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steal syndrome&#44; venous hypertension&#44; pseudoaneurysms and thrombosis&#46;&#160; Stenosis and subsequent thrombosis represents the most common complication in this type of vascular access&#46; Between 60&#37; and 90&#37; of them are located in the venous anastomosis or close to it due to intimal hyperplasia secondary to turbulence at the prosthesis-vein interface &#40;caliber discrepancy between the vein and the prosthesis&#44; high flow rate of blood in the anastomosis or periodic exposure to activated blood leaving the dialyzer&#41;<span class="elsevierStyleSup">4-7</span>&#46;</p><p class="elsevierStylePara">The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative &#40;NKF-K&#47;DOQI&#41;<span class="elsevierStyleSup">8</span> guidelines recommend that whatever therapeutic option applied to thrombosed arteriovenous grafts must achieve favorable results in 40&#37; at 3 months for endovascular&#44; or 50&#37; at 6 months and 40&#37; at 1 year for surgical as well as an immediate patency of 85&#37; for any both techniques&#46; Until now&#44; most of the published studies indicate superior results of traditional open surgical techniques &#40;thrombectomy and PTFE extension in a permeable proximal vein&#41; on endovascular procedures&#44; with a significant advantage of the first one&#44; in terms of relative risk&#59; 1&#46;32 at 30 days&#44; 1&#46;34 at 60 days&#44; 1&#46;22 at 90 days and 1&#46;22 at 1 year&#44; respectively<span class="elsevierStyleSup">9</span>&#46;</p><p class="elsevierStylePara">However&#44; since 2002&#44; endovascular treatment of arteriovenous graft thrombosis is offering&#44; at least immediately&#44; promising results<span class="elsevierStyleSup">10-16</span>&#44; this is also a treatment promoted by its less invasiveness and reduced need for hospitalisation&#46; This study evaluates the results of a hybrid treatment &#40;minimally invasive surgery plus endovascular treatment&#41; of arteriovenous graft thrombosis associated to venous anastomotic stenosis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">PATIENTS AND METHOD</span></p><p class="elsevierStylePara">Between 2008 and 2012&#44; 27 consecutive patients underwent urgent surgery &#40;mean age 69&#46;7 years&#44; 52&#37; male&#41; due to arteriovenous graft thrombosis associated to venous anastomotic stenosis&#46; The clinical characteristics of these patients are summarised in Table 1&#46;&#160; The arteriovenous grafts were placed in upper extremity in 74&#46;1&#37; of cases&#46; All prostheses were 6mm PTFE &#40;GORE-TEX<span class="elsevierStyleSup">&#174;</span> Standard-Wall&#41;&#46; The arterial anastomosis was performed latero-terminal in the distal 1&#47;3 of the brachial artery in all cases&#46; The venous anastomosis was performed termino-lateral in the basilic or brachial vein in 58&#46;6&#37;&#44; and termino-terminal in all other cases&#46; In addition&#44; 27&#46;6&#37; of prostheses had already been treated for a thrombotic episode using traditional surgical techniques &#40;thrombectomy and extension to a proximal vein segment&#41;&#46;</p><p class="elsevierStylePara">The mean time between implantation of the arteriovenous graft and the thrombotic episode treated by the hybrid procedure was 370 days&#46; Basically&#44; the technique employed is summarized in the following sequence&#58; 1&#41; under local anesthesia&#44; perform a cutaneal mini-incision over the graft&#44; near the arterial anastomosis in order to allow a comfortable proximal thrombectomy and not interfere usual dialysis puncture points&#59; 2&#41; transverse incision over the graft and proximal and distal thrombectomy using Fogarty balloon&#59; 3&#41; regional heparinization&#59; 4&#41; diagnostic fistulogram through&#160; a 23cm 10F introducer placed across the prosthetic incision&#59; 5&#41; venous stenosis demonstration and catheterization thereof with a guide&#59; 6&#41; exchange to support centimeter guide &#40;MagicTorque<span class="elsevierStyleSup">&#174;</span>&#44; Boston&#41;&#59; 7&#41; measurements taken&#59; 8&#41; self-expandable covered nitinol stent release &#40;Fluency <span class="elsevierStyleSup">&#174;</span>&#44; Bard&#41;&#59; 9&#41; high-pressure balloon angioplasty &#40;Conquest <span class="elsevierStyleSup">&#174;</span>&#44; Bard&#41; at &#62; 20 atm&#59; 10&#41; fistulogram to check results and incision closure of the prosthesis with discontinuous PTFE 6&#47;0 sutures &#40;Figure 1&#41;&#46; No delay was recommended in the use of arteriovenous graft for hemodialysis&#44; once patency was reestablished&#46;</p><p class="elsevierStylePara">All data were collected and analyzed using SPSS statistical software&#44; version 15&#46;0&#46; Patency values were calculated using the Kaplan-Meier method&#44; with log rank statistic to analyze the influence on it of qualitative variables studied&#46; We considered primary patency to be the uninterrupted patency of the arteriovenous graft from the hybrid process described until the end of the follow-up with a functioning or the occurrence of a thrombotic event&#46; In the latter case&#44; and if the permeability of the prosthesis could be restored again using a hybrid process with similar characteristics to the previous one&#44; was added to the new primary patency the interval until the end of trace with a permeable arteriovenous graft or the appearance of a new thrombotic event&#44; considering that extended permeability as secondary patency&#46; All results with a P-value &#60;&#46;05 were considered to be statistically significant&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">Immediate patency &#40;30 days&#41; with possibility of effective hemodialysis was 89&#37;&#46; The average hospital stay associated with the procedure was 1&#46;9 days and there was a total absence of postoperative complications&#46;</p><p class="elsevierStylePara">Primary patency associated with the procedure at 3&#44; 6 and 12 months was 51&#46;9&#37;&#44; 44&#46;4&#37; and 16&#46;2&#37;&#44; respectively&#44; with standard error less than 10&#37; &#40;Figure 2&#41;&#46; Primary patency was not significantly influenced by the location of the arteriovenous graft &#40;upper or lower extremity&#41;&#44; type of venous anastomosis &#40;termino-lateral or termino-terminal&#41;&#44; prior surgical repair or sex&#46;</p><p class="elsevierStylePara">Throughout the follow-up &#40;mean 15 months&#41; 36 new similar procedures were necessary&#44;&#160; in 62&#46;9&#37; of cases&#44; by iterative thrombotic events&#46; Secondary patency after a second procedure was raised to 70&#46;4&#37;&#44; 51&#46;9&#37; and 37&#37;&#44; respectively&#44; with standard error less than 10&#37; &#40;Figure 3&#41;&#46; Stenoses responsible for new thrombotic episodes were located intra-stent in 50&#37; &#40;in the most proximal section&#41; and at the end of the stent without actually affect it in 50&#37;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">Vascular access thrombosis is accompanied by the need to place a central venous catheter to perform hemodialysis&#44; which is associated with high rates of early or late complications&#46; For this reason&#44; it is advisable&#44; whenever possible&#44; an emergency treatment of vascular access thrombosis to preserve it and avoid the need for catheter&#46; This treatment can be basically a surgical rescue and although endovascular procedures are also available&#44; depending on the type of access&#44; and the availability and team expertise<span class="elsevierStyleSup">8&#44;17</span>&#46;</p><p class="elsevierStylePara">Beyond the aforementioned NKF-K&#47;DOQI guidelines&#44; meta-analysis of Green<span class="elsevierStyleSup">9</span>&#44; which reviews of randomized controlled trials published up to 1999 on the treatment of arteriovenous graft thrombosis&#44; concluded that surgical thrombectomy provides primary patency results better than endovascular equivalent&#44; with relative risks &#40;confidence interval 95&#37;&#41; at 30&#44; 60&#44; 90 days and 1 year of 1&#46;31 &#40;1&#46;07&#44; 1&#46;60&#41;&#44; 1&#46;34 &#40;1&#46;13&#44; 1&#46;58&#41;&#44; 1&#46;22 &#40;1&#46;05&#44; 1&#46;40&#41; and 1&#46;22 &#40;1&#46;07&#44; 1&#46;40&#41;&#44; respectively&#44; considering surgical treatment of choice in arteriovenous graft thrombosis&#46; However&#44; more recent studies&#44; such as Tordoir&#44; published in 2009 and based on a an exhaustive literature review regarding endovascular and surgical repair of thrombosed vascular access&#44; reported better results in the application of endovascular techniques &#40;with a mean success rate of 92&#37; and better midterm patency results&#41;&#44; although conclusions were difficult to extrapolate due to the wide variety of techniques used<span class="elsevierStyleSup">18</span>&#46;</p><p class="elsevierStylePara">Indeed&#44; given the variety of indications in applying these procedures &#40;access thrombosis&#44; preventive treatment of stenosis&#41;&#44; the different available techniques &#40;surgical thrombectomy&#44; mechanical thrombectomy&#44; pharmacomechanical thrombectomy&#41;<span class="elsevierStyleSup">9&#44;19-21</span> and the materials used to treat the underlying vascular lesion &#40;simple angioplasty&#44; nitinol stent placement with or without angioplasty&#44; covered stent placement&#41;<span class="elsevierStyleSup">22-26</span>&#44; along with the limited number of cases that are reported and the design of studies&#44; mostly case series&#44; it is very difficult any comparison between different therapeutic modalities&#46; The choice between endovascular and surgical repair therefore is increasingly in the field of controversy&#46; However&#44; given their lower invasiveness&#44; endovascular techniques are assuming an increasingly important role in the treatment of these patients<span class="elsevierStyleSup">9-15&#44;27-30</span>&#46;</p><p class="elsevierStylePara">Of the various reported endovascular techniques&#44; we believe that the hybrid treatment proposed in this study has clear advantages over others&#46; Open surgical thrombectomy through a miniincisional allows&#44; for example&#44; identify other causes of access thrombosis requiring open surgical treatment as those located in the proximal segment of the graft or within the prosthesis&#44; while providing adequate access for endovascular treatment of the proximal stenosis if this turns out to be the cause of the complication&#46; Moreover&#44; the routine use of nitinol covered stents allows the safely&#160; treatment of these stenoses&#44; typically elastic and highly resistant&#44; in areas of anastomotic suture&#44; since a simple high-pressure angioplasty may lead to a rupture in the interface between the arteriovenous graft and vein&#44; or of the vein itself&#46;</p><p class="elsevierStylePara">The recent study by Kakisis et al&#46;<span class="elsevierStyleSup">23</span>&#44; which is probably the one that shares more technical similarities with ours&#44; since they also present a hybrid rescue technique to treat a patient sample with similar clinical characteristics to our own&#44; concluded that thrombectomy associated with angioplasty and implantation of self-expanding nitinol stent is associated with better outcomes that a thrombectomy plus angioplasty alone&#44; showing a 85&#37; primary patency values at 3 months&#44; 63&#37; at 6 months and 49&#37; at 12 months in the stent group&#46; Despite the limitations inherent to a case study with a small sample size and retrospective study design&#44; in our study&#44; the results of this series were more satisfactory than our own&#46; In fact&#44; we only observed competitive patency against Kakisis study or against traditional open surgery when taking into account the secondary patency values&#44; that is&#44; after a second hybrid treatment of arteriovenous graft thrombosis&#46;</p><p class="elsevierStylePara">In summary&#44; although endovascular treatment used is attractive because of its low invasiveness and reduced need for hospitalization&#44; results of patency and costs lead us probably to reserved for those stenoses that are difficult to access surgically&#44; allowing to extend the life of the vascular access when surgical approach is no longer possible&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11756&#95;16025&#95;46791&#95;en&#95;t11511756i&#95;traduccin&#95;de&#95;autora&#95;02&#95;&#46;jpg" class="elsevierStyleCrossRefs"><img src="11756_16025_46791_en_t11511756i_traduccin_de_autora_02_.jpg" alt="Patient characteristics"></img></a></p><p class="elsevierStylePara">Table 1&#46; Patient characteristics</p><p class="elsevierStylePara"><a href="grande&#47;11756&#95;16025&#95;46792&#95;en&#95;f11511756i&#95;traduccin&#95;de&#95;autora&#95;02&#95;&#46;jpg" class="elsevierStyleCrossRefs"><img src="11756_16025_46792_en_f11511756i_traduccin_de_autora_02_.jpg" alt="Diagnostic fistulogram through the introducer placed within the arteriovenous graft&#46; This image displays&#58; a stenosis posterior to the venous anastomosis &#40;A&#41;&#44; placement of the stent at the site of the lesion &#40;B&#41;&#44; stent dilation &#40;C&#41;&#44; and fistulogram demonst"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Diagnostic fistulogram through the introducer placed within the arteriovenous graft&#46; This image displays&#58; a stenosis posterior to the venous anastomosis &#40;A&#41;&#44; placement of the stent at the site of the lesion &#40;B&#41;&#44; stent dilation &#40;C&#41;&#44; and fistulogram demonst</p><p class="elsevierStylePara"><a href="grande&#47;11756&#95;16025&#95;46794&#95;en&#95;f21511756i&#95;traduccin&#95;de&#95;autora&#95;02&#95;&#46;jpg" class="elsevierStyleCrossRefs"><img src="11756_16025_46794_en_f21511756i_traduccin_de_autora_02_.jpg" alt="Primary patency"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Primary patency</p><p class="elsevierStylePara"><a href="grande&#47;11756&#95;16025&#95;46795&#95;en&#95;f31511756i&#95;traduccin&#95;de&#95;autora&#95;02&#95;&#46;jpg" class="elsevierStyleCrossRefs"><img src="11756_16025_46795_en_f31511756i_traduccin_de_autora_02_.jpg" alt="Secondary patency"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Secondary patency</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducci&#243;n&#47;objetivo</span><span class="elsevierStyleBold">&#58;</span> La gu&#237;a de la National Kidney Foundation-Kidney Disease Outcomes Quality Initiative &#40;NKF-K&#47;KDOQI&#41; recomienda que la repermeabilizaci&#243;n de pr&#243;tesis arteriovenosas &#40;AV&#41; para hemodi&#225;lisis trombosadas debe alcanzar resultados favorables en el 40 &#37; a 3 meses si es por t&#233;cnica endovascular&#44; o en el 50 &#37; a 6 meses y el 40 &#37; al a&#241;o si es por un procedimiento quir&#250;rgico&#46; Este estudio eval&#250;a los resultados de un tratamiento h&#237;brido &#40;endovascular y quir&#250;rgico m&#237;nimamente invasivo&#41; de las trombosis de pr&#243;tesis AV asociadas a estenosis anastom&#243;ticas venosas&#46; <span class="elsevierStyleBold">Pacientes y m&#233;todos</span><span class="elsevierStyleBold">&#58;</span> Entre 2008 y 2012 se intervinieron 27 pacientes consecutivos &#40;edad media&#58; 69&#44;7 a&#241;os&#59; 52 &#37; varones&#41; con trombosis de pr&#243;tesis AV &#40;74&#44;1 &#37; extremidad superior&#41; asociadas a estenosis anastom&#243;tica venosa mediante trombectom&#237;a abierta &#40;miniincisi&#243;n en trayecto&#41;&#44; <span class="elsevierStyleItalic">stent</span> cubierto autoexpandible &#40;Fluency<span class="elsevierStyleSup">&#174;</span>&#44; Bard&#41; y angioplastia a alta presi&#243;n &#40;&#62; 20 atm&#41;&#46; <span class="elsevierStyleBold">Resultados&#58;</span> La permeabilidad inmediata con hemodi&#225;lisis eficaz fue del 89 &#37;&#44; con una estancia media de 1&#44;9 d&#237;as y ausencia de complicaciones posoperatorias&#46; La permeabilidad primaria a 3&#44; 6 y 12 meses fue&#44; respectivamente&#44; del 51&#44;9 &#37;&#44; 44&#44;4 &#37; y 16&#44;2 &#37; &#40;seguimiento medio&#58; 15 meses&#41;&#46; La permeabilidad secundaria tras un nuevo episodio tromb&#243;tico y procedimiento de similares caracter&#237;sticas &#40;62&#44;9 &#37; de los casos&#41; fue del 70&#44;4 &#37;&#44; 51&#44;9 &#37; y 37 &#37;&#44; respectivamente&#46; <span class="elsevierStyleBold">Conclusiones&#58;</span> A pesar de ser seguro y poco invasivo&#44; este tratamiento h&#237;brido de las trombosis de pr&#243;tesis AV asociadas a estenosis anastom&#243;ticas venosas solo alcanza resultados competitivos respecto a la cirug&#237;a abierta tras un segundo procedimiento iterativo&#46; Debido a esto y a su coste&#44; esta t&#233;cnica deber&#237;a reservarse para estenosis a las que sea dif&#237;cil acceder quir&#250;rgicamente&#46;</p>"
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