Needle Directed Pulse Spray Pharmacomechanical Thrombolysis for Acute Thrombosis of Dialysis Fistulas – Technique, Efficacy and Short Term Follow UP
Pharmacomechanical Thrombolysis for Acute Thrombosis of Dialysis Fistulas
Background: The incidence of end stage renal disease is on the rise and most of these patients are undergoing dialysis either through tunnelled/non tunnelled dialysis catheters or through arteriovenous fistulas/grafts. The dialysis grafts and fistulas have limited durability of about 3 years and are more prone for thrombosis and stenosis. Catheter directed interventions are successful in establishing flow in most of the thrombosed fistulas, but require dedicated Cath lab and tertiary care centre. Needle directed thrombolysis is a novel economical, safe technique for thrombolysis of dialysis fistulas and grafts. The aim of the studt is to review the technique, safety, efficacy of needle directed pulse spray pharmacomechanical thrombolysis of dialysis fistulas and grafts with short term follow up. Subjects and Methods: This was a prospective observational study done in department of Radio diagnosis, Narayana medical college, Nellore. Selectively 25 patients with thrombosed AV fistulas were referred from nephrology OPD for needle directed thrombolysis to our department from December 2018 to May 2019. The procedure was performed on OPD basis in ultrasound procedure room. Regular Doppler follow up of patients is done up to 6 months. Results: Out of twenty five cases about seventeen cases (68%) were successful in achieving adequate recanalization in single session. four cases (16%) required repeat sessions of thrombolysis and were successful in second attempt. In four cases (16%) there was failure in attaining adequate recanalization due to marked multisegment attenuation/flow limiting stenosis of the draining vein. Conclusion: Needle directed Pulse spray pharmacomechanical thrombolysis is a novel technique, which can be done bedside, under portable ultrasound guidance and is an economical procedure as no intervention hardware is required. Continuous monitoring allows procedure to be stopped at the earliest once there is optimal recanalization, minimizing the systemic side effects of thrombolytic agents.
Mailloux LU, Bellucci AG, Napolitano B, Mossey T, Wilkes BM, Bluestone PA. Survival estimates for 683 patients starting dialysis from 1970 through 1989: identification of risk factors for survival. Clin Nephrol. 1994;42(2):127–135.
Chazan JA, London MR, Pono LM. Long-Term Survival of Vascular Accesses in a Large Chronic Hemodialysis Population. Nephron. 1995;69(3):228–233. Available from: https://dx.doi.org/10.1159/000188461.
I. NKF-K/DOQI Clinical Practice Guidelines for Hemodialysis Adequacy: update 2000. Am J Kidney Dis. 2001;37(Suppl. 1):7–64. Available from: https://doi.org/10.1016/s0272-6386(01)70005-4.
Cooper SG. Pulse-spray thrombolysis of thrombosed hemodial- ysis grafts with tissue plasminogen activator. Am J Roentgenol. 2003;180:1063–1066. Available from: https://dx.doi.org/10.2214/ajr.180.4.1801063.
Bookstein JJ, Fellmeth B, Roberts A, Valji K, Davis G, Machado T. Pulsed-spray pharmacomechanical throm- bolysis: preliminary clinical results. Am J Roentgenol. 1989;152(5):1097–1100. Available from: https://dx.doi.org/10.2214/ajr.152.5.1097.
Palder SB, Kirkman RL, Whittemore AD, Hakim RM, Lazarus JM, Tilney NL. Vascular Access for Hemodialysis Patency Rates and Results of Revision. Ann Surg. 1985;202(2):235–239. Available from: https://dx.doi.org/10.1097/00000658-198508000-00015.
Burger H, Kluchert BA, Kootstra G, Kitslaar PJ, Ubbink DT. Survival of arteriovenous fistulas and shunts for haemodialysis. Eur J Surg. 1995;161(5):327–334.
Schwab SJ, Raymond JR, Saeed M, Newman GE, Dennis PA, Bollinger RR. Prevention of hemodialysis fistula thrombosis. Early detection of venous stenoses. Kidney Int. 1989;36(4):707–711. Available from: https://dx.doi.org/10.1038/ki.1989.250.
Riordan S, Frawley J, Gray L, Niesche J. Primary access surgery for long-term haemodialysis. ANZ J Surg. 1994;64(11):763–767. Available from: https://dx.doi.org/10.1111/j.1445-2197.1994.tb04535.x.
Kumpe DA, Cohen MAH. Angioplasty/thrombolytic treat- ment of failing and failed hemodialysis access sites: Com- parison with surgical treatment. Prog Cardiovasc Dis. 1992;34(4):263–278. Available from: https://dx.doi.org/10.1016/0033-0620(92)90021-q.
Zaleski GX, Funaki B, Kenney S, Lorenz JM, Garofalo R. Angioplasty and Bolus Urokinase Infusion for the Restoration of Function in Thrombosed Brescia-Cimino Dialysis Fistulas. J Vasc Interv Radiol. 1999;10(2):129–136. Available from: https://dx.doi.org/10.1016/s1051-0443(99)70454-9.
Schon D, Mishler R. Salvage of occluded autologous arteriovenous fistulae. Am J Kidney Dis. 2000;36(4):804–810. Available from: https://dx.doi.org/10.1053/ajkd.2000.17671.
Rajan DK, Clark TWI, Simons ME, Kachura JR, Sniderman K. Procedural Success and Patency after Percutaneous Treatment of Thrombosed Autogenous Arteriovenous Dialysis Fistulas. J Vasc Interv Radiol. 2002;13(12):1211–1218. Available from: https://dx.doi.org/10.1016/s1051-0443(07)61967-8.
Middlebrook MR, Amygdalos MA, Soulen MC, Haskal ZJ, Shlansky-Goldberg RD, Cope C, et al. Thrombosed hemodial- ysis grafts: percutaneous mechanical balloon declotting versus thrombolysis. Radiology. 1995;196(1):73–77. Available from: https://dx.doi.org/10.1148/radiology.196.1.7784593.
Gibbens DT, Triolo J, Yu T, Depalma J, Iglasias J, Castner D. Contemporary treatment of thrombosed hemodialysis grafts. Tech Vasc Interv Radiol. 2001;4:122–126.
Sofocleous CT, Cooper SG, Schur I, Patel RI, Iqbal A, Walker S. Retrospective Comparison of the Amplatz Thrombec- tomy Device with Modified Pulse-Spray Pharmacomechanical Thrombolysis in the Treatment of Thrombosed Hemodialysis Access Grafts. Radiology. 1999;213(2):561–567. Available from: https://dx.doi.org/10.1148/radiology.213.2.r99nv32561.
Kinney TB, Valji K, Rose SC, Yeung DD, Oglevie SB, Roberts AC. Pulmonary Embolism from PulseSpray Pharma- comechanical Thrombolysis of Clotted Hemodialysis Grafts: Urokinase versus Heparinized Saline. J Vasc Interv Radiol. 2000;11(9):1143–1152. Available from: https://dx.doi.org/10.1016/s1051-0443(07)61355-4.
Turmel-Rodrigues L, Pengloan J, Rodrigue H, Brillet G, Lataste A, Pierre D. Treatment of failed native arteriovenous fistulae for hemodialysis by interventional radiology. Kidney Int. 2000;57(3):1124–1140. Available from: https://dx.doi.org/10.1046/j.1523-1755.2000.00940.x.
Vikrama KA, Srivalli N, Venkataramana RS. USG-guided needle-directed pulse-spray pharmaco-mechanical thromboly- sis of hemodialysis grafts/fistula: A novel technique. Indian J Radiol Imaging. 2015;25(3):244–244. Available from: https://dx.doi.org/10.4103/0971-3026.161442.
Vasanthraj P, Bandi VK, Sai V, Shekar M. Pulse-Spray Pharmacomechanical Thrombolysis of Native Arteriovenous Fistulas and Grafts under Ultrasound Guidance: Our Initial Experience. J Clin Interv Radiol. 2016;01:46–48. Available from: https://dx.doi.org/10.1055/s-0036-1597840.