CC BY 4.0 · The Arab Journal of Interventional Radiology 2025; 09(01): 042-047
DOI: 10.1055/s-0044-1795086
Original Article

Rheolytic Pharmacomechanical Thrombectomy in Renal Dialysis Arteriovenous Fistula and Graft Thrombosis: Outcomes from a Tertiary Hospital in Qatar

1   Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
,
1   Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
,
Ahmad N. Al-Ekeer
1   Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
,
1   Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
,
Ali Barah
1   Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
,
Saad Rehman
1   Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
,
1   Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
,
Qayed Al-Debyani
1   Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
,
Ayman Elmagdoub
1   Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
,
1   Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
2   Aston Medical School, Aston University, Birmingham, United Kingdom
› Author Affiliations
 

Abstract

Purpose To investigate the ability to salvage an acutely thrombosed dialysis access using rheolytic pharmacomechanical thrombectomy (PMT), the short- and medium-term patency rates and safety at a tertiary care hospital.

Methods A retrospective review of all patients who underwent rheolytic PMT for a thrombosed arteriovenous fistula (AVF) or arteriovenous graft (AVG) from October 2020 to 2023 was performed. Primary patency was defined as the ability to successfully dialyze through the treated access site without further intervention. Secondary patency included patients who required additional interventions that enabled them to continue dialysis. Data analysis was conducted using SPSS for comprehensive statistical evaluation.

Results A total of 37 thrombectomy procedures, involving 15 AVF and 22 AVG cases, were performed on 31 patients; 20 males and 11 females with a mean age of 62 ± 13 years. The average time from recognizing dialysis access site dysfunction to intervention was 2.6 ± 1.4 days. The mean total rheolytic PMT run time was 295 ± 119 seconds. Immediate technical success was defined as restoration of flow between the arteriovenous anastomosis and the central veins. Technical success was achieved in 91.9% (34/37) of thrombectomies. Clinical success was defined as the ability to achieve successful dialysis within 48 hours of the intervention. In total, 72.9% (27/37) of these cases achieved clinical success. Primary patency rates at 1, 3, and 6 months were 87.5, 78, and 46.9%, respectively. Secondary patency rates at 3, 6, and 12 months were 87.5, 66.7, and 58.3%, respectively. Angioplasty was performed in all procedures, and stent insertion was required in 13.5% (5/37) of thrombectomies.

Conclusion This study adds to the evidence that rheolytic PMT is a safe and effective tool for AVF and AVG salvage. After an initial thrombosis, the chance of re-thrombosis within 12 to 24 months is high and teams looking after these patients should have a strategy for future dialysis access.


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Introduction

End-stage renal disease (ESRD) is a significant global health care challenge with increasing prevalence in the Gulf region, including Qatar, as reported by recent studies.[1] [2] Hemodialysis is a vital lifeline for many ESRD patients, which is often facilitated through arteriovenous fistula (AVF), arteriovenous graft (AVG), or central venous catheters.[2]

Thrombosis is a relatively common complication of AVF and AVG, usually stemming from underlying stenoses, which challenge the long-term patency.[3] Failure to salvage these access sites leads to a higher number of patients on central venous lines, which harbors the risk of infection and central venous stenosis. However, several endovascular therapeutic options are available, including mechanical thrombus maceration, aspiration thrombectomy, thrombolysis infusion, and rheolytic pharmacomechanical thrombectomy (PMT).[4]

In this retrospective study, we aim to investigate the safety, technical success, and short- and medium-term patency rates of rheolytic PMT in the management of thrombosed dialysis AVF and AVG.


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Materials and Methods

Study Design

Institutional review board approval and patient consent waiver were obtained.

Retrospective analysis of 31 patients who underwent rheolytic thrombectomy with or without thrombolysis for a thrombosed dialysis AVF or AVG between 2020 and 2023 and were followed up for 12 months. Exclusion criteria included thrombosed fistula with no intervention. A total of 35 patients had thrombosed dialysis AVF or AVG during this period of time; however, 4 patients were excluded as the thrombus was deemed hard and chronic when attempting to pass a wire. No alternative methods of thrombectomy were utilized in patients suitable for thrombectomy. [Tables 1] and [2] list in detail the inclusion and exclusion criteria.

Table 1

Inclusion criteria for procedure

Inclusion criteria for procedure

AV fistula/graft occlusion confirmed with ultrasound

and history of occlusion/inability to dialyze less than 10 days

and age 18–80

and life expectancy of 12 months or longer

and potassium level <5 mmol/L after dialysis

Abbreviation: AV, arteriovenous.


Table 2

Exclusion criteria for procedure

Exclusion criteria

Absolute contraindications

Relative contraindications

Pregnancy

Potassium (K+) >5 mmol/L—the patient should be dialyzed via a line to bring this into an acceptable range.

Known right to left cardiac/pulmonary shunt

Bleeding risk—to be performed without tPA (only mechanical thrombectomy) or with reduced tPA dose

● Any procedure in the last 7 days

● Previous hemorrhagic stroke

● Recent head trauma/brain surgery

● Intracranial neoplasm

● Active bleeding or known bleeding disorder

● Major surgery, trauma, or bleeding <3 months

● GI bleed within 28 days

Uncontrolled hypertension (systolic >200 mm Hg)

Active intravenous drug user

Chronically thrombosed access not suitable for intervention

Fistula/graft creation less than 2 months

Abbreviations: GI, gastrointestinal; tPA, tissue plasminogen activator.


We collected data regarding patients' demographics, site and type of fistula/graft, time between access thrombosis and procedure, and adjunctive treatments. Patients' follow-up was performed in dialysis clinics with physical examination, access function, or Doppler ultrasound (US) examination.

Patients are referred to interventional radiology from the dialysis clinic upon suspected access thrombosis based on nonfunctioning access, lack of thrill or pulse on physical examination, and Doppler US assessment. The patient is then assessed by the interventional radiology team for suitability for intervention. If the access site has been thrombosed for more than 10 days, they are not offered thrombectomy. Following this, the patient is scheduled for intervention as soon as possible within normal daytime hours. The nephrologist optimizes the serum potassium to <5.0 mEq/L, as rheolytic PMT can cause a rise in the potassium level. Medical management and temporary central dialysis catheters can be used for this purpose. The potassium level is rechecked on the morning of the procedure with a venous gas.


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Thrombectomy procedure

Preprocedure on table Doppler US assessment is performed to identify the location and volume of thrombus and to plan whether antegrade, retrograde, or bi-directional access is required.

US-guided access to the fistula or graft is obtained using either a 21G micropuncture set or a 18G access needle. Access is secured with a 7 Fr × 6 cm Sheath. Systemic heparinization with a bolus injection of 50 IU/kg of heparin at the beginning of the procedure was performed and repeated as necessary depending on the length of procedure.

The occlusions are crossed with a 5 Fr angled catheter and a 0.035-inch hydrophilic guidewire. If the guidewire passes easily through the thrombus, it is deemed acute thrombus and suitable for thrombectomy.

A 50-cm AngioJet AVX 6F (Boston Scientific, Natick, Massachusetts, United States) or 90-cm Solent Proxi catheter (Boston Scientific, Natick, Massachusetts, United States) is used for our procedures. An initial debulking thrombectomy for up to 100 seconds is completed. Following this, 10 mg tissue plasminogen activator (tPA) in 100 mL of 0.9% saline is injected through the thrombus via a 5-Fr catheter using a Y connector with the wire in situ (no pulse spray on 50-cm AngioJet AVX) or via the pulse spray mode (90-cm Solent Proxi catheter). The tPA was allowed to dwell for 30 minutes. Patients were kept inside the angiography suite during the dwell time.

Following this, rheolytic thrombectomy is performed up to the maximum run time (240 seconds in flow/480 seconds in an occluded system). After thrombus clearance, any underlying stenosis is treated with plain balloon angioplasty (Mustang, Boston Scientific, Natick, Massachusetts, United States). Any significant resistant stenosis post-angioplasty is treated with a covered self-expandable stent (Fluency, Bard Inc., New Jersey, United States).

The choice of AngioJet catheter was based on availability of the catheter. The older generation 50-cm AngioJet AVX (Boston Scientific, Natick, Massachusetts, United States) was used in the earlier procedures and the newer generation 90-cm Solent Proxi (Boston Scientific, Natick, Massachusetts, United States) was used in the more recent procedures. Our preference was always to use the newer generation 90-cm Solent Proxi (Boston Scientific, Natick, Massachusetts, United States) when available due to the ability to deliver tPA via pulse spray mode.

[Fig. 1] demonstrates a treated case of left radiocephalic fistula thrombosis.

Zoom Image
Fig. 1 A 60-year-old man with end-stage renal disease who was dialyzed through left forearm radiocephalic fistula. The patient was referred for fistulography and possible further intervention due to failure of dialysis at his most recent session. Bedside ultrasound demonstrated thrombus in the venous limb of the fistula. Angiogram obtained after antegrade puncture of fistula demonstrates filling defect in the cephalic vein draining fistula, consistent with thrombosed fistula (a), black arrow. Accordingly, endovascular catheter and wire (white arrows) were advanced in the antegrade direction across the thrombosed vein into the central veins (b). Successful restoration of flow was obtained (gray asterisks) after treating with Angiojet followed by percutaneous transluminal angioplasty (c).

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Definitions

  • Technical success is blood flow restoration from the arterial anastomosis to the central veins with no significant residual stenosis of more than 30%.[5]

  • Clinical success is the ability to perform at least one successful hemodialysis session within 48 hours of the procedure.[6]

  • Primary patency was defined as the ability to use the treated dialysis access site without additional future intervention. Secondary patency included patients who needed additional radiological interventional procedures at a future date (not including surgery), which allowed them to continue successful dialysis.[6]


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Statistical Analysis

Data were analyzed using SPSS 64-bit version 25. A chi-square test was used to assess the relationship between qualitative variables. The t-test was used to examine potential associations between dependent quantitative variables and qualitative independent variables. p-Values ≤0.05 were set as the cutoff for the results to be considered statistically significant.


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#

Results

A total of 37 AngioJet thrombectomy procedures were performed on 31 patients: 20 males and 11 females with the mean age of 62 (range: 30–85) years. The average time from thrombosis to intervention was 2.6 ± 1.4 days. Immediate technical success, resulting in flow restoration, was achieved in 91.9% (34/37) of rheolytic PMT cases, and 72.9% (27/37) of these cases experienced successful dialysis within the first 48 hours postprocedure. Primary patency rates at 1, 3, and 6 months were 87.5, 78, and 46.9%, respectively. Secondary patency rates at 3, 6, and 12 months were 87.5, 66.7, and 58%, respectively. Angioplasty was performed in all procedures, and stent insertion was required in 13.5% (5/37) of thrombectomies. We used the Solent Proxi catheter in 24 cases (65%), while AVX was used in 13 (35%) cases only. [Table 3] summarizes the sample characteristics.

Table 3

Sample characteristics

Variable

AVF (15)

AVG (22)

p-Value

Age (year)

62.4

62.7

0.936

Gender

 Male

10 (67%)

14 (64%)

0.850

 Female

5 (33%)

8 (36%)

Diabetes

13 (87%)

14 (13%)

0.121

Hypertension

14 (93%)

21 (95%)

0.779

Time to AngioJet (day)

2.61

2.62

0.407

Immediate technical successfulness

13 (87%)

21 (95%)

0.336

Successful dialysis after 48 hours

12 (80%)

15 (68%)

0.427

Stent use

2 (13%)

3 (14%)

0.979

Time from procedure to thrombosis (year)

2.8

3.1

0.542

Complications

1 (7%)

4 (18%)

0.3

Abbreviations: AVF, arteriovenous fistula; AVG, arteriovenous graft.


The longer the time from AVF/AVG surgical creation to thrombosis, the better the primary patency outcomes (p = 0.03). Female gender was associated with poor outcome (p = 0.03). Otherwise, no statistically significant association was noted between the outcomes of primary patency and patient age, AVF/AVG procedure, AngioJet catheter used, and diabetic/hypertension status.

No major complications of limb ischemia or limb loss occurred as a result of our procedures. Vascular complications were encountered, including four cases of mild hematomas and extravasations which were managed conservatively and a single case of AVG pseudoaneurysm that was managed surgically.


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Discussion

The current population of Qatar is 2,787575 people.[7] Ghonimi et al[1] estimated the number of ESRD patients in Qatar is around 500 per million with about 75% of them receiving renal replacement therapy, among which 80% through hemodialysis. The remainder undergo peritoneal dialysis.

According to local databases, approximately 1,020 patients in Qatar's government health care system are undergoing hemodialysis through either AVF or AVG. Despite the occurrence of 50 renal transplants annually in Qatar, benefiting only a fraction of the patient population, the significance of maintaining the longevity of renal access remains crucial.

The immediate technical success rate in both AVG and AVF combined is 91.9%, observed in our study, which is comparable to Littler et al[8] and Drouven et al[9] who reported a comparable success rate of 89.2 and 92.6%, respectively, in their studies on rheolytic PMT for occluded dialysis fistulae. This reinforces the notion that rheolytic PMT is a reliable tool for achieving flow restoration.

The primary patency rates observed in our study at 1, 3, and 6 months are 87.5, 78, and 46.9%, respectively, which are relatively higher than what was reported by Littler et al[8] , who reported primary patency rates of 26 to 86% at 3 months after endovascular mechanical thrombectomy. Our outcomes could be enhanced by the use of the newer generations of AngioJet system with power pulse mode, implementation of standardized treatment protocols, and operator experience; however, study populations in different regions are heterogenous and this could be multifactorial.

Secondary patency rates at 3, 6, and 12 months in our study (87.5, 66.7, and 58.3%, respectively) demonstrate the sustained effectiveness of rheolytic PMT in salvaging the dialysis access over an extended period. Chan and Goh[4] performed a systematic review and found that the AngioJet device (Boston Scientific, Natick, Massachusetts, United States) exhibited safety and efficacy in the treatment of thrombosed AVF and AVG, corroborating our findings. Repeat rheolytic PMT to achieve secondary patency was required in six patients. Angioplasty was required in all patients to achieve secondary patency.

The need for additional interventions, such as angioplasty and stent insertion, is 100% and 13.5% of our procedures, respectively. This reflects the complexity of access salvage procedures and is related to the need for additional periprocedural treatment to ensure enough outflow. Additional effective treatment of underlying stenosis is needed to support long-term patency rather than depending on thrombectomy solely. The use of adjunctive measures is consistent with the multifaceted approach advocated by Chan and Goh[4] and Drouven et al,[9] emphasizing the importance of a comprehensive strategy for optimal outcomes.

The comprehensive analysis of demographic and clinical variables in our study ([Table 1]) further enriches the understanding of factors influencing the outcomes of AngioJet thrombectomy in AVF and AVG for dialysis access. Our study revealed that female gender is a predictor of failure of primary patency (p < 0.05), which can be attributed to their general small vessel diameter, similar to the study by Valji et al.[3] However, no other statistically significant associations were observed between primary patency and variables, such as patient age, type of access procedure (AVF/AVG), use of AngioJet catheter, and diabetic/hypertension status.

Diabetes, a prevalent comorbidity in ESRD patients, exhibited a higher prevalence in the AVF group (87%) compared with the AVG group (59%). Although the difference did not reach statistical significance (p = 0.121), it emphasizes the need for tailored interventions in diabetic patients to optimize outcomes. Chan and Goh[4] also acknowledged the relevance of comorbid conditions in the context of rheolytic PMT.

Hypertension, another common comorbidity, showed a similar distribution between AVF (93%) and AVG (95%) groups, reinforcing the notion that hypertension may not be a decisive factor in predicting thrombectomy success. The high prevalence of hypertension in both groups is consistent with the general population of ESRD patients.

Time from access thrombosis to intervention was not a predictor for patency in this study. This is likely because the bulk of our cases have the same reported time to intervention along with low sample size statistical power. Time to intervention was on average 2.6 days, which is considered delayed compared with Drouven et al's[9] study, which reported a mean of 0.4 to 0.6 days of interval for intervention. This delay is explained by the fact that this procedure is not performed out of duty hours, including the weekends along with many patients needing to optimize their potassium level prior to the procedure. However, our interval is still shorter than the time reported by Littler et al[8] with an average interval of 4 days' delay.

Interestingly, the time from AVF/AVG surgical creation to thrombosis emerged as a significant variable influencing primary patency outcomes (p = 0.032). A longer duration between access creation and thrombosis correlated with better primary patency rates. This observation aligns with clinical intuition, suggesting that a more mature access site might confer improved resistance to thrombotic events, while the more recent access thrombosis could be related to creation technique issues or improper care. Previous related studies did not specifically explore this variable, emphasizing the unique contribution of our study in highlighting the temporal aspect in predicting thrombectomy success, as mentioned by multiple studies.[4] [7] [8]

Our study showed that AngioJet is safe for mechanical thrombectomy. We had only a few minor complications that did not result in limb ischemia or loss. Vascular complications were encountered, including four cases of mild hematomas and extravasations that were managed conservatively and a single case of AVG pseudoaneurysm that was managed surgically. These could be encountered during any vascular procedure, so could not be directly attributed only to the AngioJet system, as Littler et al explained.[8] No hemolysis-related complications were encountered. Information about hemoglobinuria was not well-documented on the electronic patient record; therefore, these data were not collected. Also, our technique with good preoperative evaluation trying to use only one puncture either uphill or downhill direction with implementing compression venogram to check the arterial side anastomosis in case of uphill puncture further minimizes vascular complications. No significant cardiovascular complications encountered in our study, which likely is attributable to meticulous control of potassium level prior to procedure along with intermittent brief pausing during the intervention allowing the body to control the released electrolytes from the lysed blood cells and to subside any subclinical arrhythmia, as previously reported by Chan and Goh.[4]

We used the Solent Proxi catheter in majority of our cases due its additional advantageous power pulse lytic delivery of thrombolytic drug to clots for more effective thrombus clearance, as described by Kasirajan et al.[10] The AVX catheter was used in the other patients, especially those who had contraindications to thrombolysis. However, no statistically significant difference in the primary patency was noted, which could be attributed to low sample size statistical power or nonbalanced distribution of the two catheters among the two groups.

The strength in our study is that it studied the outcome and safety of the latest versions of the AngioJet system. Limitations include low sample size, which limits the generalization of our results masking some significant associations. These data add to a pool of data that could be used for larger meta-analysis studies.


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Conclusion

Our study underscores the significance of rheolytic PMT in the context of Qatar's health care system, where there is a high prevalence of end-stage renal disease. Our findings and the evidence from the cited literature collectively support the contention that AngioJet (Boston Scientific, Natick, Massachusetts, United States) is a safe and effective tool for salvaging both AVF and AVG. Additionally, our study highlights the need for proactive strategies in managing patients post-thrombectomy, considering the relatively high likelihood of re-thrombosis within 12 to 24 months. This emphasizes the importance of continuous monitoring and long-term planning for dialysis access in this patient population.


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Conflict of Interest

None declared.

  • References

  • 1 Ghonimi TA, Hamad A, Iqbal Z. et al. Mortality of dialysis patients in Qatar: a retrospective epidemiologic study. Qatar Med J 2021; 2021 (01) 02
  • 2 Vachharajani T, Jasuja S, AlSahow A. et al. Current status and future of end-stage kidney disease in Gulf Cooperation Council countries: challenges and opportunities. Saudi J Kidney Dis Transpl 2021; 32 (04) 1073-1088
  • 3 Valji K, Bookstein JJ, Roberts AC, Davis GB. Pharmacomechanical thrombolysis and angioplasty in the management of clotted hemodialysis grafts: early and late clinical results. Radiology 1991; 178 (01) 243-247
  • 4 Chan PG, Goh GS. Safety and efficacy of the AngioJet device in the treatment of thrombosed arteriovenous fistula and grafts: a systematic review. J Vasc Access 2018; 19 (03) 243-251
  • 5 Gray RJ, Sacks D, Martin LG, Trerotola SO. Society of Interventional Radiology Technology Assessment Committee. Reporting standards for percutaneous interventions in dialysis access. J Vasc Interv Radiol 2003; 14 (9, Pt 2): S433-S442
  • 6 Access V. Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006; 48 (Suppl. 01) S176-S247
  • 7 Qatar National Planning Council [Internet]. Monthly figures on total population. Accessed October 25, 2024 at: https://www.psa.gov.qa/en/statistics1/StatisticsSite/Pages/Population.aspx
  • 8 Littler P, Cullen N, Gould D, Bakran A, Powell S. AngioJet thrombectomy for occluded dialysis fistulae: outcome data. Cardiovasc Intervent Radiol 2009; 32 (02) 265-270
  • 9 Drouven JW, de Bruin C, van Roon AM, Oldenziel J, Bokkers RPH, Zeebregts CJ. Outcomes after endovascular mechanical thrombectomy in occluded vascular access used for dialysis purposes. Catheter Cardiovasc Interv 2020; 95 (04) 758-764
  • 10 Kasirajan K, Gray B, Ouriel K. Percutaneous AngioJet thrombectomy in the management of extensive deep venous thrombosis. J Vasc Interv Radiol 2001; 12 (02) 179-185

Address for correspondence

Rahil Hussein Kassamali, BSc (hons), MBChB, FRCR, EBIR
Clinical Imaging Department, Hamad Medical Corporation
Doha
Qatar   

Publication History

Article published online:
20 December 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Ghonimi TA, Hamad A, Iqbal Z. et al. Mortality of dialysis patients in Qatar: a retrospective epidemiologic study. Qatar Med J 2021; 2021 (01) 02
  • 2 Vachharajani T, Jasuja S, AlSahow A. et al. Current status and future of end-stage kidney disease in Gulf Cooperation Council countries: challenges and opportunities. Saudi J Kidney Dis Transpl 2021; 32 (04) 1073-1088
  • 3 Valji K, Bookstein JJ, Roberts AC, Davis GB. Pharmacomechanical thrombolysis and angioplasty in the management of clotted hemodialysis grafts: early and late clinical results. Radiology 1991; 178 (01) 243-247
  • 4 Chan PG, Goh GS. Safety and efficacy of the AngioJet device in the treatment of thrombosed arteriovenous fistula and grafts: a systematic review. J Vasc Access 2018; 19 (03) 243-251
  • 5 Gray RJ, Sacks D, Martin LG, Trerotola SO. Society of Interventional Radiology Technology Assessment Committee. Reporting standards for percutaneous interventions in dialysis access. J Vasc Interv Radiol 2003; 14 (9, Pt 2): S433-S442
  • 6 Access V. Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006; 48 (Suppl. 01) S176-S247
  • 7 Qatar National Planning Council [Internet]. Monthly figures on total population. Accessed October 25, 2024 at: https://www.psa.gov.qa/en/statistics1/StatisticsSite/Pages/Population.aspx
  • 8 Littler P, Cullen N, Gould D, Bakran A, Powell S. AngioJet thrombectomy for occluded dialysis fistulae: outcome data. Cardiovasc Intervent Radiol 2009; 32 (02) 265-270
  • 9 Drouven JW, de Bruin C, van Roon AM, Oldenziel J, Bokkers RPH, Zeebregts CJ. Outcomes after endovascular mechanical thrombectomy in occluded vascular access used for dialysis purposes. Catheter Cardiovasc Interv 2020; 95 (04) 758-764
  • 10 Kasirajan K, Gray B, Ouriel K. Percutaneous AngioJet thrombectomy in the management of extensive deep venous thrombosis. J Vasc Interv Radiol 2001; 12 (02) 179-185

Zoom Image
Fig. 1 A 60-year-old man with end-stage renal disease who was dialyzed through left forearm radiocephalic fistula. The patient was referred for fistulography and possible further intervention due to failure of dialysis at his most recent session. Bedside ultrasound demonstrated thrombus in the venous limb of the fistula. Angiogram obtained after antegrade puncture of fistula demonstrates filling defect in the cephalic vein draining fistula, consistent with thrombosed fistula (a), black arrow. Accordingly, endovascular catheter and wire (white arrows) were advanced in the antegrade direction across the thrombosed vein into the central veins (b). Successful restoration of flow was obtained (gray asterisks) after treating with Angiojet followed by percutaneous transluminal angioplasty (c).