Procedural success and patency after percutaneous treatment of thrombosed autogenous arteriovenous dialysis fistulas.
OBJECTIVE
To retrospectively evaluate success and midterm patency after percutaneous thrombectomy, lytic therapy, and angioplasty for thrombosed autogenous arteriovenous dialysis fistulas.


METHODS
From March 1996 to September 2001, 24 patients with 25 fistulas presented with 30 episodes of thrombosis of their autogenous fistulas, including 19 forearm radiocephalic fistulas in 18 patients and six upper arm brachiocephalic fistulas in six patients. Patients presented for percutaneous therapy within 48 hours of fistula thrombosis, with the exception of one patient who presented 7 days after thrombosis. Lytic therapy with urokinase or recombinant tissue plasminogen activator (rt-PA) was administered as a bolus into the fistula in 24 cases, with the exception of one case in which a 16-hour infusion of rt-PA was initiated. A mechanical thrombectomy device was used in a single case. Balloon thrombectomy was performed for residual clot. Angioplasty was performed at the arterial inflow, fistula, and outflow veins as required for identified areas of stenosis and/or maceration of thrombus.


RESULTS
Clinical success was achieved in 73% of cases (22 of 30). All patients were followed for a maximum of 66 months (mean, 12 mo). Primary patency rates were 36% at 3 months (95% CI, 18%-54%), 28% at 6 months (95% CI, 12%-46%), and 24% at 1 year (95% CI, 10%-42%). The assisted primary patency rate was 40% (95% CI, 21%-58%) at 3 months and stabilized at 32% at 6 months (95% CI, 15%-50%). The secondary patency rate stabilized at 3 months at 44% (95% CI, 24%-62%) for 15 months. Patency rates after clot removal were not significantly different between upper and lower arm fistulas (P =.14). Total observation time of the cohort of 25 fistulas was 296 months. The complication rate was 7% (two of 30), with one major complication and one minor complication.


CONCLUSIONS
Salvage of function after percutaneous clot removal from autogenous fistulas involves a steep learning curve initially and is possible with 3-month patency rates that approximate Kidney Disease Outcomes Quality Initiative recommendations for clot removal from polytetrafluoroethylene grafts.
Rajan
Dheeraj K
DK
Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network-University of Toronto, 399 Bathurst Street, 3-525, Toronto, Ontario M5S 2A8, Canada. dheeraj.rajan@uhn.on.ca
Clark
Timothy W I
TW
Simons
Martin E
ME
Kachura
John R
JR
Sniderman
Kenneth
K
D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical; D004868:Equipment Failure; D005260:Female; D006801:Humans; D007275:Injections, Intravenous; D008297:Male; D008875:Middle Aged; D010960:Plasminogen Activators / Q000008:administration & dosage*; D017534:Radial Artery / Q000473:pathology; D006435:Renal Dialysis / Q000295:instrumentation*; D012189:Retrospective Studies; D013927:Thrombosis / Q000188:drug therapy* / Q000209:etiology / Q000601:surgery; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply; D014568:Urokinase-Type Plasminogen Activator / Q000008:administration & dosage*; D014654:Vascular Patency / Q000187:drug effects; D014680:Veins / Q000473:pathology
D010960:Plasminogen Activators; D010959:Tissue Plasminogen Activator; D014568:Urokinase-Type Plasminogen Activator