Comparison of alteplase and urokinase for pharmacomechanical thrombolysis of clotted hemodialysis access

Abstract

Background: Percutaneous pharmacomechanical thrombolysis is increasingly used to salvage thrombosed hemodialysis access. We aim to evaluate the effectiveness of alteplase compared to urokinase in percutaneous pharmacomechanical thrombolysis clotted access. Methods: Records of patients who underwent pharmacomechanical thrombolysis at Interventional Nephrology Suite in a tertiary teaching hospital from 1 January 2016 to 31 December 2016 were reviewed. Technical and clinical success rates, thrombosis-free and cumulative survivals, procedure time, and radiation dose imparted to patients were compared for pharmacomechanical thrombolysis with urokinase versus alteplase. Results: A total of 122 incident patients underwent pharmacothrombolysis (n = 53 for urokinase, n = 69 for alteplase) during the study period. The mean dose of urokinase and alteplase used was 176,897 ± 73,418 units and 3.7 ± 0.8 mg, respectively. Pharmacomechnical thrombolysis using urokinase versus alteplase has similar technical success rate (98.1% vs 97.1%, p = 0.599), clinical success rate (88.7% vs 97.1%, p = 0.068), complication rate (9.4% vs 13.0%, p = 0.373), and primary patency rates at 3 months (57.1% vs 70.1%, p = 0.106). Thrombosis-free survivals of the vascular access were 113.2 (35.3, 196) days versus 122 (84, 239) days (p = 0.168). Cumulative survivals were 239 (116, 320) vs 213 (110.5, 316.5) days (p = 0.801). Procedure time, fluoroscopy time, skin dose, and dose were significantly lower for pharmacomechanical thrombolysis using alteplase compared to urokinase (p = 0.045, p < 0.0001, p = 0.006, p = 0.001, respectively). Stenting was found to be associated with successful dialysis following thrombolysis on univariate analysis (odds ratio: 9.167, 95% confidence interval: 1.391–19.846, p = 0.021), although this was no longer significant in multivariate analysis (p = 0.078). Conclusion: Alteplase is an effective and safe alternative to urokinase for pharmacomechanical thrombolysis of clotted vascular access.

The Cleaner XT™ Device as an Endovascular Adjunct for Pharmacomechanical Thrombolysis of Thrombosed Arteriovenous Fistulas and Grafts

“…However, the type of thrombolysis agent did not lead to a significant difference in primary or secondary patency rates. 13) A study comparing hydrodynamic recirculation devices (Angiojet rheolytic system, Boston Scientific, Marlborough, MA, USA) to rotational recirculation devices (Arrow-Trerotola percutaneous thrombectomy device, Teleflex, Wayne, PA, USA) showed a higher clinical success and secondary patency rate in the device with a rotational mechanism. 18) This might be due to the differences in the mechanism of action since the Venturi effect from hydrodynamic recirculation devices could potentially leave residual thrombus adherent to the wall.…”

“…The procedure was performed according to our previously described centre protocol. 13,14) Briefly, antegrade and retrograde vascular sheaths/cannulae were placed in the thrombosed AVG/AVF under ultrasound guidance. The thrombolytic agent choices and doses were at the operator s discretion.…”

Does reducing radiation levels for procedures affect image quality and radiation to proceduralists? A double-blinded randomised study of two protocols

“…One study showed the choice of thrombolytic agent (alteplase instead of urokinase) also affects the radiation exposure to patients. 5 In addition, adjusting the machine settings in imaging protocols (fluoroscopy pulse rate, DSA frame rates, magnification, and exposure rate) could potentially reduce the radiation exposure. Despite the possibility to further reduce the radiation exposure, concern remains regarding the adequacy of image quality, especially of central images on the torso; however, it is reported that most radiologists start to detect contrast changes in radiographic images only when such changes result in approximately 15% change of the image contrast index.…”

Application Value and Relevance Analysis of the Risk Evaluation System for Arteriovenous Fistula Puncture in Thrombosis after Puncture

“…Epidemiological studies have shown that [ 14 ] the incidence rate of renal disease in China is about 13%, hemodialysis is the common method to treat renal failure, and effective and well-functioning vascular access is the fundamental guarantee to perform long-term sustained hemodialysis [ 15 – 17 ]. Currently, AVF puncture has become the first choice to establish vascular access in the clinic because of fewer complications, high patency rate, and low cost [ 18 ]. However, with the influence of long-term use and various factors, the internal fistula will gradually narrow and harden, leading to thrombosis, decrease of function, and life shortening, and seriously endangering the life of patients [ 19 ].…”