Thrombolysis for the treatment of thrombosed hemodialysis access grafts

Maintaining the patency of hemodialysis access grafts remains problematic. It is best to recognize the failing graft prior to its thrombosis by noting an increase in recirculation, decreased flow (as measured by a Transonics device), changes in Doppler ultrasound findings, elevation of venous pressures, or swelling of the arm. If a failing graft is suspected, an angiogram should be performed to evaluate the graft. If a problem is identified it should be corrected. If it is a graft thrombosis, it can be opened using percutaneous techniques. Percutaneous declotting has been evolving since its introduction in the early 1980s. At first, a low-dose thrombolytic infusion through a single catheter was used. Crossing catheters with a higher-dose infusion was then introduced. Finally, pharmacomechanical thrombolysis, which used crossing catheters and a pulse-spray technique, became popular. Several mechanical devices have proven to be efficacious as well. In 1997, we described the "lyse-and-wait" technique. We believe "lyse and wait" to be a simpler and quicker technique, and its initial success has been similar to that for the previously described techniques. After the graft is successfully declotted, the arterial plug must be mobilized and the stenotic lesion must be addressed either by angioplasty, stent placement, surgery, or any combination of these interventions.