Declotting, maintenance, and avoiding procedural complications of native arteriovenous fistulae

A promising method for the salvage of thrombosed native hemodialysis fistulas: percutaneous ultrasound-guided thrombolytic injection

Background/aim

It was aimed to describe the technical aspects and outcomes of percutaneous ultrasound-guided recanalization of thrombosed hemodialysis fistulas by thrombolytic injection.

Materials and methods

A retrospective review was performed on patients with thrombosed native hemodialysis fistula who were treated using the percutaneous ultrasound-guided thrombolytic agent injection technique at the interventional radiology department. A total of 17 patients [7 women (41.2%) and 10 men (58.8%)] were included in this study. All of the data, including demographic information and clinical findings, were obtained from the patients’ medical records and follow-up form of the procedure.

Results

The mean fistula age was 5.6 years (range: 1–15 years). The mean diameter of the thrombosed segment was 5.53 cm (2–10 cm). Localization of the thrombi was in the aneurysmal segment at the level of needle insertion in 64.7% (n: 11) of patients, while it was on the venous side of the anastomosis in 35.3% (n: 6). The mean dose of tissue plasminogen activator (tPA) used in all of the sessions was 8.88 mg (5–17 mg). Overall technical success after all of the administrations was 100% and clinical success was 94.1%.

Conclusion

Percutaneous ultrasound-guided thrombolytic injection in native hemodialysis fistulas is a rapid, practical, repeatable treatment method that is received on an outpatient basis with low risk of bleeding, and prevents unnecessary endovascular interventions or surgical operations.

Long-term durability of Oakes salvage procedure to preserve Brescia-Cimino arteriovenous fistula

BACKGROUND

In 2002, Oakes et al described a novel procedure designed to salvage the distal cephalic venous outflow of a Brescia-Cimino fistula by placing a prosthetic graft between the brachial artery in the antecubital space and the cephalic vein at the wrist. In this fashion, the more proximal veins were saved for future procedures. Their approach was reported and found to be successful in the short term, but the long-term durability of the Oakes procedure has not been described. This study aimed to determine the long-term primary, primary-assisted, and secondary patency rates of the brachial to distal cephalic vein Oakes procedure.

METHODS

This is a retrospective review of a prospective database in a large, single institution. All patients who underwent the Oakes procedure from 1998 to 2012 were followed up to 2018. We reviewed the time to intervention, type of intervention, patency rates, and mortality of this patient population.

RESULTS

Over the 5-year study period, 14 patients were identified who underwent the Oakes procedure, of whom seven (50%) were female. The average age was 55.7 years (range, 38-73 years). All patients had a previously placed Brescia-Cimino that was not suitable for dialysis but was patent. The average number of days to placement of an Oakes brachial to distal cephalic graft was 396 (range, 119-1167) days. A total of 71% (10) of patients underwent an intervention to maintain the graft, of whom 50% (5) underwent an angioplasty and 50% (5) had a thrombectomy/revision procedure. The average number of days to first intervention was 367.3 (range, 21-1048) days from Oakes placement. Of this cohort, 30% (3) of patients had a second intervention, of whom one (33%) underwent an angioplasty and two (66%) had revisions. One patient had a third and a fourth intervention at 39 days and 74 days, respectively, that were both angioplasties. The overall number of days the Oakes procedure remained usable from placement was 843.6 (range, 21-3790) days or 2.3 years.

CONCLUSIONS

This study concluded that the Oakes procedure may extend the use of the distal dialysis access site by 2.3 years without increasing infection and is hence a durable solution that should be considered in patients requiring dialysis access.

Transjugular Venous Approach for Endovascular Interventions in Hemodialysis Grafts and Fistulas of the Upper Extremities

OBJECTIVE

This article describes the use of a transjugular venous access for interventions in upper extremity hemodialysis arteriovenous fistulas (AVFs) and grafts. This access is used in selected patients in whom direct puncture of the hemodialysis access is considered to be difficult or cumbersome. Technical success was achieved in 96.7% of patients. If an intervention is unsuccessful, the transjugular access offers the possibility of placement of a dialysis catheter for temporary or long-term hemodialysis.

CONCLUSION

The transjugular approach for hemodialysis access endovascular interventions is technically successful and safe. Initially described as an intervention to treat malfunctioning arteriovenous grafts, we have used it successfully in AVF interventions. In our opinion, this approach is a safe and effective alternative that may prove useful in selected patients.

Transjugular venous approach for endovascular intervention in upper-extremity dialysis access fistulae and grafts

A transjugular venous access is an alternative approach for endovascular intervention in upper-extremity dialysis arteriovenous fistulae and grafts. The transjugular access is recommended for patients who have an unfavorable anatomy for the direct arm access approach. Ultrasound evaluation of the arteriovenous access is essential before intervention and includes evaluation of the inflow artery and outflow vein diameters, arteriovenous anastomosis, and the entire outflow vein, specifically looking into potential problem areas. Patency of the ipsilateral internal jugular vein needs to be assessed. If patency of the ipsilateral internal jugular vein is confirmed, it can be used for access. Retrograde access into the outflow vein is obtained with a reverse-curve catheter and a Glidewire. In some cases, puncture of the outflow vein is necessary along with the use of snares to direct the catheter system into the outflow vein. The techniques for intervention are described. Successful access into the outflow vein is possible in >95% of cases. The technique is useful for fistula maturation, declotting procedure, and arteriovenous fistula and graft maintenance. If intervention is unsuccessful, the transjugular access offers the possibility of placement of a dialysis catheter for temporary or long-term dialysis.

Dialysis Access Anatomy and Interventions: A Primer

The creation of arteriovenous fistulae and the use of arteriovenous grafts are a vital component in the treatment of patients undergoing dialysis. For many patients in this population, these accesses represent the permanent solution to their dialysis needs. Understanding the basic anatomy of the most common accesses used, as well as initial treatment of many underlying causes of access failure is vital for any interventionalist performing such procedures. This article outlines the most common approaches to surgically placed accesses used for renal replacement therapy, as well as the basics of interventional approaches used to treat the most common abnormalities causing their dysfunction.

Fatal pulmonary embolism after hemodialysis vascular access declotting

Patient: Male, 59

Final Diagnosis: Pulmonary embolism

Symptoms: Cardiac arrest • chest pain • dyspnea

Medication: —

Clinical Procedure: Angioplasty

Specialty: Nephrology