Thrombosed synthetic hemodialysis access fistulas: failure of fibrinolytic therapy.

Abstract

Seven episodes of acute thrombosis occurring in five patients with polytetrafluoroethylene dialysis fistulas were treated with local infusions of low-dose streptokinase. Bleeding from previous dialysis puncture sites necessitated stopping the infusion in six out of seven patients, although in one of these six, the graft reopened. The seventh patient had never been dialyzed through the graft and thrombolysis was achieved without incident. Surgery was avoided in only one patient. The authors contend that in these patients the risks of fibrinolytic therapy outweigh the benefits. Surgical thrombectomy, coupled with intraoperative angiography and possible angioplasty, is the preferred method of treating these patients. Venography prior to the creation of the fistula helps the surgeon avoid diseased vessels and may avert early failure of the fistula.

Systemic Streptokinase Infusion for Declotting of Hemodialysis Arteriovenous Fistulas

“…It must be stressed, however, that in 35% of our cases the occlusion occurred as a result of hypotension, which is considered a positive predictive factor of the effectiveness of the method [6]. In 9 of 17 patients (52.9%) the function of the fistula was restored without surgical intervention and we were able to establish long-term patency in 8 of them (table l).…”

“…In many centers local fibrinolytic therapy with strep tokinase or urokinase infusion directly into the thrombosed area has been used with unequivocal results depending on the type of the access [4][5][6][7][8]. Successful thrombolysis oc curred in 20-77% of cases.…”

“…Successful thrombolysis oc curred in 20-77% of cases. Local bleeding from previous dialysis puncture sites into the soft tissue remains the major complication and has been reported as a prime cause of thrombolysis failure in some centers [6,10], The streptoki nase dose used in local infusion (5,000 units/h) is much lower than the usual systemic dose, but a high concentra tion of the agent achieved in the fistula results in the dissolution of hemostatic plugs at the sites of vascular trauma with subsequent local bleeding.…”

“…Although systemic hypotensive episodes, infection and compression of vessels can be implicated, the most frequent factor precipitating thrombosis is the narrowing of the arterialized vein [3,6,10,12], Severe stenosis of the venous limb may be the result of (1) repeated trauma from dialysis needle punctures, (2) extravasation of blood with local fibrosis, (3) kinking caused by enlargement and elongation of the veins, and (4) intimal thickening [3,12], In these cases local fistula revision or reanastomosis does not correct the whole problem, and rethrombosis is often observed. The only method to identify any underlying anatomic abnor mality is fistulography; selecting the best operative method can be critical.…”

“…Since the early 1970s there have been several studies concerning a local intravascular infusion of thrombolytic agents, streptokinase or urokinase, in acute arteriovenous fistula (AVF) thrombosis; various contradictory results have been published [4][5][6][7][8].…”