Fistulogam following Arteriovenous(AV) Dialysis Graft Thrombectomy should be Mandatory

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shakthi kumar, bs, krishna M. jain, md, shikha jain, ba, john S. munn, md, mark C. rummel, md.
kalamazoo center for medical studies,michigan state college of human medicine, kalamazoo, MI, USA.

Performing an intraoperative fistulogram following thrombectomy of an AV dialysis graft is often left to the discretion of the surgeon. Our hypothesis is that a significant number of patients have an underlying anatomic abnormality, resulting in thrombosis of the graft, which could be detected by intraoperative fistulogram. To test this hypothesis we looked at thrombectomies carried out between January 1, 2000 and July 31, 2005. We reviewed the findings of fistulograms when they were performed. A stenosis of greater than 70% was determined to be significant and was repaired. Demographic data and risk factors were collected.
A total of 61 patients, 32 men and 29 women, underwent a total of 192 thrombectomies (3.15 thrombectomies per patient). Thrombectomy was carried out in the forearm in 109, upper arm in 64 or thigh in 19. Group I consists of 99 procedures when routine fistulogram following thrombectomy was performed. In this group a significant lesion was identified and repaired in 77 (78%). Patency was 4.32 months when repair was carried out versus 4.95 months when no repair was needed. (p=NS) Group II consists of 93 procedures entailing thrombectomy without fistulogram. Revision was carried out in 53 (57%) based on the operative findings or suspicion of the surgeon. When revision was carried out without fistulogram (n=53), average patency was 5.6 months and without revision (n = 40) patency was 2.9 months (p=0.047), suggesting missed underlying stenosis. A significant abnormality was more likely to be encountered by routine fistulography than surgical exploration alone 78% versus 57% (p < 0.01). . Risk factors including tobacco use, sex, hypertension, diabetes, high cholesterol, coronary disease and peripheral vascular disease showed no statistically significant different correlation with presence of stenosis at the time of thrombectomy.
Outcome
We conclude that routine fistulogram following thrombectomy of an AV dialysis graft increases the likelihood of identifying a significant stenosis. Revision of the graft increases the longevity of the graft. We recommend routine use of fistulogram during thrombectomy.

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