A THRILLING
EPISODE

Novel Interventional therapy performed to treat
Thrombosis of AVF on a 30-year-old female

A normal functioning vascular access is vital for the wellbeing of patients on hemodialysis. The thrombosis of haemodialysis fistula or graft is an acute event that can interrupt dialysis treatment, and it may be considered a clinical emergency. Prompt clinical recognition and timely management are necessary to restore access patency.

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A 30-year-old female with End Stage Renal Disease (ESRD), undergoing haemodialysis twicea-week regularly for 6 months, was referred to BLK from a peripheral centre after the sudden onset of pain and swelling of her left upper limb following her regular haemodialysis session. Clinically, there was tenderness and absence of thrill over the left radio-cephalic fistula. There was no sign of any history of trauma or prolonged pressure over the AVF and also no history of other thrombotic events in the past. Ultrasound doppler revealed the presence of thrombus at the anastomotic site with no blood flow. Fistulogram showed near total occlusion of the left radio-cephalic fistula with thrombus.

Fistula thrombi are chief causes of Arteriovenous Fistula (AVF) Dysfunction. Re-establishment of AVF patency can be achieved by Percutaneous Endovenous Intervention (PEVI) which includes Catheter-Directed Thrombolysis (CDT),

Percutaneous Transluminal Angioplasty (PTA) or Surgical Embolectomy with a fogarty catheter. Endovascular thrombolysis is a minimally invasive approach that preserves the AVF function promptly.

After ruling out any contraindication for thrombolysis, retrograde access to the AVF was achieved from the right femoral artery, and a catheter was positioned at the level of the AVF. Pulse spray pharmacomechanical catheterdirected thrombolysis was performed with tissue plasminogen activator (tPAalteplase), which was reconstituted to a concentration of 1 mg/ ml. A total volume of 10 ml (10 mg) was injected manually (1 ml aliquots with 1 ml Luer lock syringe) over half an hour through a locally fashioned multi-side hole catheter into the AVF segment, within the thrombus. After the completion of thrombolysis, there was partial recanalisation of the thrombotic segment with the appearance of a faint thrill. A tight stenosis was also found in the proximal limb of the AVF which was initially obscured by the thrombus. The tight stenosis was dilated with a balloon. Post-procedure, the patient's symptoms completely disappeared with the appearance of prominent thrill over the fistula. Hemodialysis was done the next day following the procedure.

 

dr-neeraj

Dr. Neeraj Bhalla
Director &
Sr. Consultant
Cardiology
BLK Heart Centre
BLK Super Speciality
Hospital, New Delhi

dr-amit

Dr. Amit Goel
Associate Consultant
BLK Heart Centre
BLK Super Speciality
Hospital, New Delhi

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