessions 1, interquartile range 1-2), was performed in 50 grafts. These interventions increased primary patency from 69% and 63% at 12 and 18 months respectively to a secondary patency rate of 86% (p<0.001, Figure). Taking into account grafts removed for late infection, usage rate dropped to 83% and 81%, at 12 and 18 months respectively. Age, gender, history of previous vascular access procedures, graft site and side had no effect on primary or secondary patency rates, although there was a trend towards better primary patency in males (74% and 67% at 12 and 18 months, respectively, compared to 64% and 56% for females, p=0.06) and secondary patency for upper arm grafts (87% at 12 and 18 months compared to 78% for forearm grafts, p=0.09).
Conclusions: Aggressive graft surveillance and endovascular treatment increases significantly secondary patency rates of Vectra vascular access grafts. Excellent results were maintained at 18 months, while longer follow-up will determine the effectiveness of this policy.