Thrombolysis With Alteplase: A Non-Invasive Treatment for Occluded Arteriovenous Fistulas and Grafts

Abstract

Thrombolysis with recombinant tissue type plasminogen activator (t-PA) has been successfully used in occluded arteriovenous (AV) hemodialysis grafts and tunneled catheters, especially as an adjunctive regimen to invasive or semi-invasive procedures. We performed a retrospective study to evaluate the effectiveness and outcomes of thrombolysis with t-PA in occluded AV hemodialysis accesses. We used low doses of t-PA in 40 cases of thrombosed AV fistulas and grafts. Primary success was noted in 55% of the cases ensuring patency rates of 30 and 90 days at 90.9 and 69.8%, respectively. Inflammation (increased C-reactive protein concentration) and shorter functioning time of AV access were independently associated with primary outcome, whereas there was no difference in outcome between AV fistulas or grafts. No major complications were noted. We conclude that the use of t-PA is a safe and easy treatment for clotted AV accesses that can be applied in an outpatient setting.

Time‐extended local rtPA infiltration for acutely thrombosed hemodialysis fistulas

“…The first part of the L&W technique consists of the local rtPA infiltration and can easily be performed, even in the absence of an interventional radiologist. Recently, it has been recommended this part should be done by HD nurses, particular in order to optimize the remaining interval from access thrombosis until beginning of the local thrombolysis . In the study presented thrombus infiltration was done by radiological assistants.…”

“…From February 2009 to August 2014, 84 (35 female and 49 male) patients on HD were retrospectively identified. All of them admitted hospital due to an acutely thrombosed AVF and proceeded to modified time‐extended L&W thrombolysis using recombinant tissue Plasminogen activator (rtPA) (Boehringer Ingelheim, Germany) …”

“…The patency status of the AVF was documented 2–40 hours from the thrombus infiltration in an interventional radiology suite by contrast fistulography. One or two 5‐ to 7‐Fr introducer sheath (Terumo, Tokyo, Japan) was inserted into the fistula, and angioplasty of all demasked stenosis was performed using a balloon catheters 4–12 mm (Abbott Vascular, IL, USA or Boston Scientific, MA, USA) . Residual thrombi were managed either by manual thromboaspiration or by mechanical fragmentation techniques.…”

“…The so called lyse‐ and‐ wait (L&W) technique is the most commonly used percutaneous thrombolysis procedure. The interval from starting the thrombolysis procedure until performing percutaneous angioplasty of demasked stenoses was reported to be between 10 and 40 minutes (Table ) . The angioplasty maneuver could be challenging and is frequently performed outside regular working hours.…”

Comparison between open and pharmacomechanical repair of acutely thrombosed arteriovenous hemodialysis fistulae within a decade

“…The patency status of the AVF was documented 2 to 40 hours from the thrombus infiltration in an interventional radiology suite by contrast fistulography. One or two 5‐ to 7‐Fr introducer sheath (Terumo, Tokyo, Japan) was inserted into the fistula, and angioplasty of culprit stenosis was performed using a balloon catheters with diameters from 4 to 12 mm (Abbott Vascular, IL, USA or Boston Scientific, MA, USA) . Residual thrombi were managed either by manual thromboaspiration or by mechanical fragmentation techniques.…”