Print this pageNative Arteriovenous Fistulae Thrombosis: Does Percutaneous Rheolytic Thrombectomy and Thrombolysis Have a Role?
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Timothy P. Milner, MD, Chris D. Scibelli, George H. Meier, MD, Marc H. Glickman, MD, Gregory A. Barber, MD, Hosam F. El Sayed, MD, Gordon K. Stokes, MD, Richard J. DeMasi, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
BACKGROUND:
Native arteriovenous fistulas (AVF) are the “gold standard” for long term hemodialysis access. While patency and resistance to infection are significantly better than grafts or catheters in the long term, autologous accesses that occlude are often abandoned due to their poor response to conventional balloon thrombectomy. The damage to their endothelial layer secondary to thrombus and the trauma of its extraction is felt to markedly impact long term patency, resulting in permanent loss of the access in most cases. Given the trauma of conventional clot extraction with balloon catheters, this project was undertaken to determine whether less traumatic methods of clot extraction provide any patency advantage after autologous access thrombosis in comparison to conventional balloon thrombectomy.
METHODS:
A retrospective chart review of all patients who underwent percutaneous rheolytic thrombectomy using the AngioJet thrombectomy catheter (with or without thrombolysis) of occluded AVF between April 2002 and August 2004 was performed. Demographic data and patient co-morbidities were analyzed. The use of adjuncts such as thrombolysis, angioplasty, or stents was also reviewed. Primary, assisted primary and secondary patency rates were calculated.
RESULTS:
During the study period, 18 patients with clotted autologous AVF were treated with percutaneous thrombectomy. Technical success was achieved in 14 patients (77.8%). A primary patency of 28.6% at one month (4 patients) and 14.6% at 6 months (2 patients) was found in this group. Early rethrombosis occurred in less than one month in 10 patients (71.4%). Of all patients, only 2 used their fistula for dialysis for more than 6 months following the thrombectomy procedure (11.1%).
CONCLUSIONS:
Percutaneous rheolytic thrombectomy for occluded native AVF was technically feasible. Although the technique was used in an attempt to prolong the life of thrombosed autologous accesses, clinically effective patency was not achieved. The rate of early rethrombosis was 89% with most occurring within the first week after the procedure. Only a minority were able to continue the use of the AVF for more than 6 months. Based on these observations, we do not recommend either thrombectomy or thrombolysis for native arterio-venous fistula thrombosis.