Mechanical thrombectomy in acute thrombosis of dialysis fistulas: a multi-center study Clément Marcelin 1 Y Le Bras 1, MD, F. Petitpierre 1, MD, N. Grenier 1, MD PHD, J V D Berg MD PHD 3, B Huasen 2, MD Interventional Radiology :Hôpital Pellegrin, Bordeaux, France. Endovascular unit: Royal Preston Hospital, Preston, United Kingdom. Interventional Radiology: Centro Vascolare Ticino, Lugano, Switzerland.
Percutaneous intervention is universally included in the management of thrombosed dialysis fistula. Fistula salvage is a long procedure. Arterio-venous stenosis Cause: stenosis ++
Thrombosis of dialysis fistulas CLINICAL ULTRASOUND DOPPLER NO THRILL & No dialysis possible.
PENUMBRA SYSTEM Original Penumbra System was developed for thrombectomy on stroke (6, 7), and further developed with the Indigo System for peripheral indications such as acute limb ischemia (8, 9), pulmonary artery, and renovisceral occlusive event (10). 6- Papanagiotou et al 7- Son et al 8- Oklu et al 9- Yamada et al 10- Bisdas et al
STUDY To prospectively analyze the technical and clinical outcome of percutaneous thrombectomy aspiration using the Indigo System in acute thrombosed dialysis fistulas.
MATERIAL & METHODS Patients with acute thrombosis of their dialysis fistula (native AVF and prosthetic grafts AVG) were prospectively enrolled in Bordeaux University Hospital, Preston University Hospital and Lugano s Centro Vascolare Ticino Hospital. From June 2016 to April 2017, 35 patients with an average age of 61.8 years (range 33-81) presenting with thrombotic events in dialysis fistulas.
PROCEDURE Systemic heparinization (30UI/kg of heparin) is initiated prior to the procedure. Both antegrade and retrograde vascular access to the venous segment pf the AVF is performed using an 8-French sheath under ultrasound (US) guidance. Aspiration with Indigo Penumbra device was firstly used on the antegrade sheath (CAT 8). Then angioplasty of venous stenosis was performed with a balloon. Finally, aspiration on the retrograde sheath until the anastomose was performed.
2 SHEATHS: 8 french 8
POPULATION Mean age: 61.8yo (33-81) 19 male and 16 female 19 Graft fistula and 16 Autologous fistula 22 fore arm, and 13 upper arm 42% of history of thrombosis, 74% of history previous angioplasty for AVG/AVF stenosis, and 20% of history of previous stenting.
RESULTS Average of time procedure was 38.1 minutes (20-120). Average of blood loss during the procedure was 122.5ml (50-300). Technical efficacy was 97.1% (34/35). Clinical success was 91% (32/35). Six-month primary patency, primary assisted patency and secondary patency were respectively 71%, 80% and 88.5%. Balloon angioplasty (94% 33/35), and stent graft deployment (5.7% 2/35). Arrow-Trerotola (2.8% 1/35) and Fogarty (5.7% 2/35).
EXAMPLE 1 Man of 71 years old with thrombosed of right brachio cephalic AVG
We attempted to recanalize the AVG with the Indigo CAT8 device from the introducer to the cephalic vein
Clot being extracted through Tubing 14
EXAMPLE 2 62 yo male presented acute thrombosis of right brachiocephalic AVF
DISCUSSION Various of systems for thrombosed of vascular access exists: Systemic thrombolysis. Mechanical thrombectomy such Trerotola (Arrow ). Angiojet system (Boston ). Manual thrombo-aspiration.
ADVANTAGES OF INDIGO EFFECTIVE FAST: 38.1 minutes (15-140). 92 min to 116 min (PTD, Lai et al). 78+/-31min (Angiojet device, Maleux et al).
COMPLICATION There was one major complication during the procedure, as a perforation of the vein without clot removal, treated with surgery. We didn t reported embolization from thrombosis fragmentation into the peripheral arterial system or into the pulmonary circulation. No hemolytic complication are expected with the Indigo system. 12- Turmel-Rodrigues et al
CONCLUSION Percutaneous aspiration of thrombosed dialysis fistulas with Indigo device is a fast and effective procedure.
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BIBLIOGRAPHY Lee H-W, Allon M. When should a patient receive an arteriovenous graft rather than a fistula? Semin Dial. 2013 Feb;26(1):6 10. Heye S, Van Kerkhove F, Claes K, Maleux G. Pharmacomechanical thrombectomy with the Castañeda brush catheter in thrombosed hemodialysis grafts and native fistulas. J Vasc Interv Radiol JVIR. 2007 Nov;18(11):1383 8. Yuo TH, Chaer RA, Dillavou ED, Leers SA, Makaroun MS. Patients started on hemodialysis with tunneled dialysis catheter have similar survival after arteriovenous fistula and arteriovenous graft creation. J Vasc Surg. 2015 Dec;62(6):1590 1597.e2. Bent CL, Sahni VA, Matson MB. The radiological management of the thrombosed arteriovenous dialysis fistula. Clin Radiol. 2011 Jan;66(1):1 12. Ascher E, Hingorani A. The Dialysis Outcome and Quality Initiative (DOQI) recommendations. Semin Vasc Surg. 2004 Mar;17(1):3 9. Oklu R, Ghasemi-Rad M, Irani Z, Brinegar KN, Toner E, Hirsch JA. Aspiration thrombectomy using the penumbra catheter. J Vasc Interv Radiol JVIR. 2015 Mar;26(3):454 5. Yamada R, Adams J, Guimaraes M, Schönholz C. Advantages to Indigo mechanical thrombectomy for ALI: device and technique. J Cardiovasc Surg (Torino). 2015 Jun;56(3):393 400.
Papanagiotou P, White CJ. Endovascular Reperfusion Strategies for Acute Stroke. JACC Cardiovasc Interv. 2016 Feb 22;9(4):307 17. Son S, Choi DS, Oh MK, Hong J, Kim S-K, Kang H, et al. Comparison of Solitaire thrombectomy and Penumbra suction thrombectomy in patients with acute ischemic stroke caused by basilar artery occlusion. J Neurointerventional Surg. 2016 Jan;8(1):13 8. Bisdas T, Stavroulakis K, Beropoulis E, Schwindt A, Stachmann A, Austermann M, et al. Initial Experience With the 6-F and 8-F Indigo Thrombectomy System for Acute Renovisceral Occlusive Events. J Endovasc Ther Off J Int Soc Endovasc Spec. 2017 Aug;24(4):604 10. Maleux G, De Coster B, Laenen A, Vaninbroukx J, Meijers B, Claes K, et al. Percutaneous rheolytic thrombectomy of thrombosed autogenous dialysis fistulas: technical results, clinical outcome, and factors influencing patency. J Endovasc Ther Off J Int Soc Endovasc Spec. 2015 Feb;22(1):80 6. Turmel-Rodrigues LA. Declotting a thrombosed Brescia-Cimino fistula by manual catheterdirected aspiration of the thrombus. Cardiovasc Intervent Radiol. 2005 Feb;28(1):10 6.
Mechanical thrombectomy in acute thrombosis of dialysis fistulas: a multi-center study Clément Marcelin 1 Y Le Bras 1, MD, F. Petitpierre 1, MD, N. Grenier 1, MD PHD, J V D Berg MD PHD 3, B Huasen 2, MD Interventional Radiology :Hôpital Pellegrin, Bordeaux, France. Endovascular unit: Royal Preston Hospital, Preston, United Kingdom. Interventional Radiology: Centro Vascolare Ticino, Lugano, Switzerland.