Endovascular Management of Thrombosed Dialysis Vascular Circuits

Abstract

A functional hemodialysis vascular access is the lifeline for patients with end-stage kidney disease and is considered a major determinant of survival and quality of life in this patient population. Hemodialysis therapy can be performed via arteriovenous fistulas, arteriovenous grafts, and central venous catheters (CVCs). Following dialysis vascular access creation, the interplay between several pathologic mechanisms can lead to vascular luminal obstruction due to neointimal hyperplasia with subsequent stenosis, stasis, and eventually access thrombosis. Restoration of the blood flow in the vascular access circuit via thrombectomy is crucial to avoid the use of CVCs and to prolong the life span of the vascular access conduits. The fundamental principles of thrombectomy center around removing the thrombus from the thrombosed access and treating the underlying culprit vascular stenosis. Several endovascular devices have been utilized to perform mechanical thrombectomy and have shown comparable outcomes. Standard angioplasty balloons remain the cornerstone for the treatment of stenotic vascular lesions. The utility of drug-coated balloons in dialysis vascular access remains unsettled due to conflicting results from randomized clinical trials. Stent grafts are used to treat resistant and recurrent stenotic lesions and to control extravasation from a ruptured vessel that is not controlled by conservative measures. Overall, endovascular thrombectomy is the preferred modality of treatment for the thrombosed dialysis vascular conduits.

Treating hemodialysis access thrombosis with the InThrill Thrombectomy System: Technique and case report

“…Rapid thrombus clearance and flow restoration are key to maintaining viability of an ESRD patient's vascular access and ensuring prompt resumption of dialysis treatment [6] , [7] , [8] , [9] . With the high comorbidity rate and low cardiac reserve in this patient population, it is also vital to minimize risks and potential cardiac strain [ 2 , 10 ].…”

“…Dialysis-dependent patients typically have poor cardiac health and are at a higher risk for PE mortality, further escalating the potential harm from such treatments [2] , [3] , [4] . Rheolytic and continuous aspiration thrombectomy techniques are often dependent on adjunctive thrombolytics [7] and can result in uncomfortable side-effects such as chest pain [11] . Furthermore, these treatments do not have a mechanism to remove wall-adherent or organized thrombus, a significant limitation as complete thrombus removal is essential to improve treatment durability [12] .…”

Shuntinterventionen bei stenosierten Hämodialyseshunts

“…Nach der Thrombusreduktion durch die Aspiration kann mittels der fokussierten Anwendung eines adäquat auf den Shuntdiameter dimensionierten Ballonkatheters die Zerkleinerung des resistenten Thrombusmaterials durchgeführt werden. Mit einem Fogarty-Katheter, der durch den Thrombus manövriert wird, kann anschließend nach der Balloninflation durch den Rückzug weiteres Material geborgen werden [8].…”

“…Je nach Literaturquelle ist damit zu rechnen, dass etwa jede zweite chirurgische primäre Shuntanlage kurz- bis mittelfristig versagt. Bei nativen Hämodialyseshunts ist dies im Mittel nach 3–7 Jahren und bei künstlichen Kunststoffshunts nach 1,5 Jahren zu beobachten 8 – entsprechend häufig sind wiederholte Eingriffe unterschiedlichster Art die Folge.…”

Restoring Access in a Thrombosed Hemodialysis Reliable Outflow Graft Using the InThrill Thrombectomy System

“…Arteriovenous grafts (AVGs) are one of the common vascular accesses used for hemodialysis. AVGs can be functional within days following their creation but are associated with a higher risk of venous stenosis and thrombosis compared to arteriovenous fistulas (AVFs), with more than 50% of AVGs reported to thrombose within one year of creation [ 1 ]. Dialysis vascular access thrombosis is the leading cause of AVF and AVG failure [ 2 ].…”