- Email: [email protected]
Transjugular venous approach for endovascular intervention in upper-extremity dialysis access fistulae and grafts
Author’s Accepted Manuscript Transjugular Venous Approach for Endovascular Intervention in Upper Extremity Dialysis Access Fistulae and Grafts Hector Ferral, Marc J. Alonzo www.elsevier.com/locate/enganabound
PII: DOI: Reference:
S0895-7967(17)30015-7 http://dx.doi.org/10.1053/j.semvascsurg.2017.06.002 YSVAS50535
To appear in: Seminars in Vascular Surgery Cite this article as: Hector Ferral and Marc J. Alonzo, Transjugular Venous Approach for Endovascular Intervention in Upper Extremity Dialysis Access Fistulae and Grafts, Seminars in Vascular Surgery, http://dx.doi.org/10.1053/j.semvascsurg.2017.06.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Seminars Vascular Surgery Dec – 2016 – Improving Dialysis Access Outcomes
Transjugular Venous Approach for Endovascular Intervention in Upper Extremity Dialysis Access Fistulae and Grafts.
Hector Ferral, MD Marc J. Alonzo, MD
Section of Interventional Radiology, Department of Radiology, NorthShore University Health System, Evanston, Illinois
Corresponding author: Hector Ferral, MD. NorthShore University Health System, Evanston Hospital, Department of Radiology, Section of Interventional Radiology 2650 Ridge Ave, Evanston, IL 60201 Phone: 847-570-2160 e-mail: [email protected]
Conflict of interest: Hector Ferral is a consultant for Terumo and W.L. Gore Marc J. Alonzo has no conflict of interest
2
Abstract A transjugular venous access is an alternative approach for endovascular intervention in upper extremity dialysis arteriovenous fistulae (AVF) and grafts. The transjugular access is recommended for patients who have an unfavorable anatomy for direct arm access approach. Ultrasound evaluation of the arteriovenous (AV) access is essential before intervention and includes evaluation of the inflow artery and outflow vein diameters, arteriovenous anastomosis and the entire outflow vein, specifically looking into potential problem areas. Patency of the ipsilateral internal jugular vein needs to be assessed. If patency of the ipsilateral internal jugular vein is confirmed, it can be used for access. Retrograde access into the outflow vein is obtained with a reversecurve catheter and a glidewire. In some cases, puncture of the outflow vein is necessary along with the use of snares to direct the catheter system into the outflow vein. The techniques for intervention are described. Successful access into the outflow vein is possible in over 95% of cases. The technique is useful for fistula maturation, declotting procedures and arteriovenous fistula and graft maintenance. If intervention is unsuccessful, the transjugular access offers the possibility of placement of a dialysis catheter for temporary or long-term dialysis.
3
Introduction The practice of interventional radiology is an always changing, dynamic process. For some reason, newer generations of practitioners in the medical field focus on the most current literature to either establish or modify their practice. Some useful endovascular techniques have been described in the past and for some reason they never became popular, and were either ignored or archived in the files and not given the attention they deserve. Such is the case of performing interventions in upper extremity arteriovenous fistulae (AVF) or grafts using a transjugular vein approach (1). The technique was originally described by Zaetta et al in 1998 (1). The original technique described 24 patients with thrombosed dialysis grafts with successful interventions in most patients (1). The purpose of this manuscript is to describe the transjugular venous approach technique for endovascular interventions in patients with dysfunctional hemodialysis AVF’s or grafts.
Technique This is a technical review that describes a technique that in our experience has been useful and in our opinion, underutilized. At our institution, the transjugular approach has become the approach of choice for patients with dysfunctional upper extremity hemodialysis access who have problematic venous outflow, short arms, or unfavorable anatomy for direct arm access.
4
Access Evaluation Evaluation of the AV access starts with a detailed ultrasound examination of the AV access (2, 3). This step is critical to the success of this technique as identification of the inflow artery and outflow vein is extremely important to plan the procedure. The upper extremity is scanned with ultrasound using a 9 MHz linear probe. The anatomy of the entire AV access should be carefully evaluated. The AV anastomosis is identified, measured and checked for patency. The outflow vein is then followed in its entire length and its diameter is measured at various segments (Figure # 1). The patency of the ipsilateral internal jugular vein is then examined. If the anatomy of the arteriovenous access is suitable and the internal jugular vein is found to be patent, then the neck and the entire upper extremity are prepped and draped in a sterile fashion in preparation to access the AV fistula or graft using the transjugular approach. Catheterization Technique Access into the internal jugular vein is obtained under ultrasound guidance. Once the access has been achieved, a 7 Fr. 10 cm endovascular sheath is placed. This is followed by retrograde access into the main outflow vein, which can be achieved with a reverse-curve catheter (SOS select) and a glidewire (Figure # 2). In certain cases, it may be difficult to achieve retrograde access into the cephalic vein; in these circumstances, it may be necessary to directly puncture the outflow vein with a micropuncture system and advance a 0.018” guidewire into the central veins. Then, with the use of a snare, the 0.018” guidewire is captured and the snare and wire combination are then pulled into the desired outflow vein (1) (Figure # 3).
5
Once a successful retrograde access is achieved into the main outflow vein, most interventions can be performed in a retrograde fashion. The transjugular venous access technique has been utilized for AV access maturation assistance, declotting procedures and access maintenance.
Fistula Maturation Interventions to assist fistula maturation may be technically challenging. Previous studies have shown that approximately 60% of AV fistulae fail to mature (3) and the most important causes of failed maturation include stenosis within the outflow vein (4) and the presence of large collaterals stealing the flow from the main outflow conduit (3, 5). Most AV fistulae salvage procedures are performed with bi-directional punctures within the system with either very small systems or sheathless technique to avoid occlusion of the veins by the vascular sheaths (3). In these instances, although it may be technically difficult to find the outflow vein in patients with non-maturing fistulae and small outflow veins, the transjugular approach offers the possibility of gaining access to the fistula, and perform fistula-saving interventions without occluding the outflow system (Figure # 4). The patient illustrated in Figure # 4 is a patient who had a non-maturing AV fistula in the upper arm. The cause for non-maturation was a greater than 90% stenosis approximately 4 cm central to the arteriovenous anastomosis. The entire upper extremity was evaluated with ultrasound and it was decided to proceed with a transjugular approach since a direct access into the outflow vein was thought to be cumbersome from the technical standpoint. As shown in the images, a retrograde access was obtained and the severe stenosis was negotiated with a wire and catheter combination. Balloon angioplasty
6
of the stenosis was performed, however results were suboptimal with a significant residual stenosis and a local area of extravasation that required placement of a stent-graft (3). The final outcome was good and the fistula was functional after intervention. The transjugular approach was useful for three reasons: a) it avoided the technical difficulties of a direct puncture into the outflow vein; 2) allowed interventions requiring larger sheaths without interfering with the outflow vein and 3) avoided the hemostasis problems in a recently treated AV fistula. Hemostasis was simple and easily achieved with manual compression of the ipsilateral jugular vein.
Fistula declotting Declotting of an AV fistula may be more demanding from the technical standpoint than declotting of an AV graft (6). Several techniques for fistula and graft declotting have been described including pulse spray infusion of tissue plasminogen activator (rtPA), thromboaspiration, and mechanical thrombectomy (6-10). These techniques are usually complemented with balloon angioplasty or stent placement to restore or improve flow into the system. The most common approach employed is the criss-cross placement of sheaths directly into the outflow vein (6). As mentioned previously, a crossed access into the outflow vein may be cumbersome, laborious and may make the declotting more difficult as sometimes the sheaths themselves may interfere with the flow within the system. The transjugular approach may be a suitable solution for a problematic arteriovenous fistula declotting. Figure # 5 illustrates an example of AV fistula declotting using the transjugular approach. In this case, the patient had a native fistula from the distal brachial artery to a transposed basilic vein. Her arm
7
was anatomically short and she had a self-expanding metallic stent within the outflow vein in the mid-arm that had been placed during a previous declotting procedure. After evaluation of the clotted fistula, it was determined that a direct crossed access into the outflow basilic vein would be difficult. The fistula was declotted using a transjugular venous access. As the images demonstrate, it was possible to declot the entire fistula successfully using this approach. The thrombus burden was macerated with an over the wire Arrow mechanical thrombectomy device (PTD; Arrow, Reading, PA). Fistulogram after thrombus maceration demonstrated a severe stenosis in the outflow vein which was treated with balloon angioplasty. The transjugular approach offers advantages as the outflow vein is not punctured at all. Successful retrograde access into the inflow artery is possible and intervention is possible to improve the inflow. If for any reason the declotting procedure is unsuccessful, a temporary dialysis catheter may be inserted.
AV access maintenance. Management of bleeding complications. Endovascular intervention for AV access maintenance is common practice in any busy endovascular practice. Procedures are usually completed in an outpatient basis and usually straightforward. A low percentage of cases can be challenging from the management standpoint. Cases that are especially challenging are bleeding problems in elderly patients secondary to the formation of pseudoaneurysms at previous puncture sites (11). These lesions tend to bleed profusely and may be difficult to control without the insertion of self-expandable stent-grafts. Figure # 6 illustrates the case of an 85 yearold woman with end stage renal disease and a native fistula from the distal brachial artery
8
to a transposed basilic vein. This patient had presented previously with two bleeding pseudoaneurysms that required the insertion of two overlapping Viabahn stent-grafts (W.L. Gore, Flagstaff, AZ). She presented to the Emergency Department with two new bleeding pseudoaneurysms that had developed through the graft material of the previously placed stent-grafts. The clinical image shows the patient’s arm and ultrasound evaluation showed that at least 80% of the course of her outflow vein had been covered with the previously placed stent-grafts. At the time of evaluation it was decided that this patient needed additional stent-graft placement. The 10 Fr Viabahn stents are inserted through a 12 Fr endovascular sheath. Technically and anatomically, it would have been quite difficult to find a good space within the outflow vein to successfully achieve the two main goals in this case: 1) cover the two pseudoaneurysms successfully with a stentgraft and 2) place a 12 Fr sheath within the outflow vein in a suitable location without affecting the flow in the system. The patient was evaluated and it was decided to proceed with the intervention using a transjugular approach. The images show successful placement of two overlapping 10 mm diameter Viabahn stent-grafts to cover the bleeding pseudoaneurysms. The procedure was entirely done via the transjugular approach without interfering with the flow in the AV system. Hemostasis was simple, with manual compression over the jugular vein puncture site.
9
Summary The transjugular venous approach to gain access to upper extremity AV fistulae and grafts is in our opinion a very useful, yet underutilized technique. The transjugular approach offers several advantages: 1) Single puncture intervention with a puncture site that does not involve the outflow vein, 2) simple hemostasis which is achieved with manual compression over the jugular vein, not affecting the flow within the AV system and avoiding the use of compression dressings or “purse strings” over the puncture sites at the outflow vein, 3) the possibility of using sheaths to deploy devices that use larger French sizes for insertion, 4) less radiation to the operator as the operator’s hands are never within the fluoroscopic field, 5) allows intervention for fistula maturation, declotting and fistula maintenance and 6) if intervention is unsuccessful an access for a temporary dialysis catheter is already in place. This approach has the disadvantage that retrograde catheterization of the outflow vein may be technically difficult, however, once the skill is obtained, it is usually straightforward and possible in over 95% of cases. In our practice, the transjugular approach is selected as the approach of choice in roughly 10-15% of our dialysis access intervention cases. It is advantageous to know the technique as it may be very helpful and practical in patients with difficult arm anatomy or patients with veins of small size where the presence of a sheath may severely interfere with the flow of the AV system.
10
References
1.
Zaetta JM, Baum RA, Haskal ZJ, Shlansky-Goldberg RD, Soulen MC. Thrombosed dialysis grafts: percutaneous mechanical declotting using a central venous approach. J Vasc Interv Radiol. 1998;9:833-6.
2.
Singh P, Robbin ML, Lockhart ME, Allon M. Clinically immature arteriovenous hemodialysis fistulas: effect of US on salvage. Radiology. 2008;246:299-305.
3.
Miller GA, Goel N, Khariton A, Friedman A, Savransky Y, Trusov I, et al. Aggressive approach to salvage non-maturing arteriovenous fistulae: a retrospective study with follow-up. J Vasc Access. 2009;10:183-91.
4.
Clark TW, Cohen RA, Kwak A, Markmann JF, Stavropoulos SW, Patel AA, et al. Salvage of nonmaturing native fistulas by using angioplasty. Radiology. 2007;242:286-92.
5.
Lee T, Tindni A, Roy-Chaudhury P. Improved cumulative survival in fistulas requiring surgical interventions to promote fistula maturation compared with endovascular interventions. Semin Dial. 2013;26:85-9.
6.
Zaleski G. Declotting, maintenance, and avoiding procedural complications of native arteriovenous fistulae. Semin Intervent Radiol. 2004;21:83-93.
7.
Andriani M, Drago G, Bernardi AM, Da Porto A, De Luca M, Riegler P, et al. Recombinant tissue plasminogen activator (rt-PA) as first-line therapy for declotting of haemodialysis access. Nephrol Dial Transplant. 1995;10:1714-9.
8.
Clark TW, Hirsch DA, Jindal KJ, Veugelers PJ, LeBlanc J. Outcome and prognostic factors of restenosis after percutaneous treatment of native hemodialysis fistulas. J Vasc Interv Radiol. 2002;13:51-9.
9.
Turmel-Rodrigues LA. Declotting a thrombosed Brescia-Cimino fistula by manual catheterdirected aspiration of the thrombus. Cardiovasc Intervent Radiol. 2005;28:10-6.
10.
Trerotola SO, Vesely TM, Lund GB, Soulen MC, Ehrman KO, Cardella JF. Treatment of thrombosed hemodialysis access grafts: Arrow-Trerotola percutaneous thrombolytic device versus
11
pulse-spray thrombolysis. Arrow-Trerotola Percutaneous Thrombolytic Device Clinical Trial. Radiology. 1998;206:403-14. 11.
Azevedo PN, Turmel-Rodrigues L. Never too old for an autogenous dialysis fistula? Results of endovascular interventions in nonagenarians. Semin Dial. 2015;28:E1-6.
12
13
14
15
16
PII: DOI: Reference:
S0895-7967(17)30015-7 http://dx.doi.org/10.1053/j.semvascsurg.2017.06.002 YSVAS50535
To appear in: Seminars in Vascular Surgery Cite this article as: Hector Ferral and Marc J. Alonzo, Transjugular Venous Approach for Endovascular Intervention in Upper Extremity Dialysis Access Fistulae and Grafts, Seminars in Vascular Surgery, http://dx.doi.org/10.1053/j.semvascsurg.2017.06.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Seminars Vascular Surgery Dec – 2016 – Improving Dialysis Access Outcomes
Transjugular Venous Approach for Endovascular Intervention in Upper Extremity Dialysis Access Fistulae and Grafts.
Hector Ferral, MD Marc J. Alonzo, MD
Section of Interventional Radiology, Department of Radiology, NorthShore University Health System, Evanston, Illinois
Corresponding author: Hector Ferral, MD. NorthShore University Health System, Evanston Hospital, Department of Radiology, Section of Interventional Radiology 2650 Ridge Ave, Evanston, IL 60201 Phone: 847-570-2160 e-mail: [email protected]
Conflict of interest: Hector Ferral is a consultant for Terumo and W.L. Gore Marc J. Alonzo has no conflict of interest
2
Abstract A transjugular venous access is an alternative approach for endovascular intervention in upper extremity dialysis arteriovenous fistulae (AVF) and grafts. The transjugular access is recommended for patients who have an unfavorable anatomy for direct arm access approach. Ultrasound evaluation of the arteriovenous (AV) access is essential before intervention and includes evaluation of the inflow artery and outflow vein diameters, arteriovenous anastomosis and the entire outflow vein, specifically looking into potential problem areas. Patency of the ipsilateral internal jugular vein needs to be assessed. If patency of the ipsilateral internal jugular vein is confirmed, it can be used for access. Retrograde access into the outflow vein is obtained with a reversecurve catheter and a glidewire. In some cases, puncture of the outflow vein is necessary along with the use of snares to direct the catheter system into the outflow vein. The techniques for intervention are described. Successful access into the outflow vein is possible in over 95% of cases. The technique is useful for fistula maturation, declotting procedures and arteriovenous fistula and graft maintenance. If intervention is unsuccessful, the transjugular access offers the possibility of placement of a dialysis catheter for temporary or long-term dialysis.
3
Introduction The practice of interventional radiology is an always changing, dynamic process. For some reason, newer generations of practitioners in the medical field focus on the most current literature to either establish or modify their practice. Some useful endovascular techniques have been described in the past and for some reason they never became popular, and were either ignored or archived in the files and not given the attention they deserve. Such is the case of performing interventions in upper extremity arteriovenous fistulae (AVF) or grafts using a transjugular vein approach (1). The technique was originally described by Zaetta et al in 1998 (1). The original technique described 24 patients with thrombosed dialysis grafts with successful interventions in most patients (1). The purpose of this manuscript is to describe the transjugular venous approach technique for endovascular interventions in patients with dysfunctional hemodialysis AVF’s or grafts.
Technique This is a technical review that describes a technique that in our experience has been useful and in our opinion, underutilized. At our institution, the transjugular approach has become the approach of choice for patients with dysfunctional upper extremity hemodialysis access who have problematic venous outflow, short arms, or unfavorable anatomy for direct arm access.
4
Access Evaluation Evaluation of the AV access starts with a detailed ultrasound examination of the AV access (2, 3). This step is critical to the success of this technique as identification of the inflow artery and outflow vein is extremely important to plan the procedure. The upper extremity is scanned with ultrasound using a 9 MHz linear probe. The anatomy of the entire AV access should be carefully evaluated. The AV anastomosis is identified, measured and checked for patency. The outflow vein is then followed in its entire length and its diameter is measured at various segments (Figure # 1). The patency of the ipsilateral internal jugular vein is then examined. If the anatomy of the arteriovenous access is suitable and the internal jugular vein is found to be patent, then the neck and the entire upper extremity are prepped and draped in a sterile fashion in preparation to access the AV fistula or graft using the transjugular approach. Catheterization Technique Access into the internal jugular vein is obtained under ultrasound guidance. Once the access has been achieved, a 7 Fr. 10 cm endovascular sheath is placed. This is followed by retrograde access into the main outflow vein, which can be achieved with a reverse-curve catheter (SOS select) and a glidewire (Figure # 2). In certain cases, it may be difficult to achieve retrograde access into the cephalic vein; in these circumstances, it may be necessary to directly puncture the outflow vein with a micropuncture system and advance a 0.018” guidewire into the central veins. Then, with the use of a snare, the 0.018” guidewire is captured and the snare and wire combination are then pulled into the desired outflow vein (1) (Figure # 3).
5
Once a successful retrograde access is achieved into the main outflow vein, most interventions can be performed in a retrograde fashion. The transjugular venous access technique has been utilized for AV access maturation assistance, declotting procedures and access maintenance.
Fistula Maturation Interventions to assist fistula maturation may be technically challenging. Previous studies have shown that approximately 60% of AV fistulae fail to mature (3) and the most important causes of failed maturation include stenosis within the outflow vein (4) and the presence of large collaterals stealing the flow from the main outflow conduit (3, 5). Most AV fistulae salvage procedures are performed with bi-directional punctures within the system with either very small systems or sheathless technique to avoid occlusion of the veins by the vascular sheaths (3). In these instances, although it may be technically difficult to find the outflow vein in patients with non-maturing fistulae and small outflow veins, the transjugular approach offers the possibility of gaining access to the fistula, and perform fistula-saving interventions without occluding the outflow system (Figure # 4). The patient illustrated in Figure # 4 is a patient who had a non-maturing AV fistula in the upper arm. The cause for non-maturation was a greater than 90% stenosis approximately 4 cm central to the arteriovenous anastomosis. The entire upper extremity was evaluated with ultrasound and it was decided to proceed with a transjugular approach since a direct access into the outflow vein was thought to be cumbersome from the technical standpoint. As shown in the images, a retrograde access was obtained and the severe stenosis was negotiated with a wire and catheter combination. Balloon angioplasty
6
of the stenosis was performed, however results were suboptimal with a significant residual stenosis and a local area of extravasation that required placement of a stent-graft (3). The final outcome was good and the fistula was functional after intervention. The transjugular approach was useful for three reasons: a) it avoided the technical difficulties of a direct puncture into the outflow vein; 2) allowed interventions requiring larger sheaths without interfering with the outflow vein and 3) avoided the hemostasis problems in a recently treated AV fistula. Hemostasis was simple and easily achieved with manual compression of the ipsilateral jugular vein.
Fistula declotting Declotting of an AV fistula may be more demanding from the technical standpoint than declotting of an AV graft (6). Several techniques for fistula and graft declotting have been described including pulse spray infusion of tissue plasminogen activator (rtPA), thromboaspiration, and mechanical thrombectomy (6-10). These techniques are usually complemented with balloon angioplasty or stent placement to restore or improve flow into the system. The most common approach employed is the criss-cross placement of sheaths directly into the outflow vein (6). As mentioned previously, a crossed access into the outflow vein may be cumbersome, laborious and may make the declotting more difficult as sometimes the sheaths themselves may interfere with the flow within the system. The transjugular approach may be a suitable solution for a problematic arteriovenous fistula declotting. Figure # 5 illustrates an example of AV fistula declotting using the transjugular approach. In this case, the patient had a native fistula from the distal brachial artery to a transposed basilic vein. Her arm
7
was anatomically short and she had a self-expanding metallic stent within the outflow vein in the mid-arm that had been placed during a previous declotting procedure. After evaluation of the clotted fistula, it was determined that a direct crossed access into the outflow basilic vein would be difficult. The fistula was declotted using a transjugular venous access. As the images demonstrate, it was possible to declot the entire fistula successfully using this approach. The thrombus burden was macerated with an over the wire Arrow mechanical thrombectomy device (PTD; Arrow, Reading, PA). Fistulogram after thrombus maceration demonstrated a severe stenosis in the outflow vein which was treated with balloon angioplasty. The transjugular approach offers advantages as the outflow vein is not punctured at all. Successful retrograde access into the inflow artery is possible and intervention is possible to improve the inflow. If for any reason the declotting procedure is unsuccessful, a temporary dialysis catheter may be inserted.
AV access maintenance. Management of bleeding complications. Endovascular intervention for AV access maintenance is common practice in any busy endovascular practice. Procedures are usually completed in an outpatient basis and usually straightforward. A low percentage of cases can be challenging from the management standpoint. Cases that are especially challenging are bleeding problems in elderly patients secondary to the formation of pseudoaneurysms at previous puncture sites (11). These lesions tend to bleed profusely and may be difficult to control without the insertion of self-expandable stent-grafts. Figure # 6 illustrates the case of an 85 yearold woman with end stage renal disease and a native fistula from the distal brachial artery
8
to a transposed basilic vein. This patient had presented previously with two bleeding pseudoaneurysms that required the insertion of two overlapping Viabahn stent-grafts (W.L. Gore, Flagstaff, AZ). She presented to the Emergency Department with two new bleeding pseudoaneurysms that had developed through the graft material of the previously placed stent-grafts. The clinical image shows the patient’s arm and ultrasound evaluation showed that at least 80% of the course of her outflow vein had been covered with the previously placed stent-grafts. At the time of evaluation it was decided that this patient needed additional stent-graft placement. The 10 Fr Viabahn stents are inserted through a 12 Fr endovascular sheath. Technically and anatomically, it would have been quite difficult to find a good space within the outflow vein to successfully achieve the two main goals in this case: 1) cover the two pseudoaneurysms successfully with a stentgraft and 2) place a 12 Fr sheath within the outflow vein in a suitable location without affecting the flow in the system. The patient was evaluated and it was decided to proceed with the intervention using a transjugular approach. The images show successful placement of two overlapping 10 mm diameter Viabahn stent-grafts to cover the bleeding pseudoaneurysms. The procedure was entirely done via the transjugular approach without interfering with the flow in the AV system. Hemostasis was simple, with manual compression over the jugular vein puncture site.
9
Summary The transjugular venous approach to gain access to upper extremity AV fistulae and grafts is in our opinion a very useful, yet underutilized technique. The transjugular approach offers several advantages: 1) Single puncture intervention with a puncture site that does not involve the outflow vein, 2) simple hemostasis which is achieved with manual compression over the jugular vein, not affecting the flow within the AV system and avoiding the use of compression dressings or “purse strings” over the puncture sites at the outflow vein, 3) the possibility of using sheaths to deploy devices that use larger French sizes for insertion, 4) less radiation to the operator as the operator’s hands are never within the fluoroscopic field, 5) allows intervention for fistula maturation, declotting and fistula maintenance and 6) if intervention is unsuccessful an access for a temporary dialysis catheter is already in place. This approach has the disadvantage that retrograde catheterization of the outflow vein may be technically difficult, however, once the skill is obtained, it is usually straightforward and possible in over 95% of cases. In our practice, the transjugular approach is selected as the approach of choice in roughly 10-15% of our dialysis access intervention cases. It is advantageous to know the technique as it may be very helpful and practical in patients with difficult arm anatomy or patients with veins of small size where the presence of a sheath may severely interfere with the flow of the AV system.
10
References
1.
Zaetta JM, Baum RA, Haskal ZJ, Shlansky-Goldberg RD, Soulen MC. Thrombosed dialysis grafts: percutaneous mechanical declotting using a central venous approach. J Vasc Interv Radiol. 1998;9:833-6.
2.
Singh P, Robbin ML, Lockhart ME, Allon M. Clinically immature arteriovenous hemodialysis fistulas: effect of US on salvage. Radiology. 2008;246:299-305.
3.
Miller GA, Goel N, Khariton A, Friedman A, Savransky Y, Trusov I, et al. Aggressive approach to salvage non-maturing arteriovenous fistulae: a retrospective study with follow-up. J Vasc Access. 2009;10:183-91.
4.
Clark TW, Cohen RA, Kwak A, Markmann JF, Stavropoulos SW, Patel AA, et al. Salvage of nonmaturing native fistulas by using angioplasty. Radiology. 2007;242:286-92.
5.
Lee T, Tindni A, Roy-Chaudhury P. Improved cumulative survival in fistulas requiring surgical interventions to promote fistula maturation compared with endovascular interventions. Semin Dial. 2013;26:85-9.
6.
Zaleski G. Declotting, maintenance, and avoiding procedural complications of native arteriovenous fistulae. Semin Intervent Radiol. 2004;21:83-93.
7.
Andriani M, Drago G, Bernardi AM, Da Porto A, De Luca M, Riegler P, et al. Recombinant tissue plasminogen activator (rt-PA) as first-line therapy for declotting of haemodialysis access. Nephrol Dial Transplant. 1995;10:1714-9.
8.
Clark TW, Hirsch DA, Jindal KJ, Veugelers PJ, LeBlanc J. Outcome and prognostic factors of restenosis after percutaneous treatment of native hemodialysis fistulas. J Vasc Interv Radiol. 2002;13:51-9.
9.
Turmel-Rodrigues LA. Declotting a thrombosed Brescia-Cimino fistula by manual catheterdirected aspiration of the thrombus. Cardiovasc Intervent Radiol. 2005;28:10-6.
10.
Trerotola SO, Vesely TM, Lund GB, Soulen MC, Ehrman KO, Cardella JF. Treatment of thrombosed hemodialysis access grafts: Arrow-Trerotola percutaneous thrombolytic device versus
11
pulse-spray thrombolysis. Arrow-Trerotola Percutaneous Thrombolytic Device Clinical Trial. Radiology. 1998;206:403-14. 11.
Azevedo PN, Turmel-Rodrigues L. Never too old for an autogenous dialysis fistula? Results of endovascular interventions in nonagenarians. Semin Dial. 2015;28:E1-6.
12
13
14
15
16