The management and outcome of occluded haemodialysis access: a retrospective audit.
OBJECTIVE
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.


CONCLUSIONS
Surgery with dedicated vascular surgeons remains the safest, most rapid and most effective approach to treating occluded dialysis AV fistulae and grafts.
Yehia
Maha
M
Department of Nephrology, Dunedin Hospital.
McDonald
Maree
M
Walker
Robert
R
D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D005260:Female; D006083:Graft Occlusion, Vascular / Q000175:diagnosis / Q000191:economics / Q000209:etiology / Q000628:therapy*; D006760:Hospitalization / Q000191:economics; D006761:Hospitals; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D009520:New Zealand; D006435:Renal Dialysis / Q000009:adverse effects*; D012189:Retrospective Studies; D015912:Thrombolytic Therapy / Q000191:economics; D014656:Vascular Surgical Procedures / Q000191:economics; D020246:Venous Thrombosis / Q000175:diagnosis / Q000191:economics / Q000209:etiology / Q000628:therapy*