Hemodialysis arteriovenous graft dysfunction and failure
- Michael Allon, MD
Michael Allon, MD
- Professor of Medicine
- University of Alabama at Birmingham
- Ivan D Maya, MD, FACP
Ivan D Maya, MD, FACP
- Associate Professor of Medicine
- University of Central Florida
- Section Editors
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
- David L Cull, MD
David L Cull, MD
- Section Editor — Arteriovenous Access
- Clinical Professor, Department of Surgery
- University of South Carolina School of Medicine
Hemodialysis requires access to blood vessels capable of providing rapid extracorporeal blood flow. These requirements are currently best met by arteriovenous (AV) access. Although AV fistulas are preferred for hemodialysis, AV grafts are sometime necessary, but have higher failure rates. Failure can be related to stenotic lesions affecting the feeding arteries, within the graft or in the draining veins, including the central veins. AV graft failure can also be related to complications such as pseudoaneurysm or other conditions that lead to sacrifice of the graft.
The treatment of AV graft failure due to venous stenosis and thrombotic complications are reviewed here. Issues surrounding clinical monitoring and surveillance of AV grafts to prevent thrombosis are presented in detail separately. (See "Physical examination of the arteriovenous graft" and "Monitoring and surveillance of hemodialysis arteriovenous grafts to prevent thrombosis".)
The management of stenosis and thrombosis of hemodialysis AV fistulas are discussed elsewhere. (See "Maturation and evaluation of the newly created hemodialysis arteriovenous fistula" and "Failure of the mature hemodialysis arteriovenous fistula".)
AV GRAFT DYSFUNCTION AND FAILURE
Incidence — When stenotic lesions (primarily neointimal hyperplasia) develop in association with an AV graft, it often results in thrombosis. More than 90 percent of thrombosed AV grafts have a stenotic lesion, suggesting that such an anatomic abnormality is required for AV graft thrombosis. The majority of AV grafts develop stenosis or thrombosis. Among 649 patients with new AV grafts enrolled in the Dialysis Access Consortium (DAC) Study, 77 percent developed stenosis or thrombosis within the first year . Similarly, among 201 patients with a new AV graft enrolled in the Fish Oil Inhibition of Stenosis in Hemodialysis Grafts (FISH) Study, 62 percent developed stenosis or thrombosis within one year .
Immediate — Immediate failure of AV grafts following their creation is usually due to technical issues, either from severe arterial calcification that precludes completing the anastomosis, or due to thrombosis in the immediate postoperative period. A large, single-center study observed immediate failure in 5.8 percent of upper extremity AV grafts and 12.7 percent of thigh grafts .
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- AV GRAFT DYSFUNCTION AND FAILURE
- - Immediate
- - Delayed
- CLINICAL PRESENTATION AND EVALUATION
- Abnormalities on clinical monitoring
- Further evaluation and treatment
- - Associated stenotic lesions
- TREATMENT OF STENOSIS
- Preemptive angioplasty
- Surgical revision
- TREATMENT OF THROMBOSIS
- Percutaneous thrombolysis
- Surgical thrombectomy
- Overall patency following treatment of stenosis
- Overall patency following treatment of thrombosis
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS