Outpatient use of tPA to recanalize thrombosed native fistulas a case series and discussion of literature (original) (raw)
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Percutaneous Treatment of Thrombosed Arteriovenous Fistulas
Clinical Journal of the American Society of Nephrology, 2010
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 twofold reduction in access-related expenses, per patient-month at risk
Percutaneous treatment of thrombosed primary arteriovenous hemodialysis access fistulae
Kidney International, 2000
Percutaneous treatment of thrombosed primary arteriovenous contributing significantly to morbidity and hospitalizahemodialysis access fistulae. tion in the dialysis patient [2]. In the past, the creation Background. We reviewed the efficacy of percutaneous inand preservation of the vascular access were primarily tervention in acute thrombotic occlusion of native arteriovethe responsibility of the surgeon, and dialysis shunt nous (AV) fistulae for hemodialysis. thrombosis was regularly corrected with surgical throm-Methods. Eight-one percutaneous procedures were performed in 54 patients presenting with a clotted native dialysis bectomy. Over the last decade, vascular access complicafistula. There were 60 cases of a long-segment thrombosis of tions have been increasingly approached on a multidiscithe fistula. In 20 cases, a small thrombus usually caused by an plinary basis. Today, dialysis centers are often using underlying severe stenosis was observed. A proximal arterial percutaneous interventions performed by the intervenocclusion was seen in one case. Treatment depended on clot size and included balloon dilation (N ϭ 20), mechanical thromtional radiologist in the management of hemodialysis bectomy with various devices (N ϭ 58), as well as pharmacoaccess-related problems. Currently, available percutanemechanical thrombolysis (N ϭ 3). ous treatment regimens for thrombosed dialysis grafts Results. Full restoration of flow was established in 72 cases and fistulae include mechanical thrombectomy, pharma-(88.9%). Early reobstruction within 14 days occurred in eight comechanical thrombolysis, and percutaneous infusion cases (11.1%). Primary patency rates after a 1-, 3-, 6-, and 12month period were 74, 63, 52, and 27%, respectively. Overall pharmacologic thrombolysis. According to the clinical fistula patency was 75% after 3 months, 65% after 6 months, practice guidelines for vascular access by the National 51% after 12 months, and 22% after 24 months. Kidney Foundation [3], each institution should choose to Conclusions. Acute thrombotic occlusion of native AV fisresolve thrombosis based on the expertise of the center. tulae is a major complication of hemodialysis. The results of
Catheterization and Cardiovascular Interventions, 2012
Objectives: To compare clinical outcomes between mechanical thrombectomy devices with hydrodynamic mechanism and rotational mechanism. Background: A number of advantages and concerns have been raised for different mechanical devices but the comparisons of clinical outcomes are absent, especially for the treatment of autogenous hemodialysis arteriovenous (AV) fistulas. Methods: The authors retrospectively reviewed 275 percutaneous thrombectomy procedures in AV fistulas. Procedures included were thrombectomy using devices with hydrodynamic mechanism, the Angio-Jet rheolytic catheter (AngioJet) (n 5 134) or devices with rotational mechanism, the Arrow-Trerotola percutaneous thrombectomy device (PTD) (n 5 141). Measured outcomes included clinical success, complications and patency rates. Results: Clinical success was achieved in 76% (102 of 134) of the AngioJet procedures and in 91% (128 of 141) of the PTD procedures (P 5 0.002). The procedure time for the PTD method was significantly shorter than that of the AngioJet method (52 vs. 88 min, P < 0.001). Complications occurred in 14% of the AngioJet procedures and 11% of the PTD procedures. The post-intervention primary patency rates at 6 months were 45% for the AngioJet group and 43% for the PTD group (P 5 0.70). The postintervention secondary patency rates at 1 year were 74% for the AngioJet group and 87% for the PTD group (P 5 0.01). Conclusions: For the salvage of thrombosed AV fistulas, a device using rotational mechanism is more time-saving with a higher immediate success rate and secondary patency rate. However, the long-term patency results were not different.
Nephrology Dialysis Transplantation
shoulder and the inability to switch blood flow from the v. cephalica into v. basilica (or vice versa). However, on rare occasions we used a graft to drain the outflow into the axillary vein, this allowed us to maintain access. The results of the interventions depended greatly on the surgeons experience and the ability to provide monthly monitoring function of vascular access and patient s compliance. CONCLUSIONS: Our experience clearly shows that preventive stenosis surgery is possible without stopping the use of AVF and without the need for central venous catheter implantation. This tactic allows to improve the AVF/AVG patency, but is possible only in the regional center. In a case of an extended lesion of the proximal vein segment, preventive interventions do not seem to improve the results of treatment.
Percutaneous Treatment of Thrombosed Arteriovenous Fistulas: Clinical and Economic Implications
Clinical Journal of the American Society of Nephrology, 2010
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 twofold reduction in access-related expenses, per patient-month at risk
Asian Journal of Medical Radiological Research
Background: The incidence of end stage renal disease is on the rise and most of these patients are undergoing dialysis either through tunnelled/non tunnelled dialysis catheters or through arteriovenous fistulas/grafts. The dialysis grafts and fistulas have limited durability of about 3 years and are more prone for thrombosis and stenosis. Catheter directed interventions are successful in establishing flow in most of the thrombosed fistulas, but require dedicated Cath lab and tertiary care centre. Needle directed thrombolysis is a novel economical, safe technique for thrombolysis of dialysis fistulas and grafts. The aim of the studt is to review the technique, safety, efficacy of needle directed pulse spray pharmacomechanical thrombolysis of dialysis fistulas and grafts with short term follow up. Subjects and Methods: This was a prospective observational study done in department of Radio diagnosis, Narayana medical college, Nellore. Selectively 25 patients with thrombosed AV fistulas...
Endovascular treatment of thrombosed dialysis fistulae
Catheterization and Cardiovascular Interventions, 2011
Objectives: In the present study, we determined the cumulative costs and outcomes of endovascular treatment of thrombosed autogenous arteriovenous fistulae (AVF) at our medical center. Background: Previous studies examining the salvage procedures of thrombosed AVFs have focused exclusively on clinical outcomes, and, in the absence of costing data, current guidelines do not take into consideration economic issues. Methods: A retrospective cohort study was performed among local hemodialysis patients with completely thrombosed AVFs receiving endovascular treatment in our institution between January 1 and December 31, 2008. Forty‐four patients were enrolled and followed‐up for 1 year. Success and complications were recorded according to consensus definitions, and a comprehensive measurement of total vascular access care‐related costs was obtained. Costs are reported in 2010 in U.S. dollars. Results: Clinical success was achieved in 95% of cases. The primary and secondary patency rates w...
Ultrasound guided interventional procedures on arteriovenous fistulae
The Journal of Vascular Access
Autogenous (AVF) and prosthetic (AVG) arteriovenous fistulas are the vascular accesses (VA) of choice for hemodialysis thanks to their improved patency, reduced costs, and lower rate of infections relative to catheters. In an effort to maximize the number of primary AVF and AVG, shorten maturation times for AVF, and reduce the number of indwelling catheters, several new techniques have been developed within the context of an overall program designed to optimize access care. This approach includes: (a) Primary Intraoperative Balloon Angioplasty on the vessels selected for AV creation whether small-sized or altered by pre-existing lesions; (b) Percutaneous Transluminal Angioplasty (PTA) on AVF and AVG stenosis, performed under ultrasonographic (UG) or fluoroscopic guide (FG). We report the experience of two Center in performing the above mentioned procedures on even complex VA. The wise adoption of these techniques may avail to meet the stringent demands for reliable VA placement as d...
American Journal of Kidney Diseases, 2003
Background: Vascular access surveillance by ultrasound dilution blood flow rate (Qa) measurement is widely recommended; however, optimal criteria for detecting stenosis and predicting thrombosis in arteriovenous fistulae (AVFs) are still not clearly defined. Methods: In a blinded trial, we evaluated the accuracy of single Qa measurement, Qa adjusted for mean arterial pressure (Qa/MAP), and decrease in Qa over time (dQa) in detecting stenosis and predicting thrombosis in an unselected population of 120 hemodialysis subjects with native forearm AVFs (91 AVFs, located at the wrist; 29 AVFs, located at the midforearm). All AVFs underwent fistulography, which identified greater than 50% stenosis in 54 cases. Results: Receiver operating characteristic curve analysis showed that dQa, Qa, and Qa/MAP have a high stenosis discriminative ability with similar areas under the curve (AUCs), ie, 0.961 ؎ 0.025, 0.946 ؎ 0.021, and 0.912 ؎ 0.032, respectively. In the population as a whole, optimal thresholds for stenosis were Qa less than 750 mL/min alone and in combination with dQa greater than 25% (efficiency, 90%); however, the best threshold depended on anastomotic site; it was Qa less than 750 mL/min for an AVF at the wrist and Qa less than 1,000 mL/min for an AVF in the midforearm. Qa was the best predictor of incipient thrombosis (AUC, 0.981 ؎ 0.013) with an optimal threshold at less than 300 mL/min (efficiency, 94%). Pooled intra-assay and interassay variation coefficients were 8.2% for MAP, 7.9% for Qa, and 11.2% for Qa/MAP. Conclusion: Our study shows that ultrasound dilution Qa measurement is a reproducible and highly accurate tool for detecting stenosis and predicting thrombosis in forearm AVFs. Neither Qa/MAP nor dQa improve the diagnostic performance of Qa alone, although its combination with dQa increases the test's sensitivity for stenosis.