Arteriovenous fistula (AVF) thrombosis occurs less often when compared to arteriovenous grafts. Since the number of AVFs has increased in the United States, AVF thrombosis is seen more frequently today. AVF thrombectomy can be tedious, requires physician ingenuity, and many times results in failure. Substantial clot burden in megafistulas and aneurysms is considered a relative contraindication to endovascular thrombectomy. Usually, it results in surgical referral for open thrombectomy or, at times, abandonment of the fistula altogether. Herein, we describe the technique, results, and cautions of combining a continuous infusion of recombinant tissue plasminogen (rTPA) followed by angioplasty of the culprit stenotic lesion that was successful in opening five of six AVFs with a substantial clot burden.
BeathardGA.Thrombolysis versus surgery for the treatment of thrombosed dialysis access grafts. J Am Soc Nephrol1995; 6(6): 1619–1624.
2.
KuhanGAntoniouGANikamM, et al. A meta-analysis of randomized trials comparing surgery versus endovascular therapy for thrombosed arteriovenous fistulas and grafts in hemodialysis. Cardiovasc Intervent Radiol2013; 36(3): 699–705.
3.
Turmel-RodriguesLPengloanJBourquelotP.Interventional radiology in hemodialysis fistulae and grafts: a multidisciplinary approach. Cardiovasc Intervent Radiol2002; 25(1): 3–16.
4.
MarstonWACriadoEJaquesPF, et al. Prospective randomized comparison of surgical versus endovascular management of thrombosed dialysis access grafts. J Vasc Surg1997; 26(3): 373–80; discussion 380–381.
5.
Turmel-RodriguesL.Application of percutaneous mechanical thrombectomy in autogenous fistulae. Tech Vasc Interv Radiol2003; 6(1): 42–48.
6.
Turmel-RodriguesL.Dilatation and declotting of arteriovenous accesses. Ther Apher Dial2003; 7(2): 244–251.
7.
BeathardGALitchfieldT; Physician Operators Forum of RMS Lifeline, Inc. Effectiveness and safety of dialysis vascular access procedures performed by interventional nephrologists. Kidney Int2004; 66(4): 1622–1632.
8.
GrebenyukLAMarcusRJNahumE, et al. Pulmonary embolism following successful thrombectomy of an arteriovenous dialysis fistula. J Vasc Access2009; 10(1): 59–61.
9.
Koraen-SmithLKrasunMBottaiM, et al. Haemodialysis access thrombosis: outcomes after surgical thrombectomy versus catheter-directed thrombolytic infusion. J Vasc Access2018; 19(6): 535–541.
10.
PetronisJDReganFBriefelG, et al. Ventilation-perfusion scintigraphic evaluation of pulmonary clot burden after percutaneous thrombolysis of clotted hemodialysis access grafts. Am J Kidney Dis1999; 34(2): 207–211.
11.
KinneyTBValjiKRoseSC, et al. Pulmonary embolism from pulse-spray pharmacomechanical thrombolysis of clotted hemodialysis grafts: urokinase versus heparinized saline. J Vasc Interv Radiol2000; 11(9): 1143–1152.
KearonCKahnSRAgnelliG, et al. Antithrombotic therapy for venous thromboembolic disease: American college of chest physicians evidence-based clinical practice guidelines (8th edition). Chest2008; 133(Suppl. 6): 454S–545S.
14.
MercadoCSalmanLKrishnamurthyG, et al. Early and late fistula failure. Clin Nephrol2008; 69(2): 77–83.
15.
SmitsHFVan RijkPPVan IsseltJW, et al. Pulmonary embolism after thrombolysis of hemodialysis grafts. J Am Soc Nephrol1997; 8(9): 1458–1461.
16.
SadjadiSASharif-HassanabadiM.Fatal pulmonary embolism after hemodialysis vascular access declotting. Am J Case Rep2014; 15: 172–175.
17.
ToosyKSaitoSPatrascuC, et al. Cardiac arrest following massive pulmonary embolism during mechanical declotting of thrombosed hemodialysis fistula: successful resuscitation with tPA. J Intensive Care Med2008; 23(2): 143–145.
18.
FengQCLiXDongGX, et al. Comparison of curative effect and thrombolysis time between r-tPA application and urokinase in the interventional thrombectomy and thrombolysis for acute and severe pulmonary embolism. Beijing Da Xue Xue Bao Yi Xue Ban2014; 46(3): 460–463.
19.
DemaerschalkBMKleindorferDOAdeoyeOM, et al. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2016; 47(2): 581–641.
