State-of-the-Art Review : Treatment of Hemodialysis Access Failure: A Role for Thrombolysis

Abstract

Thrombosis of hemodialysis accesses remains a major source of morbidity, hospitalization, and expense for patients with end-stage renal disease. Treatment of hemodialysis accesses includes strategies to prevent ac cess failure and methods for treating acute thromboses. Such techniques as Doppler ultrasonography, venous pressure monitoring during dialysis, measurement of ra tios of venous to systemic pressures, and measurement of recirculation have been used to predict accesses at risk of thrombosis. Elective interventions, including surgical re visions and angioplasties, have been shown to lessen the thrombosis rate in both polytetrafluoroethylene (PTFE) grafts and arterio-venous fistulas. Elective revision has also improved long-term patency of both grafts and fistu las when compared with repairing the accesses only after thrombosis. Despite these attempts, acute thrombosis of hemodialysis accesses remains a common complication for patients with end-stage renal disease. Historically, surgical thrombectomy has been the gold standard for treatment of acute hemodialysis access failure. Over the past 10 years, thrombolytic therapy has gained an in creasing role in the treatment of acutely thrombosed PTFE grafts. Thrombolysis has had at least comparable results to surgical thrombectomy in the best centers, with similar complication rates. Thrombolytic therapy is also significantly less expensive than surgical thrombectomy. In summary, we believe that hemodialysis access treat ment should encompass a comprehensive program, in cluding access surveillance to select accesses at risk of failure. Elective intervention should be performed in an attempt to prevent thrombosis and increase long-term ac cess patency. When thrombosis does occur, pharmaco mechanical thrombolysis is the preferable first interven tion for acutely occluded PTFE hemodialysis accesses.