Percutaneous laser-facilitated thrombectomy: an innovative, easily applied, and effective therapeutic option for recanalization of acute and subacute thrombotic hemodialysis shunt occlusions.
OBJECTIVE
To report our experience with excimer laser-facilitated recanalization of acute and subacute thrombotic occlusions of hemodialysis shunts.


METHODS
Twenty-one patients (16 women; mean age 54+/-19 years, range 31-76) presented with acute and subacute thrombotic occlusions of their hemodialysis shunts (4 Cimino, 17 prosthetic; 18 forearm, 3 upper arm); mean occlusion time was 4.1+/-3 days (range 1-14), and the thrombotic occlusion measured a mean 17.4+/-9 cm (range 5-27). Fresh thrombus was observed in addition to the total shunt occlusion in all cases. All patients were treated initially with a pulsed ultraviolet (308-nm) excimer laser. Eighteen (85.7%) patients received adjunctive local thrombolysis for treatment of residual thrombus. Nineteen (90.5%) patients underwent angioplasty of the underlying anastomotic stenosis.


RESULTS
The angiographic occlusion was reduced from 100% to 63%+/-28% after laser treatment and to 36%+/-18% after 1 hour of thrombolytic therapy (20 mg tissue plasminogen activator). TIMI flow increased significantly from grade 0 to 2.7+/-0.5 following laser ablation (p<0.001) and to 3.0+/-0.2 upon completion of the angioplasty procedure (p>0.001 versus baseline). The immediate procedural success was 95.2% (20/21). Detectable thrombotic embolization and laser-related complications were not observed in any case. Primary patency was 85%; 3 patients had abnormal Doppler flow within 6 weeks and underwent reintervention (secondary patency 100%). All successfully treated shunts were usable for further dialysis at the 6-week follow-up.


CONCLUSIONS
Percutaneous excimer laser-facilitated thrombus vaporization is safe and effective for recanalization of acute and subacute thrombotic occlusions of hemodialysis shunts.
Dahm
Johannes B
JB
Department of Angiology, Clinic Neu-Bethlehem, Goöttingen, Germany. dahm@herz-gefaesszentrum.org
Ruppert
Joerg
J
Doerr
Marcus
M
Bordihn
Nils
N
Maybauer
Werner
W
D000208:Acute Disease; D000328:Adult; D000368:Aged; D017222:Angioplasty, Balloon, Laser-Assisted / Q000009:adverse effects / Q000379:methods*; D001132:Arm / Q000098:blood supply / Q000000981:diagnostic imaging; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D017115:Catheter Ablation / Q000295:instrumentation; D003131:Combined Modality Therapy; D005240:Feasibility Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D005500:Follow-Up Studies; D005542:Forearm / Q000098:blood supply / Q000000981:diagnostic imaging; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D011859:Radiography; D012039:Regional Blood Flow; D006435:Renal Dialysis / Q000009:adverse effects; D012086:Reoperation; D012189:Retrospective Studies; D015607:Stents; D017131:Thrombectomy / Q000009:adverse effects / Q000379:methods*; D015912:Thrombolytic Therapy; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome; D014654:Vascular Patency
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator