Percutaneous treatment of thrombosed prosthetic brachial-basilic access by the transradial approach
Article Outline
We report on the percutaneous treatment of thrombosed prosthetic brachial-basilic access using the transradial approach. Seven procedures in five patients with a thrombosed prosthetic brachial-basilic access were performed using this approach. Balloon angioplasty of the prosthetic graft and the venous anastomosis site was performed in all patients. In addition, pulse spray thombolysis, before balloon angioplasty, and maceration were performed in one patient. All procedures were clinically and anatomically successful. There were no procedure-related complications.
There are a variety of different methods for the treatment of thrombosed hemodialysis grafts. These include pulse-spray pharmacomechanical thrombolysis, balloon thrombectomy, and the use of a variety of mechanical thrombectomy devices. The first step in performing any of these percutaneous thrombectomy procedures is to gain access into the occluded graft. The classic technique is crossed-catheter pulse-spray thrombolysis, and the more recently described methods using mechanical thrombectomy devices; all utilize two separate puncture sites to gain entry into the graft.1, 2
The prosthetic brachial-basilic access technique is difficult to perform with two separate puncture sites because of its short straight course. The transradial approach (TRA) has been commonly used in percutaneous coronary interventions.3, 4 It is common knowledge that the TRA not only reduces access-site complications, but also allows for the immediate mobility of the patient, with consequent shortening of the hospitalization period.
We present a novel access technique with the TRA used for the endovascular treatment of thrombosed prosthetic brachial-basillic access.
Methods
Patients
From May 2007 to July 2008, 50 consecutive patients with dysfunctional or thrombosed hemodialysis access presented for treatment. Among them, five patients (two men and three women; mean age, 54 years; range, 41-69 years) with thrombosed prosthetic brachial-basilic access were enrolled in this study. All patients had a thrombosed graft and stenosis of the venous anastomosis site but no arterial inflow lesion on Doppler ultrasonography. A repeated procedure was performed 13 and 17 days after first procedures in two patients. Finally, seven procedures were performed in five patients.
Radial artery access used for thrombosed hemodialysis grafts
All endovascular interventions were performed with angiography of the graft through a retrograde, radial artery puncture with micropuncture set (a 21G needle, 50cm flexible 0.18 guide-wire and 4-Fr vascular sheath, Cook, Bloomington, Indiana, USA) under ultrasound guidance. All patients had the Allen's test before the procedure. For the endovascular treatments, a 5- or 6-Fr introducer sheath was inserted and 5,000 units of heparin mixed with 0.2 mg of nitroglycerin was administered intra-arterially. Angiography was performed using a 5-Fr angled catheter (60cm, Slip-Cath Beacon Tip KMP catheter, Cook) placed at the brachial artery level (Fig 1).
Fig 1.
A 57-year-old female patient with a thrombosed prosthetic brachial-basilic access. A. Angiogram obtained from the frontal view before the intervention demonstrates the origin of the thrombosed arterial limb of the graft (arrow). B. Angiogram obtained from the frontal view with the catheter placed just distal to the venous limb of the graft shows a tight stenosis at the venous limb. C. Angiogram obtained from the frontal view after the PTA shows patency.
The stenosed or occluded segments were traversed with a hydrophilic guide wire, and angiography was performed to check the proximal stenotic segment. Balloon angioplasty for the stenotic segment was performed using high-pressure balloons with an 8 mm diameter and up to 20 atm of pressure. Intravenous boluses of fentanyl citrate (0.05 mg, up to a total dose of 0.15 mg) were administered if the patient experienced pain during the balloon dilation. Balloon inflation for 30 seconds was routinely used, and in cases of flow-limiting dissections and/or elastic recoil, inflation for up to two minutes was performed. Thrombotic lesions in the grafts were macerated with a PTA balloon, 6 mm in diameter. Additional thrombectomy such as aspiration was not performed.
Pharmacomechanical thrombolysis and boluses of urokinase (10,000 units/mL, total of 200,000 units) were forcefully injected into the thrombotic segment through a pulse-spray type of catheter (1 mL/dose, two boluses per minute, with a 1-mL syringe) during the intervention in only one patient with extensive thrombosis in the graft; however, prolonged injections were not used and maceration of the residual thrombus was carried out.
After the endovascular intervention, the introducer sheath was immediately removed, and the puncture site was manually compressed for 15-20 minutes, after which a compressive band was placed for six hours. Radial and ulnar pulses were manually assessed by nursing staff and primary operator. Hemodialysis through the graft was initiated on the same day.
Criteria for the classification of procedure outcome
The procedure outcome was classified according to the recommendations of the Society of Interventional Radiology.5 Anatomic success for the treated lesion was defined as the achievement of a stenosis of less than 30% of the residual diameter. Clinical success after the treatment of a thrombosed graft was defined as resumption of normal dialysis; clinical success after the treatment of a stenosis was defined as improvement of the clinical parameters (flow during dialysis, >250 mL/min).
Results
The thrombosed graft was evaluated by angiography. The stenotic segment was at the venous anastomosis site in all cases. There were no inflow lesions on angiography. The anatomic and clinical success rates for the treated lesions were both 100% (7/7). Pulmonary complications such as a pulmonary embolism and puncture-related complications did not occur. The mean follow-up length was 235 days (range, 138 to 343 days). The four-month primary and secondary patency rates were 60% (3/5) and 100% (5/5).
Discussion
The majority of interventionalists utilize a dual-access, crossed-catheter type approach for endovascular thrombectomy procedures for loop-configuration polytetrafluoroethylene hemodialysis grafts. The presence of the initial vascular sheath, inserted into the arterial limb, often interferes with the removal of thrombus from the arterial limb. The thrombus can “hide” behind the sheath and be inaccessible to a mechanical thrombectomy. Dislodging the arterial plug can also be problematic due to the presence of a second sheath; this is because there is twice the likelihood that the arterial plug, or other residual debris, will become trapped in the graft.6
For prosthetic loop grafts, when using the apex puncture technique, the thrombus can be more readily removed from both limbs of the graft, unencumbered by the presence of vascular sheaths.6 However, this technique may not be suitable for a straight arteriovenous fistula such as the prosthetic brachial-basilic access. In these fistulas, it is difficult to change sheath direction from the arterial limb to the venous limb because of its straight course; in addition, it is hard to perform the procedure with an arm puncture site that has a short working range.
The TRA for coronary procedures has gained widespread acceptance since it was first introduced by Campeau3 in 1989. As noted in a recent meta-analysis of randomized trials, the radial approach can virtually eliminate local vascular complications.7 The major limitation of the transradial approach is potential access failure because of the smaller radial artery size. True puncture failures using the TRA have been reported to be as low as 0.25%.8 However, the puncture failure rate can be improved by ultrasound guidance. In this study, we easily accessed the radial artery in all patients with ultrasound guidance.
In our study, a repeated procedures were performed in two patients, and successive TRA in same arm was reported to be possible in three to five times.9 In this report, they used 5 and 6-Fr sheath and the same as ours. It is sometimes very difficult to conduct complex procedures such as PTA with high pressure balloon, stent placement, and aspiration thrombectomy through 6-Fr sheath, but sheath equal to or greater than 7-Fr was reported to be feasible to place in the radial artery for these procedures in selected patients after Doppler examinations.10
In conclusion, thrombosed prosthetic brachial-basilic access was safely and effectively managed by the transradial approach. In addition, thrombosed or dysfunctional arteriovenous fistulas with a straight type configuration at the upper arm level can also be treated using this technique.
Author contributions
References
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- Quality improvement guidelines for percutaneous management of the thrombosed or dysfunctional dialysis access. J Vasc Interv Radiol. 2003;14:S247–S253
- . The apex-puncture technique for mechanical thrombolysis of loop hemodialysis grafts. J Vasc Interv Radiol. 1999;10:775–779
- Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004;44:349–356
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- . Influence of the ratio between radial artery inner diameter and sheath outer diameter on radial artery flow after transradial coronary intervention. Catheter Cardiovasc Interv. 1999;46:173–178
Conflict of interest: none.
PII: S0741-5214(08)02273-8
doi:10.1016/j.jvs.2008.12.034
© 2009 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
