Management of Thrombosed or Failed Dialysis Access

Abstract

Hemodialysis (HD) access for patients with end stage renal disease (ESRD) is a steadily increasing necessity and maintaining patency of native or synthetic fistulas can be challenging. The main physiologic changes of a HD access that cause it to fail are inflow or outflow vessel stenosis or access thrombosis. These are propagated by factors intrinsic to ESRD, altered hemodynamics from a fistula, and typically further exacerbated by associated co-morbidities. Diagnosis of fistula dysfunction can be made with a combination of history, physical exam, HD dynamic measurements, laboratory findings, and invasive or non-invasive imaging. Stenoses can be managed with endovascular interventions, including angioplasty with or without stenting, or open operations. Thrombosis of HDaccess, which is most often a result of an underlying stenosis, can be managed similarly with either endovascular or surgical thrombectomy with adjunctive treatment. Our goal was to review the pathophysiology of the most common forms of fistula failure, diagnosis, and endovascular and surgical options for flow restoration.