Hanyang Med Rev.  2011 Feb;31(1):38-46. 10.7599/hmr.2011.31.1.38.

Intervention of the Dysfunctional and Thrombosed Autogenous Vascular Access

• Kim YJ

• KMID: 2053750
• DOI: http://doi.org/10.7599/hmr.2011.31.1.38

Abstract

In South Korea at the end of 2006, the total number of patients that had undergone renal replacement therapy was 46,730 (hemodialysis: 62.1%, peritoneal dialysis: 17.1%, functioning kidney transplantation: 20.8%). There were 9,197 new renal replacement therapy patients in 2006 and the incidence rate per million 185.3. In South Korea, the most common primary cause of end stage renal disease was diabetic nephropathy (42.3%), hypertensive nephrosclerosis (16.9%), and chronic glomerulonephritis (13.0%). The National Kidney Foundation Dialysis Outcomes Quality Initiative (K/DOQI) has recommended placement of autogenous arteriovenous fistulas over alternatives including the use of arteriovenous grafts and central venous catheters to improve the overall outcome of patients undergoing hemodialysis. However, autogenous arteriovenous fistulas, like polytetrafluoroethylene grafts, are also subject to dysfunction and eventual failure. Since first described in 1982, percutaneous transluminal balloon angioplasty has become the mainstay of treatment for accesses failing because of underlying central or peripheral venous stenoses. When angioplasty alone fails, alternative treatment modalities, including stent placement and atherectomy, allow immediate salvage in most cases. Consequently, interventional treatment should be attempted first for dysfunctional and thrombosed autogenous vascular access and should be initiated in all dialysis centers so long as the local radiologists are trained and enthusiastic.

Keyword

Autogenous arteriovenous fistula; Dysfunction; Thrombosis; Percutaneous transluminal balloon angioplasty

MeSH Terms

Angioplasty
Angioplasty, Balloon
Arteriovenous Fistula
Atherectomy
Central Venous Catheters
Constriction, Pathologic
Diabetic Nephropathies
Dialysis
Glomerulonephritis
Humans
Incidence
Kidney
Kidney Failure, Chronic
Nephrosclerosis
Polytetrafluoroethylene
Renal Dialysis
Renal Replacement Therapy
Republic of Korea
Stents
Thrombosis
Transplants
Polytetrafluoroethylene

Figure

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  Fig. 1 Following suprasystolic inflation of a blood pressure cuff, fistulogram demonstrates reflux across the arteriovenous anastomosis, revealing a short high-grade stenosis (arrow) and radial artery (arrowheads).

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  Fig. 2 Frequency of stenoses identified at first intervention.

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  Fig. 3 A 40-year-old man with right radio-cephalic fistula. A) A road-map fistulogram shows radial artery (small arrows), anastomotic site (arrow), and multiple stenoses at the cephalic vein adjacent to arteriovenous anastomosis (arrowheads). B) The stenoses are dilated using a 7mm balloon catheter. Note that the guidewire (arrow) has been left across the radial artery. C) Immediate post-procedural fistulogram shows improvement of the stenosis.

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  Fig. 4 Diagnostic fistulogram for the thrombosed radiocephalic fistula. Note that there are multiple thrombi (arrows) and multiple stenoses (arrowheads).

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  Fig. 5 Schemas of puncture site by considering thrombus locations. A) If there is no thrombus (arrowheads) at the cephalic vein adjacent to arteriovenous anastomosis (arrow), an antegrade puncture (star) can be performed just after the anastomotsis. B) If there are thrombi (arrowheads) at the anastomotic site (arrow), a retrograde puncture (star) can be performed just after the thrombus. C) If the thrombi (arrowheads) are clumped together in the fistula, antegrade and retrograde puncture (stars) in the thrombi should be performed.

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  Fig. 6 A 56-year-old woman with thrombosed radio-cephalic fistula. A, B) The arterial inflow and the venous outflow are blocked by Forgarty catheter (arrow). C) The surgical curette(arrow) scrapes the old thrombi off the radio-cephalic fistula. D) The stenosis is dilated using a 7 mm balloon catheter. E, F) In the post-procedural fistulogram, there are no residual stenosis and thrombi.

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  Fig. 7 A 45-year-old man with thrombosed brachio-cephalic fistula. A) There are large amount of thrombi (arrows) in the brachio-cephalic fistula. B) The blood flow is blocked by Forgarty catheter (arrow). C) The operator's fingers (arrow) are pushing the thrombi out of the fistula. D) In the post-procedural fistulogram, there are no residual thrombi.

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