Early rethrombosis of clotted hemodialysis grafts: Graft salvage achieved with an aggressive approach

OBJECTIVE. The purpose of this study was to assess the efficacy of repeated pulsed-spray pharmacomechanical thrombolysis for salvage of early rethromb osis of hemodialysis grafts and to identify factors that predict successful outcome. MATERIALS AND METHODS. Thirty-four patients with initial successful thrombo lysis were referred for repeated thrombolysis because of early rethrombosis . Repeated thrombolysis occurred within 1 month of initial thrombolysis. Te chnical success and patency rates were calculated. Causes of graft thrombos is and procedural modifications were analyzed. RESULTS. The 39 rethrombosed grafts were successfully treated using pharmac omechanical thrombolysis, and patients underwent subsequent hemodialysis. T he underlying flow-limiting stenoses were treated with balloon angioplasty using a larger balloon (41%), a same-size angioplasty balloon (18%), stent placement (15%), or increased anticoagulation (5%). A new stenosis location was discovered in 18%. Mean primary patency was 80.9 days (2.6 months) and secondary patency was 235.4 days (7.8 months). With life table analysis, 1 -, 3-, 6-, and 12-month primary patency rates were 72%, 31%, 23%, and 15%, and secondary patency rates were 77%, 62%, 51%, and 31%, respectively. Graf t patency rates in our study were compared with our institutional historic graft patency rates, with no significant difference noted (p = 0.76). No ma jor procedural complications occurred. CONCLUSION. Adequate technical success and patency rates for pharmacomechan ical thrombolysis occur even for hemodialysis grafts that rethrombose withi n 1 month. After thrombolysis, aggressive search for and treatment of addit ional stenoses are warranted.