Management of vascular graft stenosis in a patient with recurrent thrombosis

venous anastomosis stenosis with thrombosis

Challenge

  • Right brachial artery to axillary vein ePTFE was placed but developed a venous anastomosis stenosis with thrombosis of the graft at 13 months post creation (see image above)
  • Relevant patient history
    • 84-year-old end-stage renal disease patient with a history of recurrent thrombosis and stenosis of ePTFE grafts
    • Left arm graft was dialyzed for 23 months before it was abandoned after three episodes in two months of recurrent thrombosis attributed to venous anastomosis stenosis and managed by balloon angioplasty

Image courtesy of Daniel V. Patel, M.D. Used with permission.

endovascular thrombectomy

Procedure

  • An endovascular thrombectomy of the right arm graft was performed. Antegrade and retrograde access was obtained directly through the ePTFE graft.
  • A pullback angiogram confirmed venous anastomosis stenosis, resulting in graft thrombosis
  • Heparin was administered and angioplasty performed. Further maceration of the graft thrombus, EDWARDS FOGARTY® Catheter clearance of the arterial plug, and clot removal with thromboaspiration was performed.
  • With flow restored to the graft, the graft remained pulsatile with a weak thrill
  • Stenosis was persistent and observed at the graft venous anastomosis
  • An 8 mm x 5 cm GORE® VIABAHN® Endoprosthesis was placed at the venous anastomosis resulting in restoration of brisk flow and strong thrill in access, with resolution of recoil

Images courtesy of Daniel V. Patel, M.D. Used with permission.

secondary patency

Result

  • At 60-months postplacement, the GORE® VIABAHN® Endoprosthesis has maintained secondary patency without any further episodes of thrombosis
  • The patient has required periodic intra-graft angioplasty on average two to three times per year

Images courtesy of Daniel V. Patel, M.D. Used with permission.

Case Takeaways

  • In this case, balloon angioplasty management of the previous left arm graft ultimately resulted in graft failure and recurrent thrombosis at just under two years
  • At six years the right arm graft has maintained significantly longer secondary patency than the original left arm graft, with no further episodes of graft thrombosis after placement of the GORE® VIABAHN® Endoprosthesis at the venous anastomosis
  • The GORE® VIABAHN® Endoprosthesis is an excellent option for management of the venous anastomosis of AV grafts versus balloon angioplasty, as demonstrated in the Gore REVISE Clinical Study1

In the Gore REVISE Clinical Study, the GORE® VIABAHN® Endprosthesis lowered the mean number of interventions over two years by 40% in thrombosed grafts2

EDWARDS and FOGARTY® are trademarks of Edwards Lifesciences Corporation.

The outcomes and observations reported are based on individual case experience and the patients treated. The steps described here may not be complete, and are not intended to be a replacement for the Instructions for Use or the education, training and professional judgment of Healthcare Providers. Healthcare Providers remain solely responsible for making decisions about patient care and the use of medical technologies.

1. Vesely T, DaVanzo W, Behrend T, Dwyer A, Aruny J. Balloon angioplasty versus Viabahn stent graft for treatment of failing or thrombosed prosthetic hemodialysis grafts. Journal of Vascular Surgery 2016; 64(5):1400-1410.e1. http://www.sciencedirect.com/science/article/pii/S0741521416301756

2. Mohr BA, Sheen AL, Roy-Chaudhury P, Schultz SR, Aruny JE; REVISE Investigators. Clinical and economic benefits of stent grafts in dysfunctional and thrombosed hemodialysis access graft circuits in the REVISE Randomized Trial. Journal of Vascular & Interventional Radiology 2018;30(2):203-211.e4.

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