In one multicenter prospective randomized study, Haskal et al [63] demonstrated superior patency rates following the treatment of a stenosis in an AVG using a stent graft versus PTA with patency rates at 12 months of 47.6% versus 24.8% and at 24 months of 26.9% versus 13.5%, respectively. Surgical Consultation Multidisciplinary care in support of the maintenance of hemodialysis access are critical in achieving optimal patient outcomes [64]. According to SIR Quality Improvement Guidelines, endovascular management has emerged as the preferred alternative to open surgery as first-line therapy for dialysis access dysfunction or thrombosis [7]. However, vascular surgery consultation for possible revision or creation of a new fistula should be considered if >2 interventions for dialysis access dysfunction occur within a 3-month period or after a clinical failure of an endovascular treatment [7]. Vascular surgery consultation for access revision may be performed if thrombosis of the access occurs >2 times within a single month, or if recurrence of a correctable stenosis is delineated in the circuit. In patients with recurrent occlusions of their vascular access, hypercoagulability testing ought to be considered [65]. While endovascular interventions are often performed in the setting of suspected stenosis of the vascular access, surgical revision remains a viable option. Multiple nonrandomized prospective and retrospective studies have shown that while surgical revision has significantly higher postintervention primary patency rates when compared to endovascular intervention, repeat endovascular interventions can extend the life of the AVF or AVG [66-71]. Placement of a New Tunneled Dialysis Catheter The KDOQI guidelines suggest that it is preferable for patients requiring hemodialysis to utilize an AV access (AVF or AVG) as opposed to a CVC, whenever possible.
Dialysis Fistula Malfunction. In one multicenter prospective randomized study, Haskal et al [63] demonstrated superior patency rates following the treatment of a stenosis in an AVG using a stent graft versus PTA with patency rates at 12 months of 47.6% versus 24.8% and at 24 months of 26.9% versus 13.5%, respectively. Surgical Consultation Multidisciplinary care in support of the maintenance of hemodialysis access are critical in achieving optimal patient outcomes [64]. According to SIR Quality Improvement Guidelines, endovascular management has emerged as the preferred alternative to open surgery as first-line therapy for dialysis access dysfunction or thrombosis [7]. However, vascular surgery consultation for possible revision or creation of a new fistula should be considered if >2 interventions for dialysis access dysfunction occur within a 3-month period or after a clinical failure of an endovascular treatment [7]. Vascular surgery consultation for access revision may be performed if thrombosis of the access occurs >2 times within a single month, or if recurrence of a correctable stenosis is delineated in the circuit. In patients with recurrent occlusions of their vascular access, hypercoagulability testing ought to be considered [65]. While endovascular interventions are often performed in the setting of suspected stenosis of the vascular access, surgical revision remains a viable option. Multiple nonrandomized prospective and retrospective studies have shown that while surgical revision has significantly higher postintervention primary patency rates when compared to endovascular intervention, repeat endovascular interventions can extend the life of the AVF or AVG [66-71]. Placement of a New Tunneled Dialysis Catheter The KDOQI guidelines suggest that it is preferable for patients requiring hemodialysis to utilize an AV access (AVF or AVG) as opposed to a CVC, whenever possible.