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Failing and failed hemodialysis access sites: management with percutaneous catheter methods
1Department of Radiology, University of Colorado Health Sciences Center, Denver, USA.
Insights
Catheter-directed thrombolysis and angioplasty offer results comparable to surgery for thrombosed dialysis access. Combining these approaches with surveillance maximizes access longevity.
Area of Science:
- Nephrology
- Vascular Surgery
- Interventional Radiology
Background:
- Chronic dialysis access frequently develops stenoses and thrombosis, impacting patient treatment.
- Traditional surgical management of thrombosed accesses includes thrombectomy, patch angioplasty, and bypass.
- Thrombosis rates range from 0.5 to 0.8 episodes per year.
Purpose of the Study:
- To compare the efficacy of percutaneous catheter-directed thrombolysis with surgical revascularization for thrombosed dialysis access.
- To evaluate the role of angioplasty in treating underlying stenoses.
- To assess the impact of access surveillance and combined therapeutic approaches on long-term patency.
Main Methods:
- Percutaneous catheter-directed thrombolysis and angioplasty of stenoses.
- Surgical revascularization (thrombectomy, patch angioplasty, bypass).
- Access surveillance with fistulography and angioplasty.
Main Results:
- Technical success for thrombolysis is 75-92%, comparable to surgical revascularization.
- Both catheter-directed and surgical procedures show poor long-term patency (<90 days) after a single intervention, necessitating repeat procedures.
- Access surveillance decreases thrombosis rates by a factor of 3 and increases graft patency.
Conclusions:
- Percutaneous catheter-directed thrombolysis with angioplasty is a viable alternative to surgery for thrombosed dialysis access, preserving vein conduits.
- Repeat maintenance procedures are essential for both methods.
- A combined strategy of catheter-directed therapies, surgical interventions, and surveillance optimizes dialysis access longevity.
Abstract:
Chronic dialysis access is plagued with the formation of stenoses and access thrombosis, with a thrombosis rate of 0.5 to 0.8 episodes per year. Surgical management of thrombosed accesses, including thrombectomy, patch angioplasty, and bypass, has been the traditional treatment for thrombosed grants. Percutaneous catheter-directed thrombolysis of thrombosed accesses, coupled with angioplasty of underlying stenoses, offers comparable results to surgical revascularization. The technical success of thrombolysis is between 75% and 92%, similar to surgical results, with the advantage of sparing vein as potential conduit for future access sites. Surgical therapy may successfully reestablish access function for those stenoses that fail angioplasty. Long-term patencies after a single revascularization procedure are poor (median patency, < 90 days) for both catheter-directed and surgical procedures, and repeat maintenance procedures are necessary. Access surveillance using various means with timely fistulography coupled with angioplasty of stenoses has been shown to decrease the rate of access thromboses by a factor of 3 and to increase patency of grafts. A combined approach with catheter-directed therapies and surgical interventions leads to maximal longevity of each access site.