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Hemodialysis Access Declotting Procedures
Keith B. Quencer, MD; Steven Wu, MD
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KEY FACTS

  • Preprocedure

    • Procedure

      • Post Procedure

        TERMINOLOGY

        • Definitions

          • Declotting: Recanalization of thrombosed hemodialysis (HD) access
            • Can be done endovascularly or surgically
              • Endovascular approach preferred
                • Less invasive
                • Access ready for immediate use
                • Underlying stenoses can be identified and corrected
              • Surgery preferred for
                • Aneurysmal fistulas with > 200 cc of clot
                • Left-to-right shunt
                • Poor cardiopulmonary reserve
                • Recently created access
            • Thrombosis is 10x more common in graft-to-vein anastomosis (AVG) than AVF
          • Endovascular declotting
            • Various nonmutually exclusive methods described
              • Pulse-spray pharmacomechanical thrombolysis
              • Lyse and wait
              • Device-related mechanical thrombolysis/thrombectomy
              • Aspiration thrombectomy
          • Surgical declotting
            • Requires small incision into access
              • Mechanical thrombus removal

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Getting Started

                PROCEDURE

                • Procedure Steps

                  • Findings and Reporting

                    • Alternative Procedures/Therapies

                      POST PROCEDURE

                      • Things to Do

                        • Things to Avoid

                          OUTCOMES

                          • Problems

                            • Complications

                              • Expected Outcomes

                                Selected References

                                1. Almasri J et al: Outcomes of vascular access for hemodialysis: A systematic review and meta-analysis. J Vasc Surg. 64(1):236-43, 2016
                                2. Bent CL et al: The radiological management of the thrombosed arteriovenous dialysis fistula. Clin Radiol. 66(1):1-12, 2011
                                3. Yurkovic A et al: Outcomes of thrombectomy procedures performed in hemodialysis grafts with early failure. J Vasc Interv Radiol. 22(3):317-24, 2011
                                4. Patel AA et al: Mechanical thrombectomy of hemodialysis fistulae and grafts. Cardiovasc Intervent Radiol. 28(6):704-13, 2005
                                5. Funaki B: Problematic declots: Complications and irritations. Semin Intervent Radiol. 21(2):69-75, 2004
                                6. Zaleski G: Declotting, maintenance, and avoiding procedural complications of native arteriovenous fistulae. Semin Intervent Radiol. 21(2):83-93, 2004
                                7. What’s New in Declots? Management of the Total Access Thrombosis Patient. An alternative technique to catheter-directed thrombolysis in the patient undergoing dialysis.
                                8. When Not to Perform Percutaneous Thrombectomy of a Clotted Native Fistula
                                9. Addressing the Clotted Access. An esteemed panel of interventional experts shares viewpoints on optimal methods for identifying and treating clotted AV fistulas and grafts.
                                10. Declotting the Thrombosed Access
                                Related Anatomy
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                                Related Differential Diagnoses
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                                References
                                Tables

                                Tables

                                KEY FACTS

                                • Preprocedure

                                  • Procedure

                                    • Post Procedure

                                      TERMINOLOGY

                                      • Definitions

                                        • Declotting: Recanalization of thrombosed hemodialysis (HD) access
                                          • Can be done endovascularly or surgically
                                            • Endovascular approach preferred
                                              • Less invasive
                                              • Access ready for immediate use
                                              • Underlying stenoses can be identified and corrected
                                            • Surgery preferred for
                                              • Aneurysmal fistulas with > 200 cc of clot
                                              • Left-to-right shunt
                                              • Poor cardiopulmonary reserve
                                              • Recently created access
                                          • Thrombosis is 10x more common in graft-to-vein anastomosis (AVG) than AVF
                                        • Endovascular declotting
                                          • Various nonmutually exclusive methods described
                                            • Pulse-spray pharmacomechanical thrombolysis
                                            • Lyse and wait
                                            • Device-related mechanical thrombolysis/thrombectomy
                                            • Aspiration thrombectomy
                                        • Surgical declotting
                                          • Requires small incision into access
                                            • Mechanical thrombus removal

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Preprocedure Imaging

                                            • Getting Started

                                              PROCEDURE

                                              • Procedure Steps

                                                • Findings and Reporting

                                                  • Alternative Procedures/Therapies

                                                    POST PROCEDURE

                                                    • Things to Do

                                                      • Things to Avoid

                                                        OUTCOMES

                                                        • Problems

                                                          • Complications

                                                            • Expected Outcomes

                                                              Selected References

                                                              1. Almasri J et al: Outcomes of vascular access for hemodialysis: A systematic review and meta-analysis. J Vasc Surg. 64(1):236-43, 2016
                                                              2. Bent CL et al: The radiological management of the thrombosed arteriovenous dialysis fistula. Clin Radiol. 66(1):1-12, 2011
                                                              3. Yurkovic A et al: Outcomes of thrombectomy procedures performed in hemodialysis grafts with early failure. J Vasc Interv Radiol. 22(3):317-24, 2011
                                                              4. Patel AA et al: Mechanical thrombectomy of hemodialysis fistulae and grafts. Cardiovasc Intervent Radiol. 28(6):704-13, 2005
                                                              5. Funaki B: Problematic declots: Complications and irritations. Semin Intervent Radiol. 21(2):69-75, 2004
                                                              6. Zaleski G: Declotting, maintenance, and avoiding procedural complications of native arteriovenous fistulae. Semin Intervent Radiol. 21(2):83-93, 2004
                                                              7. What’s New in Declots? Management of the Total Access Thrombosis Patient. An alternative technique to catheter-directed thrombolysis in the patient undergoing dialysis.
                                                              8. When Not to Perform Percutaneous Thrombectomy of a Clotted Native Fistula
                                                              9. Addressing the Clotted Access. An esteemed panel of interventional experts shares viewpoints on optimal methods for identifying and treating clotted AV fistulas and grafts.
                                                              10. Declotting the Thrombosed Access