Single Arterial Retrograde Access for Arteriovenous Access Declot in the Office-Based Laboratory

Abstract

We have described a time- and cost-efficient method for urgent percutaneous arteriovenous (AV) access declotting in the office-based laboratory (OBL). The need for declotting is an urgent case that disrupts the patient's dialysis and the surgeon's schedule and is traditionally treated by a single surgeon using bidirectional AV access. This technique is challenging, inefficient, and increases the risk of sterility breach. We evaluated a single arterial retrograde access (SARA) approach to declotting. The declot procedures were performed in the OBL for patients with thrombosed AV access referred by the dialysis center. Ultrasound-guided SARA of the brachial or radial artery was performed using a micropuncture needle. Fistulogram was performed through the transitional dilator to confirm the presence of thrombosis. Via a 5F × 4-cm sheath, the fistula was cannulated using an angled 0.035-in. glidewire. Next, a 0.035-in. Amplatz wire was placed, and 4 mg of tissue plasminogen activator was instilled using a Touhy Bourse via an angled support catheter. Blind percutaneous venous outflow angioplasty was performed with a 7-mm × 60-mm percutaneous transluminal angioplasty balloon. Proximal inflow thrombectomy was performed using a 5-mm × 40-mm percutaneous transluminal angioplasty balloon. Next, thrombus maceration and outflow thrombectomy were performed using both the 5-mm and 7-mm balloons until a thrill was palpated. Completion angiogram confirmed AV access patency and ruled out extravasation and distal arterial emboli. The OBL staff maintained manual pressure for 30 minutes. Nine patients had undergone 11 procedures with 100% technical success. One patient had required repeat thrombectomy within 30 days. No complications, including bleeding or ischemic events, occurred. All patients were able to return to dialysis successfully within 24 hours. At the last follow-up, all nine fistulas were patent and functional. In our OBL, the average cost for bidirectional AV access thrombectomy was $1170 and the average cost for the SARA procedure was $843.67. The physician time was 39.5 minutes for SARA and 47.4 minutes for bidirectional access. No treatment failures occurred in our series. The results from the present series have demonstrated that SARA is a safe, time-efficient, and cost-effective method to address clotted access in the OBL. This technique leverages fixed OBL costs, and allows the surgeon to help treat other patients.