PULSE-SPRAY PHARMACOMECHANICAL THROMBOLYSIS OF THROMBOSED HEMODIALYSIS ACCESS CRAFTS - LONG-TERM EXPERIENCE AND COMPARISON OF ORIGINAL AND CURRENT TECHNIQUES

OBJECTIVE. Pulse-spray pharmacomechanical thrombolysis is an evolving method for the treatment of vascular occlusions in which a highly conc entrated fibrinolytic agent is injected as a high-pressure spray direc tly into thrombus. The purpose of this retrospective study was to anal yze our long-term experience with this technique for the treatment of clotted hemodialysis grafts and to compare the efficacy and safety of the original and current methods. SUBJECTS AND METHODS. Over 6 years, 284 cases of dialysis graft thrombosis were considered suitable for tr eatment with pulse-spray thrombolysis. The original technique involved the injection of highly concentrated urokinase directly into a clot t hrough two crisscross catheters with multiple side holes, The current technique includes early fragmentation of residual clot with a balloon catheter, intrathrombic injection of heparin, mechanical treatment of a lysis-resistant clot at the arterial anastomosis, and routine admin istration of aspirin. After thrombolysis, underlying obstructions were treated with balloon angioplasty, atherectomy, or stents. The technic al success, immediate clinical success, and frequency of complications for the entire population were analyzed. In addition, the results for 36 cases treated with the original technique were compared with the r esults for 37 recent cases treated with the current technique, RESULTS . Of 284 cases considered suitable for treatment, thrombolysis was not done in eight cases because the venous anastomosis could not be cross ed. Thrombolysis was discontinued in two cases because of extravasatio n of contrast material. The technical success for all grafts considere d for treatment was 96%; 92% of treated grafts remained patent for at least 24 hr. Major complications occurred in 1% of cases, and minor co mplications occurred in 9% of cases. The clinical efficacies of the or iginal and current techniques were 86% and 92%, respectively The mean thrombolytic agent infusion time was reduced from 44 +/- 20 min to 23 +/- 13 min (p<.001), The overall procedure time for the recently treat ed subgroup was 67 +/- 26 min, There was no significant difference in the frequencies of major and minor complications between the treatment subgroups,CONCLUSION. Pulse-spray pharmacomechanical thrombolysis is a reliable, rapid, and safe method for recanalization of occluded dial ysis grafts. The current technique has been proven as safe and effecti ve as the original technique but offers the advantage of a significant reduction in the time required for the infusion of thrombolytic agent .