TREATMENT OF HEMODIALYSIS ACCESS FAILURE - A ROLE FOR THROMBOLYSIS

Thrombosis of hemodialysis accesses remains a major source of morbidit y, hospitalization, and expense for patients with end-stage renal dise ase. Treatment of hemodialysis accesses includes strategies to prevent access failure and methods for treating acute thromboses. Such techni ques as Doppler ultrasonography, venous pressure monitoring during dia lysis, measurement of ratios of venous to systemic pressures, and meas urement of recirculation have been used to predict accesses at risk of thrombosis. Elective interventions, including surgical revisions and angioplasties, have been shown to lessen the thrombosis rate in both p olytetrafluoroethylene (PTFE) grafts and arterio-venous fistulas. Elec tive revision has also improved long-term patency of both grafts and f istulas when compared with repairing the accesses only after thrombosi s. Despite these attempts, acute thrombosis of hemodialysis accesses r emains a common complication for patients with end-stage renal disease . Historically, surgical thrombectomy has been the gold standard for t reatment of acute hemodialysis access failure. Over the past 10 years, thrombolytic therapy has gained an increasing role in the treatment o f acutely thrombosed PTFE grafts. Thrombolysis has had at least compar able results to surgical thrombectomy in the best centers, with simila r complication rates. Thrombolytic therapy is also significantly less expensive than surgical thrombectomy. In summary, we believe that hemo dialysis access treatment should encompass a comprehensive program, in cluding access surveillance to select accesses at risk of failure. Ele ctive intervention should be performed in an attempt to prevent thromb osis and increase long-term access patency. When thrombosis does occur , pharmacomechanical thrombolysis is the preferable first intervention for acutely occluded PTFE hemodialysis accesses.