Catheter Interventions for Hemodialysis Fistulas and Grafts
John A. Bittl, MD*
Ocala Heart Institute, Munroe Regional Medical Center, Ocala, Florida
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Figure 3 Composite Illustration of Access Anatomy of the Right Arm
The commonly used configurations are shown for an autogenous radiocephalic fistula and for prosthetic brachiocephalic and brachiobasilic grafts.
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Figure 4 Pathogenesis of Hemodialysis-Access Failure
The early appearance of an inflow anastomotic stenosis may impair fistula maturation. The late development of a stenosis in the outflow segment of a fistula or graft may cause stasis and thrombosis.
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Figure 5 Facing-Sheaths Technique for Thrombosed Prosthetic Grafts
A 6-F sheath is inserted into the access near the arterial anastomosis and directed into the direction of the outflow, and a 6-F sheath is inserted into the access near the venous anastomosis in the direction of the inflow. Guidewires are advanced in the direction of the inflow and outflow under fluoroscopic guidance. No contrast is injected into a thrombosed access. Abbreviations as in Figures 1 and 2.
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Figure 6 Thrombectomy of Outflow Segment
The AngioJet AVX catheter (Possis Medical) is activated and advanced over the guidewire in the direction of the venous outflow and then withdrawn at a rate of 1 mm/s. Abbreviations as in Figures 1 and 2.
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Figure 7 Thrombectomy of Inflow Segment
The AngioJet catheter (Possis Medical) is activated and advanced over the guidewire in the direction of the arterial inflow and then withdrawn. Abbreviations as in Figures 1 and 2.
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Figure 8 Angioplasty of Stenosis
After flow has been restored, angiography of the entire graft can be completed. The stenosis causing stasis and thrombosis of the graft can be identified and treated with balloon angioplasty. Abbreviations as in Figures 1 and 2.
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Figure 9 Fogarty Thrombectomy of Resistant Thrombus
A 4-F over-the-wire Fogarty catheter is advanced into the brachial artery beyond the resistant inflow stenosis, and the balloon is inflated (A). The catheter is forcefully withdrawn (B), dislodging the resistant thrombus (C).
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Figure 10 Central Venous Stenting
Recurrent restenosis after repeat balloon angioplasty caused by the presence of defibrillator leads ipsilateral to a fistula was associated with marked arm edema and venous collaterals (A), which were no longer visible after stent implantation (B). v. = vein.
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Figure 11 Success Rates
In a consecutive series of 1,437 angiographic procedures, the success of catheter-based interventions is shown resulting in successful hemodialysis for at least 30 days without repeat angiography or surgical revision.
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Figure 12 Duration of Access Patency
Kaplan-Meier analysis of patency after percutaneous intervention is presented for 611 autogenous arteriovenous fistulas and 699 prosthetic grafts undergoing pre-emptive angioplasty or thrombectomy for thrombosis.
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Figure 13 Venous Rupture
Dilation of a stenosis in the basilic vein (A, arrow) was followed by free rupture and extravascular contrast (B, arrows) and successfully treated with a covered stent (C).
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