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Published online before print March 21, 2002, 10.1148/radiol.2232010821
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(Radiology 2002;223:339-344.)
© RSNA, 2002

Vascular and Interventional Radiology

Restoration of Thrombosed Brescia-Cimino Dialysis Fistulas by Using Percutaneous Transluminal Angioplasty1

Huei-Lung Liang, MD, Huay-Ben Pan, MD, Hsiao-Min Chung, MD, Luo-Ping Ger, MPH, Hua-Chang Fang, MD, Tung-Ho Wu, MD, Ming-Ting Wu, MD, Ping-Hong Lai, MD, Clement K-H Chen, MD and Chien-Fang Yang, MD

1 From the Departments of Radiology (H.L.L., H.B.P., M.T.W., P.H.L., C.K.H.C., C.F.Y.), Internal Medicine (Nephrology) (H.M.C., H.C.F.), Education and Research (L.P.G.), and Surgery (Cardiovascular) (T.H.W.), Kaohsiung Veterans General Hospital, National Yang-Ming University, 386 Ta-Chung 1st Rd, Kaohsiung, Taiwan 813, Republic of China. Received April 20, 2001; revision requested May 31; revision received August 24; accepted September 28. Address correspondence to C.F.Y. (e-mail: cfyang@isca.vghks.gov.tw).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To evaluate the authors’ experience with a technique for management of thrombosed Brescia-Cimino arteriovenous fistula.

MATERIALS AND METHODS: Forty patients with 42 thrombosed arteriovenous fistulas were percutaneously treated. Thrombosis occurred within 24 hours of attempted angioplasty in five fistulas, between 24 and 72 hours in 27, and longer than 72 hours in 10. Thrombosed fistulas were approached in a retrograde fashion followed by direct balloon dilation with 5–8-mm balloon catheters. If retrograde catheterization failed to cross the arterial anastomosis, an antegrade puncture directly into the thrombosed drainage vein close to the anastomosis was performed with ultrasonographic guidance, as an aid to catheterize the arterial inflow. Thrombolytic therapy with infusion of urokinase directly into the thrombus was performed in selected patients with visible thrombus that had compromised blood flow in the partially restored vascular access. Postintervention primary and secondary patency was calculated by using Kaplan-Meier analysis. Patency rates between patients without and with urokinase infusion were examined by using the log-rank test.

RESULTS: Anatomic success was achieved in 39 (93%) of 42 fistulas; and clinical patency, in 38 (90%) of 42 fistulas. Postintervention primary and secondary patencies (including initial technical failure) at 6, 12, and 18 months were 81% and 84%, 70% and 80%, and 63% and 80%, respectively. No significance of patency rate between patients without and with urokinase infusion was found (P = .912). Three patients died of unrelated causes at 1, 2, and 5 months after the procedures. No major complications were encountered.

CONCLUSION: High anatomic success and excellent clinical patency can be achieved in the salvage of thrombosed arteriovenous fistulas. Percutaneous restoration of arteriovenous fistulas should be attempted before surgical recreation to optimize outcome in patients undergoing hemodialysis.

© RSNA, 2002

Index terms: Dialysis, shunt, 91.457 • Fistula, arteriovenous, 91.494 • Thrombolysis, 91.1265 • Veins, transluminal angioplasty, 916.454


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
A functioning vascular access is essential to achieving long-term survival and optimal quality of life for patients undergoing hemodialysis. Dialysis access is usually in the form of either a Brescia-Cimino arteriovenous fistula (AVF) or a polytetrafluoroethylene graft in straight or loop configurations. There are several advantages of AVFs over polytetrafluoroethylene grafts. These include better patency (58–70 months for AVF vs 18–22 months for polytetrafluoroethylene graft), fewer infections (one per 200 years for AVF vs one per 13.5 years for polytetrafluoroethylene graft), less vascular steal syndrome, and less morbidity with creation (1–3). Despite obvious advantages, the relative number of AVFs created has been decreasing. Recent data from the U.S. Renal Data System indicate that less than 20% of U.S. patients undergoing hemodialysis have AVF access (4). The Dialysis Outcome Quality Initiative Clinical Practice Guidelines of the National Kidney Foundation recommend that, ultimately, 40% of patients undergoing hemodialysis should have an AVF (5). To increase the number of autologous AVFs, the repair and maintenance of these accesses need to be optimized. The results of surgical thrombectomy and revision are poor, with success rates varying from 28% to 73% (6–8). Percutaneous restoration of a thrombosed AVF is initially considered less likely to be successful (9), and published studies (10–12) devoted to salvage of these accesses are infrequent. The reported technical success rate has ranged from 46% to 68%. As a result, some surgeons and interventional radiologists would not attempt salvage of a thrombosed native fistula due to a presupposed poor outcome (13). Zaleski et al (14) reported an encouraging technical success rate (82%) with satisfactory patency by using percutaneous balloon dilation and thrombolysis. However, the technique they described has been considered somewhat complicated and controversial and possessed some disadvantages (15). The purpose of our study was to evaluate our experience with a technique for management of thrombosed Brescia-Cimino AVFs.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
From July 1998 to February 2001, 40 patients with 42 (two fistulas clotted twice in two patients at 11 and 15 months apart) thrombosed AVFs were referred to our radiology department for percutaneous restoration. There were 26 women and 14 men with ages ranging from 22 to 84 years (mean age, 61 years). Thrombosis of the vascular access occurred within 24 hours of attempted angioplasty in five fistulas, between 24 and 72 hours in 27 fistulas, and more than 3 days (4–9 days) in 10 fistulas. Fistula age was 16 months ± 22 (mean ± SD). Twenty-three of the 42 fistulas were considered mature (>=6 months old), eight fistulas were 6 months old or less, and 11 fistulas were 3 months old or less. Thirty-seven fistulas were created with radial-cephalic arteriovenous anastomosis, while five fistulas were created with brachio-basilic (cephalic) anastomosis.

Salvage Technique
Thrombosed vascular access was first examined (H.L.L., H.B.P.) by using high-frequency (7.0-MHz) color ultrasonography (US) (128XP; Acuson, Mountain View, Calif) from its arteriovenous anastomosis. The outflow drainage vein was traced for at least 20 cm in the cephalad direction. The puncture site was chosen as far away as possible from the anastomosis. In most patients, the entry sites were at the elbow region. In patients with brachio-basilic (cephalic) anastomoses, the access was approached either at the shoulder region or by puncturing of the ipsilateral internal jugular vein. Puncture sites were anesthetized with lidocaine hydrochloride (Xylocain; Abbott Laboratories, North Chicago, Ill). Intramuscular meperidine (50 mg) (Demerol; Abbott Laboratories) injection was used for analgesic purposes in each patient.

To access the collapsed fistula, a sterile latex tourniquet was placed tightly on the upper arm or shoulder region. The fistula was punctured with an 18-gauge cannula sheath either directly or mostly with US guidance (H.L.L.). A 0.035-inch hydrophilic guide wire and a 7-F vascular sheath (Terumo; Radiofocus, Tokyo, Japan) were introduced in a retrograde fashion. With the aid of the road-map technique, the occluded segment of the vascular access was carefully obtained with catheterization. However, in some instances, because of preexisting venous stenosis in the occluded segment and coexisting accessory vein(s) close to the arteriovenous anastomosis, retrograde catheterization into arterial inflow was not feasible. For these patients, a second antegrade puncture (18-gauge cannula sheath) directly into the thrombosed vein was performed (Fig 1). This puncture was usually performed with US guidance due to the small caliber of the thrombosed vein (Fig 2). Subsequently, a small amount of contrast medium was slowly injected to try to opacify the lumen of the thrombosed drainage vein for guiding of retrograde catheterization. If high resistance was felt during contrast medium injection or retrograde catheterization was still not feasible, a guide wire was introduced into the lower cannula sheath. Most of the stenotic segment in the thrombosed AVF was threaded without much difficulty by using this antegrade approach. This guide wire was then moved into the lumen of the 7-F vascular sheath, and both were pulled out from the upper puncture site (Fig 1). With the guide wire held tightly on both sides, an angiocatheter (RC1-65 cm, Cordis; Johnson and Johnson, Roden, the Netherlands) was advanced in a retrograde fashion, with the catheter tip placed close to the lower puncture site. (The cannula sheath was pulled back a little but was still kept in the thrombosed lumen.) The guide wire was withdrawn and reintroduced into the catheter with its soft tip in a retrograde fashion to enter the arterial inflow (Fig 3).



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  		Figure 1. Schematic illustration of two-puncture technique restoring a thrombosed AVF. Arrow indicates second antegrade puncture site. Cross-hatched area indicates the stenotic segment in the thrombosed AVF. A guide wire was inserted in the thrombosed lumen in an antegrade fashion with its soft tip in the lumen of the vascular sheath. av = accessory vein, mdv = main drainage vein, ra = radial artery.

 


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  		Figure 2. With US guidance, a needle (arrows) punctured the thrombosed lumen (TL) distal to the anastomosis in antegrade fashion. Small scale (right) = 5 mm.

 


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  		Figure 3. Venograms obtained in a 69-year-old woman who had AVF occlusion of 4 days duration. A, Road-map image shows many side branches (accessory veins) in the thrombosed AVF. The tip of a paper clip (arrowhead) indicates the superficial location of the arteriovenous anastomosis, which failed to be crossed in a retrograde fashion. B, A small amount of contrast medium was injected after the second puncture. Arrow points to stenotic segment of main drainage vein. Arrowhead points to entry site of second puncture. C, A guide wire was advanced into the thrombosed AVF in an antegrade fashion. D, Arterial inflow was crossed in a retrograde fashion. E, Follow-up venogram obtained after direct balloon dilation demonstrates well reestablished vascular access. No thrombolytic agent was administered in this patient.

 
After the arteriovenous anastomosis was crossed with a guide wire, the cannula sheath was removed, and the puncture site was slightly compressed for 1–2 minutes. Direct angioplasty at the arteriovenous anastomosis was performed with a 5 x 40-mm balloon catheter (Diamond; Meditech/Boston Scientific, Watertown, Mass) (burst pressure, 15 atm [1,520 kPa]). The venous outflow was usually dilated by using a 6–8-mm balloon catheter (Diamond; Meditech/Boston Scientific). Resistant stenosis was treated with a 7 x 40-mm balloon catheter (BlueMax; Meditech/Boston Scientific (burst pressure, 20 atm [2,027 kPa]) inflated to approximately 25 atm (2,533 kPa). After balloon dilation, complete angiography was performed from the distal supply artery to the right atrium. If rapid blood flow was restored in the vascular access after direct angioplasty, immediate hemostasis was performed. Residual thrombus that was resistant to balloon dilation and had compromised blood flow in the partially restored vascular lumen was further managed with infusion of urokinase (60,000 IU/hour for 4–8 hours). Delivery of urokinase directly into the thrombus from the preexisting catheter was performed in our early patients (seven fistulas). Because oozing from the puncture site (inserted by using a 7-F sheath) usually occurred during the thrombolytic period, we later preferred to deliver urokinase via a 22-gauge cannula sheath, which was placed by using a new puncture directly into the clots, with US guidance. The residual thrombus was followed with color Doppler US every 2–4 hours until it was totally dissolved or with infusion of urokinase for 8 hours at most. The patency and flow volume of the vascular access after thrombolysis was also evaluated (H.L.L. or H.B.P.) at color Doppler US (Fig 4). Heparin (3,000 IU per intravenous bolus) was administered at the beginning of the procedure. Informed consent was obtained from each patient. This study was approved by the ethics committee of our hospital.



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  		Figure 4. Arteriovenous anastomosis crossed by using the one-puncture technique. A, Fistula angiogram shows occlusion of the vascular access distal to the anastomosis. B, Fistula angiogram obtained after direct balloon dilation shows the vascular access is partially restored. There is a filling defect (arrow) in the slightly dilated aneurysmal segment. C, US scan confirms the residual thrombus (arrow) in the dilated segment of the vascular access. D, US scan shows the residual thrombus is completely dissolved after direct infusion of urokinase through a 22-gauge cannula sheath. E, Doppler US scan. The flow volume was estimated to be around 867 mL/min (flow volume = TAV [115 cm/sec] x {pi}{gamma}2 [3.14 x 4 mm2] x 60 sec/100).

 
Complications (including vascular rupture, arterial thromboemboli, or respiratory distress) during or immediately after the procedure were recorded. Venous rupture was managed by either prolonged balloon inflation or metallic stent placement. Arterial thromboemboli were managed with local urokinase infusion.

Definitions
According to recently published reporting standards from the Society of Cardiovascular and Interventional Radiology (16), anatomic success was defined as restoration of flow combined with a less than 30% maximal residual diameter stenosis at the conclusion of the interventional procedure, which was performed by one of the authors (H.L.L.). Clinical success was determined by one of three authors (H.M.C., H.C.F., or T.H.W.) and defined as resumption of normal dialysis for at least one session. Postintervention primary patency is the interval following intervention until the next access thrombosis or repeated intervention. Postintervention secondary patency is the interval after intervention until the access is surgically declotted, revised, or abandoned. Follow-up of this study ended on April 1, 2001.

Kaplan-Meier analysis was used to calculate all patency data. The patency rates of anatomic success between patients without and those with urokinase infusion were examined by using the log-rank test. A P value of less than .05 was considered to indicate a statistically significant difference.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Thirty-nine of the 42 thrombosed fistulas were successfully restored in the patients. Three fistulas technically failed; one failed in the second puncture of the thrombosed drainage vein, and the other two failed to cross the arterial anastomosis even with the use of the two-puncture technique.

The overall anatomic success rate was 93%. One fistula failed to achieve clinical success. Twenty-two thrombosed fistulas (52%) were successfully restored with the one-puncture technique in our study, whereas 20 fistulas required a second puncture. Urokinase was infused in 13 (31%) of 42 thrombosed fistulas, with the doses ranging from 240,000 to 480,000 IU (average dose, 320,000 IU).

The overall postintervention primary and secondary patencies of the restored vascular access (including the initial technical failure) at 6, 12, and 18 months were 81% and 84%, 70% and 80%, and 63% and 80%, respectively (Fig 5). The primary patencies at 18 months between patients without and those with urokinase infusion of the 39 anatomic successful fistulas were 69% and 62%, respectively. There was no statistical significance (P = .912) between these two groups. Three patients died of unrelated causes at 1, 2, and 5 months after the procedures.



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  		Figure 5. Graph shows primary (P, dashed line) and secondary (S, solid line) patency rates of thrombosed AVFs after percutaneous restoration.

 
Two episodes of venous rupture were complicated after balloon dilation. One fistula was managed by using a technique of prolonged inflation of the balloon catheter. The other fistula was managed by means of placement of a metallic stent (Wallstent 8 mm/4 cm) to stop extravasation. In this patient, urokinase infusion was started the morning after the procedure (14 hours later). Complications of thromboemboli in the radial artery were encountered in two patients (proximal and distal to the anastomosis in one patient each) and were managed with local infusion of urokinase (240,000 and 480,000 IU), without sequelae afterward. No patient complained of clinical respiratory distress during or immediately after the salvage procedure.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The optimum venous anatomy for AVF development is a single cephalic vein stretching from the wrist to the antecubital space. But in many instances, the main drainage vein (cephalic vein) may have one or several side branches (accessory veins). In the series of Beathard et al (2), as many as six of these accessory veins existed. For thrombosed AVFs with coexisting venous stenosis and accessory veins at close to arteriovenous anastomosis, retrograde catheterization is usually not feasible. In Hunter et al (10), nine (32%) of 28 occlusions could not be crossed in spite of aggressive attempts from multiple directions (both proximal and distal arterial or venous approach). For Zaleski et al (14), nine (53%) of 17 occlusions required a third puncture due to difficulty crossing a tight stenosis or identifying the true lumen of the fistula. In the patients, only 52% of occlusions were successfully restored by using the conventional one-puncture technique. In several studies (17–20), some authors applied a conventional retrograde one-puncture technique and used either a hydrodynamic thrombectomy catheter, direct thromboaspiration, or a thrombolysis and balloon dilation method for treatment of thrombosed fistulas, with technical success rates ranging from 81% to 94%. This is not comparable to our clinical experiences or to those of some other authors (9–14) in treating such complicated lesions by using one simple technique. We are not sure whether patient selection bias existed or if the accessory veins were ligated during shunt creation in all of the patients. By using the method of Zaleski et al (14), one or two puncture sites might be close to the arterial anastomosis, which required angioplasty to reestablish rapid flow. Therefore, purse-string sutures were used to decrease the time of compression required to achieve hemostasis (14,21). In our method, the postprocedural hemostasis is easily achieved. Because the entry site (introduced by using a sheath) is far away (>20 cm) from the arteriovenous anastomosis, complete hemostasis usually can be achieved in approximately 5 minutes.

The effectiveness of percutaneous angioplasty in maintaining access patency in patients undergoing hemodialysis has been well documented. The success rate was approximately 88%–95% for polytetrafluoroethylene graft (17–19,22–25) and 80%–91% for stenotic AVFs (9–12). The primary patencies at 6 and 12 months were 20%–34% and 4%–26%, respectively, for polytetrafluoroethylene grafts (17–19,22–25) and 77% and 64%, respectively, for stenotic AVFs (9). For thrombosed AVFs, poor patency rate was initially reported; Vorwerk et al (17) reported a primary patency of 50% at 6 months. Overbosch et al (18) reported the median primary patency being 14 weeks. Later, Turmel-Rodrigues et al (19) reported better results, with primary and secondary patency rates (including initial technical failure) at 6 and 12 months of 74% and 81% and 60% and 81%, respectively. In the study of Zaleski et al (14), the primary and secondary patency rates (excluding initial treatment failure) at 6 and 12 months were 71% and 100% and 64% and 100%, respectively (14). In our study, the primary and secondary patency rates (including initial technical failure) at 6 and 12 months were 81% and 84% and 70% and 80%, respectively, which were comparable to those of Zaleski and colleagues (14).

Percutaneous restoration of failed vascular access as early as possible is usually recommended to increase the technical success rate and to avoid unnecessary central venous catheter placement. On the basis of data from surgical thrombectomies, immediate surgical revision has been advocated to restore function of recently thrombosed fistulas (7). In thrombosed AVFs, angioplastic attempt within 24 hours of occlusion has been considered essential for successful restorations. However, some successful restoration of thrombosed AVFs in patients with occlusions of 24–72 hours has been reported (14,20). However, the authors of these studies still recommended performing angioplasty within 24 hours of occlusion. In a review (26) of 263 patients receiving catheter-directed thrombolysis for deep venous thrombosis of the iliofemoral vein, 88% of acute or subacute clots (<4 weeks old) and 60% of old clots (>4 weeks old) were successfully treated. Therefore, it is not the thrombus per se that has prevented the intervention from being performed within 24 or 72 hours of occlusion, but the technical consideration that the thrombosed vascular lumen will obliterate as time passes and consequently increase the difficulty of interventional cannulation and catheterization. Since technical cannulation and catheterization can be accomplished with the use of our technique, we had successfully restored thrombosed AVFs with occlusion of 4–9 days. Therefore, we recommend performing percutaneous restoration first for any failed vascular access, even in the case of occlusion of more than 72 hours.

The safety of direct balloon dilation prior to clearing the whole thrombus has been of concern (15). Zaleski et al (14) routinely injected 500,000 IU of urokinase for 1 minute immediately after the arterial anastomosis was dilated and used a 8–27-mm-diameter compliant occlusion balloon catheter to displace the residual adherent thrombus in their patients (14). Schon and Mishler (20) infused low-dose thrombolytic agents (0–250,000 IU of urokinase or 2.5–11.0 mg of tissue plasminogen activator) in their patients before balloon angioplasty. Turmel-Rodrigues and colleagues (15) questioned the effectiveness of bolus injection of thrombolytic agent in dissolving thrombus. They recommended manual thromboaspiration to clear all of the thrombus before balloon dilation (19). We agree that bolus injection of thrombolytic agent cannot dissolve the whole thrombus, but we disagree that the whole thrombus has to be removed before balloon dilation to prevent the complication of pulmonary emboli and to achieve better patency. Vorwerk and colleagues (17) used a hydrodynamic thrombectomy catheter to remove thrombus in the failed vascular accesses. They estimated the average residual thrombus left in the native fistula to be 21% (10%–50%). They stated that despite residual thrombus found in many cases, arterialized flow was completely established in 84% of their native fistulas. In the patients, 69% of thrombosed AVFs were successfully restored by using direct angioplasty. Comparison of the patency rates of anatomic success between 35 patients without and with urokinase revealed no significant difference. Winkler et al (27) reported that the volume of thrombus obtained from hemodialysis access grafts at surgical thrombectomy ranges from 1.5 to 4.7 mL. Although the real clot burden in thrombosed AVF is uncertain, our color sonographic study before balloon angioplasty revealed that the thrombi in most patients were usually confined in the distal drainage vein below the lower two-thirds of forearm. The length of thrombosed vascular lumen was much shorter than that of a thrombosed U-loop graft. Thus, we considered the real clot burden in these patients to be less than that in patients with polytetrafluoroethylene grafts. Although small pulmonary emboli may inevitably ensue, they were probably small and were lysed by using physiologic and/or therapeutic fibrinolysis. In our method, we only dilated the occluded vascular access without intending to remove or declot all of the adherent thrombus. None of the patients in this study complained of respiratory distress during or immediately after the procedure. Thrombolytic therapy was performed only in patients requiring it (31% of the patients). The infusion dose of urokinase ranging from 240,000 to 480,000 IU was considered safe. No complications related to drug infusion occurred in the patients.

To prevent the complication of distal arterial emboli, Zaleski et al (14) attempted to establish patency of the outflow veins before crossing the arterial anastomosis. However, it still occurred in four patients. This complication could be easily managed by using direct administration of thrombolytic agent, such as in two of the patients in this study. The incidence of venous rupture resulting from hemodialysis-related angioplasty was reported to be around 1.7%–20.0% (28–30). To restore the flow and stop extravasation, prolonged inflation of a balloon catheter or placement of a metallic stent is the treatment of choice (28–30). We placed a metallic stent in one patient because ensuing thrombolysis was considered mandatory for its residual thrombus. The benefit of placement of a metallic stent in the venous segment intended for cannulation is debated. An experimental study (31) has confirmed the feasibility of direct puncture into the stent for hemodialysis. In conclusion, although percutaneous restoration of a thrombosed arteriovenous fistula is technically more complicated, our study offers a standardized percutaneous technique with a high technical success rate and excellent vascular patency.


   FOOTNOTES
 
Abbreviation: AVF = arteriovenous fistula

Author contributions: Guarantor of integrity of entire study, C.F.Y.; study concepts and design, H.L.L.; literature research, H.B.P., C.K.H.C.; clinical studies, H.M.C., H.C.F., T.H.W.; data acquisition and analysis/interpretation, M.T.W., P.H.L.; statistical analysis, L.P.G., H.L.L.; manuscript preparation, definition of intellectual content, and editing, H.L.L.; manuscript revision/review, C.F.Y., H.B.P.; manuscript final version approval, C.F.Y., H.L.L.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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