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The management and outcome of occluded haemodialysis access: a retrospective audit
Maha Yehia1, Maree McDonald, Robert Walker
1Department of Nephrology, Dunedin Hospital.
Insights
Surgery is the safest and most effective treatment for occluded hemodialysis access, offering better patency and fewer complications than thrombolysis. This approach ensures faster restoration of dialysis access and reduces overall healthcare costs.
Area of Science:
- Vascular Surgery
- Nephrology
- Interventional Radiology
Background:
- Occluded hemodialysis access is a common complication requiring timely intervention.
- Current management options include surgery and percutaneous thrombolysis, with variable success rates.
- Concerns exist regarding high morbidity and delayed access restoration with existing methods.
Purpose of the Study:
- To identify the optimal clinical practice for managing occluded hemodialysis access.
- To compare the effectiveness and safety of surgical versus percutaneous thrombolysis.
- To evaluate outcomes, complications, and costs associated with different treatment modalities.
Main Methods:
- Retrospective audit of patients with occluded hemodialysis vascular access.
- Data collection on access type, procedure, outcome, complications, and hospital stay.
- Analysis of 45 episodes of occluded access in 17 patients between June 1995 and June 2001.
Main Results:
- Thrombolysis had a low success rate (20/45 episodes), with surgery required in 25 episodes.
- Surgery demonstrated slightly better primary patency (4.9 months vs. 3.8 months) compared to thrombolysis.
- Thrombolysis complications included bleeding; surgery after failed thrombolysis led to prolonged hospital stays and increased costs.
Conclusions:
- Surgical intervention by vascular surgeons is the safest, most rapid, and effective treatment for occluded dialysis arteriovenous fistulae and grafts.
- Surgery offers superior outcomes and cost-effectiveness in managing occluded hemodialysis access.
- This study supports surgical management as the preferred clinical practice.
Aim:
To identify best clinical practice for the management of occluded haemodialysis access. Surgery or percutaneous thrombolysis with or without angioplasty, has been used for the management of clotted haemodialysis access, with variable reported success rates. Concerns over high morbidity rates and delays in achieving satisfactory patent arterio-venous (AV) access, led to a retrospective audit of all patients with occluded haemodialysis vascular access between 1 June 1995 and 30 June 2001.
Methods:
Data recorded included type of access, procedure used, outcome, complications and hospital stay.
Results:
There were 45 episodes occurring in 17 patients. 33 of the 45 episodes occurred in synthetic grafts. Eleven of the 17 patients had multiple episodes (range 2 to 11), nine of whom had synthetic grafts. Forty three of the 45 episodes initially underwent DSA on presentation. There was a low success rate with thrombolysis, with only 20 cases effective in re-establishing dialysis. Surgery revision was required to re-establish effective dialysis in 25 of the 45 episodes. Six of 43 thrombolysis procedures experienced a major complication related to excessive bleeding. Primary patency was slightly better for surgery compared with thrombolysis (4.9 months versus 3.8 months). Temporary catheters were inserted for dialysis in 19 of 45 episodes and remained for a mean of 5.8 days. Four patients had a major episode of catheter-related sepsis. Two patients required admission to the Intensive Care Unit (ICU) for management of their sepsis. Patients who failed thrombolysis and required surgery had a prolonged stay, averaging 8.2 days. This was associated with a marked increase in hospital costs. The average cost for successful thrombolysis was $1976, compared with $5348 where surgery was subsequently required. Costing of surgical intervention alone was similar to that of thrombolysis.
Conclusion:
Surgery with dedicated vascular surgeons remains the safest, most rapid and most effective approach to treating occluded dialysis AV fistulae and grafts.
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