Endovascular treatment of thrombosed fistulae is the standard.pptx

AV-fistula
Thrombosis
Intervention

1. Endovascular treatment of thrombosed fistulae is the standard Christian Hohl, EBIR HELIOS Klinikum Siegburg

2. Endovascular treatment is the standard for thrombosed fistulae and grafts Christian Hohl, EBIR HELIOS Klinikum Siegburg

3. Pharmacologic Thrombolysis: Lyse and wait Catheter directed thrombolysis ( rtPA , Urokinase ) Mechanical thrombectomy : Aspiration Percutaneous „Fogarty – Maneuver“ Various mechanical devices Thrombectomy techniques

4. Lyse and wait Puncture of the presumably thrombosed fistula Bolus injection of 4 mg rtPA 20-30 min waiting

5. Lyse and wait Puncture of the presumably thrombosed fistula Bolus injection of 4 mg rtPA 20-30 min waiting Only recommended in grafts (if at all)

6. Catheter directed thrombolysis Initial infiltration with 2-5 mg rtPA Continous dosage 2mg/h rtPA for (2-4h) 500 IE Heparin/h

7. Mechanical Thrombectomy

8. Only venous application Thrombus maceration and “Fogarty maneuver” Pro Lumen Arrow PTD Castaneda brush AKonya Eliminator Venous and arterial application Manual aspiration Oasis Possis system Clot buster Aspirex (ab medica ) Only arterial application ( venous grafts ) Rotarex (ab medica ) Mechanical devices

9. Only venous application Thrombus maceration and “Fogarty maneuver” Pro Lumen Arrow PTD Castaneda brush AKonya Eliminator Venous and arterial application Manual aspiration Oasis Possis system Clot buster Aspirex (ab medica ) Only arterial application ( venous grafts ) Rotarex (ab medica ) Mechanical devices

10. Thrombus maceration Standard PTA balloon Shredding of thrombi Pushing thrombus fragments forward to the lung

11. Classical aspiration Cheap Quick Difficult in larger diameter vessels

12. Arrow Trerotola PTD device Motor driven nitinol-basket 5/7 F OTW 0.025“ ( only 7F) HD grafts and fistulae

13. Arrow Trerotola PTD device

14. Aspirex (ab medica ) 6, 8 or 10 F OTW 0.018“ Indication : Only fresh thrombi

15. 6 or 8 F OTW 0.018“ Indication : Acute and subacute arterial thrombi Neointimal in- stent restenosis Rotarex (ab medica )

16. Planning of declotting Clinical examination Compressibility of the vein Venous filling Stenotic string Angiography Access

17. Transbrachial angiography Simple and low risk with ultrasound guiding Retrograde arterial Puncture (22G) or ArterioFix (20G B.Braun /Germany) Manual contrast injection (1 part contrast – 3 parts saline) Access for diagnostic imaging and monitoring of declotting Diagnostic access

18. CO 2 - angiography

19. Native fistulae

20. Access ? Typical mechanisms

21. Upper arm fistula – arterial imaging

22. Retrograde cannulation of shunt vein

23. Passage of thrombosed segment

24. Christian Hohl, EBIR

25. Result

26. Result

27. Central thrombosis

28. Central thrombosis

29. Literature Data

30. Patients 54 Procedure 81 Radiocephalic 50 Brachiocephalic 4 Large thrombus 60 Short thrombus 20 Arterial thrombus 1 PTA alone 20 Mechanical thx 58 Lysis 3 Clot buster 23 Hydrolyser 24 Combined 11 Thrombectomy of native fistulae Haage et al. Kidney Int 57

31. Thrombectomy of native fistulae Technical success

32. Patients Native fistulas 93 Forearm 56 Upper arm 17 Grafts 162 Data collection 1992-1998 Use of 7 F or 8 F guiding catheter Technical success Forearm 93% Upper arm 76% Grafts 99% Stent rate Forearm 11% Upper arm 41% Grafts 45% 45% Aspiration thrombectomy Turmel -Rodrigues et al Kidney Int 57 (2000) 1124

33. Forearm AVF ( thrombosed ) Patency @ 6 months 74 %, @ 12 months 47 % Upper – arm AVF ( thrombosed ) Patency @ 6 months 27 %, @ 12 months 27 % Prosthetic grafts ( thrombosed ) Patency @ 6 months 32 %, @ 12 months 17 % Percutaneous intervention : Patency in BC fistulae Turmel -Rodrigues NDT (2000) 2029

34. Percutaneous intervention : Patency in BC fistulae Turmel -Rodrigues NDT (2000) 2029

35. Henk F. M. Smits et al Nephrol Dial Transplant (2002) 17: 467-473 Percutaneous thrombolysis of thrombosed haemodialysis access grafts : comparison of three mechanical devices

36. Arterial embolization Venous embolization Pulmonary embolism Rupture / hematoma Complications

37. Petronis et al Am J Kidney Dis 34 (1999) 207 Thrombolysis 12/ 13 patients no evidence of PE ( nuclear scan ) Smits et al Am Soc Nephrol 8 (1997) 1458 Mechanical and pharmacomechanical clot dissolution 8/23 patients (35%) evidence of PE ( nuclear scan ) Clinical symptoms of PE in one (5%) Swan et al J Vasc Interv Radiol 6 (1995) 683 Intentional pulmonary clot dislodgement 12/22 patients (59%) evidence of PE ( nuclear scan ) 2 deaths related to PE 10/12 asymptomatic Risk of PE

38. Conclusion 1 High technical success rate for endovascular treatment Various „ devices “ available . Personal experience and cost !

39. Conclusion 2 Surgical approach – first choice in forearm fistulae Percutaneous approach – first choice for the rest , but Beware of : Big aneurysms Old thrombus Infected fistula

40. Conclusion 3 Strategy depends very much on the local situation Avail ability of well trained interventionalist / surgeon

41. Graft Thrombose

42. evc 2013 Christian Hohl, EBIR 8 F 6 F Double puncture Loop Graft

43. evc 2013 Christian Hohl, EBIR 8 F Apex Punktion Loop Graft

44. evc 2013 Christian Hohl, EBIR Apex Punktion