Anti-platelet therapy in graft thrombosis: Results of a prospective, randomized, double-blind study

Sreedhara, Rajanna; Himmelfarb, Jonathan; Lazarus, J. Michael; Hakim, Raymond M.

doi:10.1038/ki.1994.192

Cited by 191 publications

(152 citation statements)

References 39 publications

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“…A small randomized clinical trial reported that dipyridamole with or without aspirin, but not aspirin alone, reduced graft thrombosis. 8 However, larger studies of aspirin alone or in combination with another anti-platelet agent have reported trends for aspirin to improve graft patency. 9 -11 The Dialysis Outcomes and Practice Patterns Study (DOPPS) found that treatment with aspirin was associated with a 16% (P ϭ 0.069) reduction in the adjusted relative risk for loss of primary graft patency and a 30% (P Ͻ 0.001) lower risk of loss of cumulative graft patency.…”

Section: Discussionmentioning

confidence: 99%

Use of Aspirin Associates with Longer Primary Patency of Hemodialysis Grafts

Dixon¹,

Beck²,

Dember³

et al. 2011

Journal of the American Society of Nephrology

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Extended-release dipyridamole plus low-dose aspirin (ERDP/ASA) prolongs primary unassisted graft patency of newly created hemodialysis arteriovenous grafts, but the individual contributions of each component are unknown. Here, we analyzed whether use of aspirin at baseline associated with primary unassisted graft patency among participants in a randomized trial that compared ERDP/ASA and placebo in newly created grafts. We used Cox proportional hazards regression, adjusting for prespecified baseline comorbidities and covariates. Of all participants, 43% reported use of aspirin at baseline; of these, 82% remained on nonstudy aspirin (i.e., excluding ERDP/ASA) at 1 year. After 1 year of follow-up, the incidence of primary unassisted patency among participants using aspirin at baseline was 30% (95% CI: 24 to 35%) and among those not using aspirin was 23% (95% CI: 18 to 27%). Use of aspirin at baseline associated with a dose-dependent prolongation of primary unassisted graft patency that approached statistical significance (adjusted HR, 0.83; 95% CI: 0.68 to 1.01; P ϭ 0.06). Use of aspirin at baseline did not associate with prolongation of cumulative graft patency or participant survival. In conclusion, use of aspirin associates with a trend toward longer primary unassisted patency of newly placed hemodialysis grafts similar to that observed for ERDP/ASA.

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Section: Discussionmentioning

confidence: 99%

Use of Aspirin Associates with Longer Primary Patency of Hemodialysis Grafts

Dixon¹,

Beck²,

Dember³

et al. 2011

Journal of the American Society of Nephrology

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“…In both the univariate and multivariable analyses, ASA use was associated with a decrease in the risk of graft thrombosis. Sreedhara et al (39) conducted a randomized trial comparing ASA to dipyridamole alone, ASA plus dipyridamole, and placebo and compared time to thrombosis. ASA was associated with an increased the risk of thrombosis (relative risk, 1.99; P ϭ 0.18) in incident grafts versus the protective effect associated with use of dipyridamole (relative risk, 0.35; P ϭ 0.02).…”

Section: Discussionmentioning

confidence: 99%

Regular Monitoring of Access Flow Compared with Monitoring of Venous Pressure Fails to Improve Graft Survival

Moist¹,

Churchill²,

House³

et al. 2003

Journal of the American Society of Nephrology

191

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ABSTRACT. Regular vascular access blood flow (Qa) surveillance is recommended to detect graft stenosis; however, there is little evidence that monitoring and correcting with angioplasty improves graft survival. This blinded, randomized, controlled trial of 112 patients studied time to graft thrombosis and graft loss, comparing monthly Qa plus standard surveillance (dynamic venous pressure and physical examination) (treatment group) to standard surveillance alone (control group). Only the treatment group was referred for angiogram if Qa <650 ml/min or a 20% decrease in Qa from baseline. Percutaneous angioplasty was performed for stenosis >50%. The rate of graft thrombosis per patient-year at risk was 0.41 and 0.51 in the control and treatment groups, respectively. Fifty-one interventions (0.93/patient-years at risk) were performed in the treatment group versus 31 interventions (0.61/patient-years at risk) in the control group. There was no difference in time to graft loss (P = 0.890). In a multivariate analysis, aspirin (ASA) therapy at baseline was associated with an 84% reduction in risk of graft thrombosis (odds ratio [OR], 0.14; P = 0.002). Higher baseline Qa (OR, 0.84; P = 0.05) and longer interval since graft insertion (OR, 0.97; P = 0.07) were associated with a decrease in graft thrombosis. Results reveal that graft surveillance that uses Qa increases the detection of stenosis, compared with standard surveillance; however, intervention with angioplasty does not improve the time to graft thrombosis or time to graft loss. E-mail: louise.moist@lhsc.on.ca

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“…In a single-center, double-blinded RCT, dipyridamole decreased AVG thrombosis by approximately 50% (30). A much larger, multicenter, double-blinded RCT observed that aspirin plus long-acting dipyridamole improved primary unassisted AVG survival by approximately 18% (31).…”

Section: Antiplatelet Agentsmentioning

confidence: 99%

A Patient with Recurrent Arteriovenous Graft Thrombosis

Allon¹

2015

Clinical Journal of the American Society of Nephrology

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Arteriovenous grafts (AVGs) are prone to frequent thrombosis that is superimposed on underlying hemodynamically significant stenosis, most commonly at the graft-vein anastomosis. There has been great interest in detecting AVG stenosis in a timely fashion and performing preemptive angioplasty, in the belief that this will prevent AVG thrombosis. Three surveillance methods (static dialysis venous pressure, flow monitoring, and duplex ultrasound) can detect AVG stenosis. Whereas observational studies have reported that surveillance with preemptive angioplasty substantially reduces AVG thrombosis, randomized clinical trials have failed to confirm such a benefit. There is a high frequency of early AVG restenosis after angioplasty caused by aggressive neointimal hyperplasia resulting from vascular injury. Stent grafts prevent AVG restenosis better than balloon angioplasty, but they do not prevent AVG thrombosis. Several pharmacologic interventions to prevent AVG failure have been evaluated in randomized clinical trials. Anticoagulation or aspirin plus clopidogrel do not prevent AVG thrombosis, but increase hemorrhagic events. Treatment of hyperhomocysteinemia does not prevent AVG thrombosis. Dipyridamole plus aspirin modestly decreases AVG stenosis or thrombosis. Fish oil substantially decreases the frequency of AVG stenosis and thrombosis. In patients who have exhausted all options for vascular access in the upper extremities, thigh AVGs are a superior option to tunneled internal jugular vein central vein catheters (CVCs). An immediate-use AVG is a reasonable option in patients with recurrent CVC dysfunction or infection. Tunneled femoral CVCs have much worse survival than internal jugular CVCs.Clin J Am Soc Nephrol 10: 2255-2262, 2015. doi: 10.2215/CJN.00190115 Patient PresentationThe following vignette illustrates the numerous challenges in optimizing arteriovenous graft (AVG) patency in hemodialysis patients. A 28-year-old woman initiated peritoneal dialysis when she developed ESRD because of focal glomerular sclerosis. She was hospitalized with an intracerebral bleed caused by a ruptured aneurysm 1.5 years later. A ventricular-peritoneal shunt was placed to treat hydrocephalus, and she was anticoagulated with warfarin to keep the shunt patent. Because of residual left-sided weakness and inadequate family support, she was no longer able to perform peritoneal dialysis. A tunneled central vein catheter (CVC) was placed in the right internal jugular vein, and she was switched to maintenance hemodialysis. A left forearm arteriovenous fistula (AVF) clotted 2 weeks after its creation. A subsequent looped left upper-arm AVG was successfully cannulated 5 weeks after its creation. It clotted four times during the ensuing 6 months and was treated each time by an interventional radiologist or nephrologist, who performed percutaneous thrombectomy, in conjunction with angioplasty of a venous anastomotic stenosis. The patient resumed hemodialysis with an internal jugular CVC when the AVG failed. A right radiocephalic AV...

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Anti-platelet therapy in graft thrombosis: Results of a prospective, randomized, double-blind study

Cited by 191 publications

References 39 publications

Use of Aspirin Associates with Longer Primary Patency of Hemodialysis Grafts

Use of Aspirin Associates with Longer Primary Patency of Hemodialysis Grafts

Regular Monitoring of Access Flow Compared with Monitoring of Venous Pressure Fails to Improve Graft Survival

A Patient with Recurrent Arteriovenous Graft Thrombosis

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