SingVaSC, Singapore Vascular Surgical Collaborative, Singapore; Faculty of Medicine, University of New South Wales, Sydney, Australia.
SingVaSC, Singapore Vascular Surgical Collaborative, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
J Vasc Surg. 2019 Jun;69(6):1976-1988.e7. doi: 10.1016/j.jvs.2018.10.102.
The major pitfall of arteriovenous grafts (AVGs) for hemodialysis patients is thrombosis and occlusion. Prompt intervention with either surgical or endovascular therapy to salvage the vascular access is crucial in maintaining effective hemodialysis. The purpose of this systematic review and meta-analysis was to assess and compare the efficacy of open surgical vs wholly endovascular therapy for the treatment of thrombosed AVGs.
This review was conducted according to the PRISMA guidelines. Relative risks **(RRs) and pooled proportions for both primary and secondary outcomes were calculated.
A total of eight randomized, controlled trials and two retrospective cohort studies were included, comprising 806 (63%) and 466 (37%) participants in the surgical and wholly endovascular treatment arms respectively. There were no significant differences between endovascular and surgical therapy in the 30-, 60-, and 90-day primary nonpatency rates. However, endovascular therapy reported a significantly higher 1-year primary nonpatency rate (rate ratio [RR], 1.22; 95% confidence interval [CI], 1.13-1.33; P < .01) and the 2-year primary nonpatency rate (RR, 1.26; 95% CI, 1.10-1.45; P < .01) as compared with surgical therapy. Similarly, the endovascular arm had a higher pooled proportion of primary nonpatency of 87.7% (95% CI, 81.5%-92.9%; P = .297), as compared with the surgical arm (72.1%; 95% CI, 66.4%-77.4%; P = .289). In terms of secondary nonpatency rates, there were no significant differences between endovascular and surgical procedures at 30, 60, and 90 days. Endovascular procedures reported a significantly higher technical failure rate as compared with surgical thrombectomy (RR, 1.58; 95% CI, 1.06-2.37; P = .03). There was no significant difference in terms of minor and major complications.
Our data suggest that, for thrombectomy of AVGs, wholly endovascular therapy seems to be inferior to open surgery plus adjuncts based on the long-term patency and technical failure rates. However, further research in the form of a well-conducted randomized trial is warranted to establish a firmer conclusion.
动静脉移植物（AVG）对血液透析患者的主要问题是血栓形成和闭塞。及时进行手术或血管内治疗以挽救血管通路对于维持有效的血液透析至关重要。本系统评价和荟萃分析的目的是评估和比较开放手术与完全血管内治疗治疗血栓形成的 AVG 的疗效。
本综述按照 PRISMA 指南进行。计算了主要和次要结局的相对风险（RR）和汇总比例。
共纳入 8 项随机对照试验和 2 项回顾性队列研究，其中手术组和完全血管内治疗组分别纳入 63%（806 例）和 37%（466 例）的参与者。在 30、60 和 90 天的主要通畅率方面，血管内治疗与手术治疗之间无显著差异。然而，血管内治疗报告的 1 年主要通畅率明显较高（率比[RR]，1.22；95%置信区间[CI]，1.13-1.33；P<.01）和 2 年主要通畅率（RR，1.26；95% CI，1.10-1.45；P<.01）与手术治疗相比。同样，血管内组的主要通畅率为 87.7%（95% CI，81.5%-92.9%；P=.297），明显高于手术组（72.1%；95% CI，66.4%-77.4%；P=.289）。在次要通畅率方面，血管内治疗与手术治疗在 30、60 和 90 天无显著差异。与手术血栓切除术相比，血管内治疗报告的技术失败率明显更高（RR，1.58；95% CI，1.06-2.37；P=.03）。在轻微和严重并发症方面无显著差异。
我们的数据表明，对于 AVG 的血栓切除术，基于长期通畅率和技术失败率，完全血管内治疗似乎不如开放手术加辅助治疗。然而，需要进行精心设计的随机试验进一步研究，以得出更确定的结论。
