Mechanical Thrombectomy Versus Pharmacomechanical Thrombolysis in Arteriovenous Grafts: A Review

Arteriovenous grafts remain an essential hemodialysis access modality for patients with end-stage kidney disease, but their high incidence of thrombosis makes thrombotic occlusion a major cause of access dysfunction and permanent access loss. Mechanical thrombectomy and pharmacomechanical thrombolysis have consequently become the principal minimally invasive strategies for restoring graft function, largely replacing open surgical thrombectomy in contemporary practice. Although both endovascular approaches achieve high immediate technical success, neither reliably overcomes the poor long-term durability of thrombosed grafts largely because thrombosis is usually precipitated by an underlying anatomic stenosis that must be identified and treated. Available comparative evidence indicates that mechanical thrombectomy and pharmacomechanical thrombolysis provide broadly similar technical success and short-term patency, with no consistently demonstrated superiority of either declotting approach as a standalone strategy. However, durability after either salvage technique depends primarily on adjunctive treatment of the inciting venous anastomotic stenosis, where randomized data show that stent grafts and, in selected lesions, drug-coated balloons yield superior patency over plain balloon angioplasty. Methodological heterogeneity, small study populations, variable procedural techniques, and inconsistent definitions of patency limit the certainty and generalizability of all of these findings. This review compares the procedural mechanisms, efficacy, complication profiles, and predictors of patency associated with mechanical thrombectomy and pharmacomechanical thrombolysis, evaluates their implications for clinical decision-making, examines current guideline recommendations, and identifies priorities for more rigorous comparative research.