Non-Surgical Salvage of Thrombosed Arterio-Venous Fistulae: A Case Series and Review of the Literature

Rotational thrombectomy versus balloon maceration in dialysis access salvage

BACKGROUND

Although end stage renal disease patients who undergo hemodialysis frequently experience dialysis-associated thrombotic complications, there remains a paucity of literature comparing the efficacy of different endovascular salvage techniques for grafts and fistulas. This study aims to compare primary patency in dialysis access following salvage mechanical thrombolysis/thrombectomy with a rotational thrombolysis device versus balloon maceration.

METHODS

Using a database of patient records at a tertiary medical center, all patients who underwent rotational thrombectomy with the Cleaner XT™ Rotational Thrombectomy System for endovascular salvage of arteriovenous fistula or arteriovenous graft from August 2016 to July 2022 were included in the population. Fourteen patients who underwent balloon maceration for endovascular salvage were matched to the patients in the rotational thrombectomy group based on date of procedure. The primary patency of the fistula or graft for the two groups was measured.

RESULTS

A total of 13 patients who underwent dialysis access salvage with rotational thrombectomy (10 grafts, 3 fistulas) were matched with 14 patients who underwent balloon maceration for dialysis access salvage (10 grafts, 4 fistulas). Six patients in both groups required additional graft access salvage (46% rotational thrombectomy; 43% balloon maceration). The median time to next dialysis salvage was 51 days for rotational thrombectomy and 43.5 days for balloon maceration (W + 9, critical value 1; compatible with statistically significant difference).

CONCLUSION

Endovascular access salvage by rotational thrombectomy may provide longer primary patency compared to salvage by balloon maceration. However, a longer follow-up prospective study of a larger study population is necessary to clarify the safety and efficacy of rotational thrombectomy using the Cleaner XT™ device.

Results of Prompt Surgical Intervention in Hemodialysis Radiocephalic Fistula Secondary Dysfunction

Radiocephalic fistula (RCF) dysfunction is a common problem due to low maturation and patency rates of these fistulas. The most common procedure in such cases is to place a temporary catheter for the dialysis. Temporary catheter placement and undergoing dialysis with this catheter cause complications, reduce the chance for fistula, and deteriorate the quality of life. The aim of this study was to demonstrate that immediate intervention in RCF dysfunctions can increase fistula success for the patient and can reduce the need for a catheter. Furthermore, the hemodialysis treatment can continue without affecting the quality of life. A total of 295 patients who were admitted for RCF dysfunction and who underwent early surgical intervention without any catheter placement were evaluated for postoperative complications, patency rates, and rates and durations of temporary catheter use over a mean time of 47 months of follow-up (range: 4–79 months). Of the patients, 77.2% (n = 228) underwent new proximal anastomosis (NEO; the radial artery and cephalic vein were reached with an incision created proximal to the previous anastomosis), 14.2% (n = 42) underwent brachiocephalic arteriovenous fistula (AVF), 8.4% (n = 25) underwent side-to-side brachiobasilic AVF + superficialization of the basilic vein. In 88.8% (n = 262) of the patients, successful cannulations were performed within the first 24 to 48 hours without any catheter requirement or complications. Temporary catheter was used for 15.1 ± 10.7 days in 11.2% (n = 33) of the patients. In RCF dysfunctions, early surgical interventions performed in the forearm and elbow provide early cannulation and thus decrease the catheter requirement, also prevent the complications of temporary catheters (infection, decreasing the fistula success, vascular injuries, etc.), increase the autogenous fistula success, and allow for the continuation of dialysis without disturbing the quality of life.

Salvage of thrombosed arteriovenous fistulae of patients on hemodialysis: report on the experience of a Brazilian center

INTRODUCTION

Hemodialysis vascular access thrombosis is an acute event that can interrupt the dialytic treatment. A timely management can restore access patency, avoiding the use of central venous catheters and their complications.

OBJECTIVE

To present the experience from a Brazilian Interventional Nephrology Center (INC) in the salvage of arteriovenous fistula (AVF) and grafts for hemodialysis.

METHODS

A retrospective study was performed to evaluate the primary and secondary patencies of 41 hemodialysis accesses with thrombosis confirmed by ultrasound and submitted to endovascular salvage procedures. We considered clinical success the use of the access for at least 3 subsequent hemodialysis sessions. The procedures were done in an outpatient center by interventional nephrologists. Patients were followed for up to 18 months with Doppler every 3 months.

RESULTS

Forty-five salvage procedures were performed in 41 accesses of 40 hemodialysis patients with native AVF or grafts. Of these, 90% were AVF, mostly upper arm, and 10% were grafts. Clinical success rate was 60% (27 procedures). Primary patency at 12 months was 39% and secondary was 52%. Gender of the patient, diabetes, and location of the access did not correlate statistically with outcomes. There were 3 major complications (anastomosis rupture, grade 3 hematoma, and anaphylactic shock).

CONCLUSION

The majority of thrombosed accesses can be successfully treated, maintaining its long-term patency. The need of repeated intervention is frequent.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Benefits of Long Versus Short Thrombolysis Times for Acutely Thrombosed Hemodialysis Native Fistulas

INTRODUCTION

Local thrombolysis with a time of exposure to recombinant tissue plasminogen activator of 15 to 150 minutes is commonly used to declot acutely thrombosed hemodialysis fistulas. The duration of thrombolysis for the restoration of arteriovenous blood flow remains controversial. The aim of this study was to investigate the outcomes of long thrombolysis treatment (LTT, 3 hours or more) and short thrombolysis treatment (STT, less than 3 hours) in our institution.

METHODS

We retrospectively analyzed 86 interventional declotting procedures (28 STT and 58 LTT) applied to 86 acutely thrombosed hemodialysis fistulas. The intervention time (IT) following thrombolysis (from the initial fistulography to the end of the angioplasty maneuvers), the time of day of the intervention (ie, during working hours vs off-hours), and the need for temporary catheter placement (TCP) were assessed. Success was defined as complete access recanalization, and major adverse events were defined as ischemia, bleeding, and access rupture.

RESULTS

The ITs were reduced after LTT (63.3 [9.3] minutes) compared to STT (106.7 [24.7], P = .01), but there was no difference in success rate (85.7% STT, 89.7% LTT, P = .722). While all (100%, 58/58) of the angioplasty maneuvers after LTT were performed during regular working hours, 75% (21/28) of those following STT were managed during off-hours ( P < .001). Despite the longer treatment, the need for TCP was not increased after LTT (10.7%) compared to STT (12.1%, P = .515), and the major complication rate was reduced (3.4% after LTT and 28.6% after STT, P = .004).

CONCLUSION

Long thrombolysis treatment results in shorter and less complicated percutaneous stenosis treatments during regular working hours. Despite the LTT of up to 25 hours until access for dialysis was achieved, no increase in the risks of TCP or major adverse events were observed following LTT.

Surgical and Endovascular Revision of Brachio-Basilic Vein Fistula

Purpose

The brachio-basilic vein fistula (BBVF) is currently the third vascular access option for patients on hemodialysis, following radio-cephalic and brachio-cephalic arterio-venous fistulas. Like all types of hemodialysis vascular access, a variety of procedures may have to be performed in order to maintain long-term use of the BBVF. The aim of the present study was to perform a literature review of endovascular or surgical revisions of BBVFs.

Methods

On Pubmed search, 676 records were obtained and reviewed for relevance with the aim of the search.

Results

A variety of endovascular and surgical revision techniques has been described to manage BBVF poor maturation, dysfunction manifested as failing BBVF (most often the result of a stenosis at the transposed/swing segment), thrombosis, aneurysm formation and hemodialysis access-induced hand ischemia (steal syndrome). The role of revision is crucial in BBVF maintenance, taking into account that around 70% of these fistulas will require some intervention by 18 months and as a result of revision, secondary patency is preserved in the vast majority, according to the results of one study. Endovascular revision is the treatment of choice for most cases of BBVF dysfunction or thrombosis, with redo surgery reserved for failures of endovascular techniques or other specific indications.

Conclusions

BBVF revision, more often in the form of endovascular surgery, plays a crucial role in BBVF maintenance and its continued use for hemodialysis, necessary for reducing graft and catheter use and the associated morbidity.

We Send Thrombosed AV Accesses to the Operating Room

A thrombosed dialysis access can be declotted either through an open surgical procedure or a percutaneous one. In choosing how the access should be managed, a nephrologist should balance the experience and outcomes of local providers to ensure the efficient and safe salvage of the vascular access. Percutaneous procedures often offer less disruption to the schedule of the patient and dialysis clinic, give more information about the central vasculature, are less invasive, and ultimately are preferred. Nephrologist should encourage local vascular surgeons and interventional radiologists to become proficient in these procedures to avoid unnecessary open cases.

Diagnosis of arteriovenous fistula dysfunction

Arteriovenous fistula (AVF) dysfunction remains a major contributor to the morbidity and mortality of hemodialysis patients. The failure of a newly created AVF to mature and development of stenosis in an established AVF are two common clinical predicaments. The goal is to identify a dysfunctional AVF early enough to intervene in a timely manner to either assist with the maturation process or to prevent thrombosis. The currently available tools in our armamentarium include clinical evaluation, physical examination of the AVF, and surveillance tests. Physical examination has been recognized as a simple and cost-effective tool, but is often not implemented either because of lack of training or time constraints. Surveillance tests include measurement of access flow or pressure as a surrogate marker of AVF dysfunction. Surveillance tests often require expensive equipment, additional personnel, and are controversial. Currently, there are guidelines and recommendations to include all of these measures while evaluating an AVF. Implementing judicious use of these tools in clinical practice can facilitate early diagnosis for timely intervention in the appropriate population. Furthermore, this strategy may avoid unnecessary interventions and assist with healthcare cost containment.

Percutaneous treatment of thrombosed arteriovenous fistulas: clinical and economic implications

BACKGROUND AND OBJECTIVES

Maintenance of previously thrombosed arteriovenous fistulas (AVFs) as functional vascular accesses can be highly expensive, with relevant financial implications for healthcare systems. The aim of our study was to evaluate the costs and health outcomes of vascular access care in hemodialysis patients with AVF thrombosis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A retrospective, controlled cohort study was performed among local hemodialysis patients with completely thrombosed AVFs between August 1, 2007, and July 1, 2008. Detailed clinical and demographic information was collected and a comprehensive measure of total vascular access costs was obtained. Costs are reported in 2009 U.S. dollars.

RESULTS

A total of 63 consecutive hemodialysis patients with thrombosed AVFs were identified--a cohort of 37 patients treated with percutaneous thrombectomy and a historic cohort of 25 patients with abandoned thrombosed AVFs. The mean cost of all vascular access care at 6 months was $2479. Salvage of thrombosed AVFs led to a near two-fold reduction in access-related expenses, per patient-month at risk ($375 versus $706; P = 0.048). The costs for access-related hospitalizations ($393 versus $91; P = 0.050), management of access dysfunction ($106 versus $28; P = 0.005), and surgical interventions ($35 versus $6; P = 0.001) were also significantly lower in the percutaneous treatment group. At 6 months, most of these patients had a functional AVF as permanent vascular access (91% versus 33%, P = 0.0001).

CONCLUSIONS

Salvage of thrombosed AVF is a highly efficient procedure; therefore, intensive efforts should be undertaken to universalize these interventions.

Surgical or endovascular repair of thrombosed dialysis vascular access: is there any evidence?

INTRODUCTION

Endovascular and surgical strategies have been used to manage patients with thrombosed vascular access for hemodialysis. We analyzed the evidence to see whether endovascular or surgical treatment has the best outcome in terms of primary success rate and long-term patency.

METHODS

We performed a systematic literature search of endovascular and surgical repair of thrombosed hemodialysis vascular access. The analysis included meta-analysis, randomized, and population-based studies of thrombosed arteriovenous fistulae and grafts.

RESULTS

One meta-analysis and eight randomized studies on the treatment of arteriovenous graft thrombosis were identified. Studies conducted before 2002 demonstrated a significantly better primary success rate and primary and secondary patencies of surgical thrombectomy vs endovascular intervention. After 2002, similar results of both techniques have been reported. Only population-based studies on the treatment of thrombosed autogenous arteriovenous fistulae have been published, showing similar outcome of surgical and endovascular intervention in terms of primary success. The long-term primary and secondary patencies are slightly better for surgical treatment, but this concerns only forearm fistulae.

CONCLUSIONS

The outcome of endovascular and surgical intervention for thrombosed vascular access is comparable, in particular for thrombosed prosthetic grafts. Surgical treatment of autogenous arteriovenous fistulae is likely to have benefit compared with endovascular means. Definitive randomized trials are needed to provide the level 1 evidence to resolve this latter issue.

Stent migration and folding in the subclavian vein during subclavian hemodialysis catheter placement

The role of stent placement in hemodialysis (HD) access intervention continues to evolve. As more stents are placed, new and unusual complications are coming to light. We describe a case in which an unsuccessful attempt to place a left subclavian dialysis catheter resulted in the inadvertent migration and folding of a previously deployed subclavian stent. Attempts to remove the stent with a snare were unsuccessful. Patency was restored to the access circuit by placing a new stent through the struts of the folded one. Clinical vascular practice guidelines for vascular access on the use of fluoroscopy for temporary HD catheter placement may need to be re-evaluated with the reported increase in stent placement in the US HD population.