Declot

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Overview

Overview content for Declot is not yet available.

Pre-Procedure

Indications:
• Thrombosed dialysis graft

Contraindications:
• Severe hyperkalemia
• Fluid overloaded
• Infected graft
• Severe coagulopathy or contraindication to thrombolysis (recent stroke, trauma, brain tumor, etc.)
• Severe contrast reaction - consider CO2
• Recently placed graft; < 4 weeks - needs surgical revision
• Severe pulmonary hypertension
Sometimes safest path forward is to place catheter to correct hyperkalemia or fluid imbalance. Bring patient back for declot

Preprocedural evaluation:
• Physical exam - evaluate the graft and skin
• Previous studies of the graft
• Dialysis schedule and last successful session
• Allergies
• Evidence of infection

Procedure

Antibiotic prophylaxis
• Not recommended for routine declot
• Special considerations: 1–2 g cefazolin IV in high-risk patients, especially those receiving covered stent
• PCN allergy: Vancomycin recommended

Position body and arm so that the whole graft and outflow to the right atrium can be imaged
• Often times, will involve breaking table
• Moveable C-arm with lower profile can have advantages in terms of maneuvering around patient and operator

Many different techniques when declotting a fistula or graft

Give local 1% lidocaine in tissues over the inflow near the arterial anastomosis.
Access with toward the venous anastomosis
• Many operator use US for access
• Many operator use micropuncture needle or an angiocath which can accept an 0.0038" wire
• There will likely be no blood return when puncturing the graft

Advance wire through needle or micropuncture sheath under fluoroscopy
Place venous outflow sheath - 7 Fr
• May be able to use smaller sheath but 7 Fr generally will allow for larger balloons in case of central stenosis

Advance a 5 Fr catheter centrally to evaluate venous outflow
• Obtain a subclavian venogram to exclude a central stenosis
• Can do pullback venogram to get a sense of clot extent and possible stenoses
• Administer heparin IV
• Treat outflow stenoses

Run fogarty through the venous limb centrally to clear path for TPA
• Administer 2-4 mg of TPA through venous sheath.
• Ok to mix TPA with contrast. Will give some diagnostic information for potential stenoses or clot extent.
• Option to perform balloon maceration with low resistance angiography or possibly using thrombectomy device

Remove arterial plug
Obtain access in the graft/fistula directed towards arterial inflow
• 6 Fr sheath
• Navigate catheter and glidewire combination across arterial anastomosis and direct wire proximally within the artery
• Confirm catheter position with angiogram
• Bring Fogarty balloon across arterial anastomosis. Pull platelet plug. Some operators will pull Fogarty across anastomosis multiple times
• Place Fogarty through venous sheath and push clot centrally
• Check sheaths for blood return. Check dialysis access for pulse

Gentle fistulagram through venous sheath
• Evaluate for stenoses or residual clot
• Angioplasty stenoses
• Reasonable to stent resistant stenotic lesions when appropriate. Angioplasty should be exhausted before stenting in most circumstances.

Once flow is restored, image entire length of dialysis circuit from inflow artery to right atrium
Remove sheaths
• Hemostasis with gentle compression
• Occlusive pressure can re-thrombose dialysis circuit
• Woggle technique helpful. Leave in place for 30-60 minutes following declot. Allows patient to be discharged without leaving suture in place. Extremely helpful if dialysis RN will remove

Post-Procedure

Outcomes:
• Technical success is flow reestablished and patient able to complete 1 session of dialysis
• Fistulas slightly less successful than grafts
• Technical success for fistulas ranging between 75%-100%
• Primary patency: 34-50% at 12 months
• Consider monitoring/surveillance program for dialysis access to reduce declots

Complications:
Major: 1%
Minor: 10%
• Bleeding and/or hematoma
• Vascular dissection or venous rupture
• Embolization of clot into arterial system: avoid; can be difficult to treat

Patients encourage to go immediately to dialysis with full anticoagulation
Avoid tight dressings

Related Procedures

No related procedures.

 

References

[1] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483‐1501.e2. doi:10.1016/j.jvir.2018.06.007
[2] Quencer KB, Friedman T. Declotting the Thrombosed Access. Tech Vasc Interv Radiol. 2017;20(1):38‐47. doi:10.1053/j.tvir.2016.11.007
[3] MacRae JM, Dipchand C, Oliver M, et al. Arteriovenous Access Failure, Stenosis, and Thrombosis. Can J Kidney Health Dis. 2016;3:2054358116669126. Published 2016 Sep 27. doi:10.1177/2054358116669126
[4] El Kassem M, Alghamdi I, Vazquez-Padron RI, et al. The Role of Endovascular Stents in Dialysis Access Maintenance. Adv Chronic Kidney Dis. 2015;22(6):453‐458. doi:10.1053/j.ackd.2015.02.001
[5] National Kidney Foundation. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 update [published correction appears in Am J Kidney Dis. 2016 Mar;67(3):534]. Am J Kidney Dis. 2015;66(5):884‐930. doi:10.1053/j.ajkd.2015.07.015
[6] Funaki B. Problematic declots: complications and irritations. Semin Intervent Radiol. 2004;21(2):69‐75. doi:10.1055/s-2004-833679
[7] BackTable, LLC (Producer). (2018, March 21). Ep 25 – Declots and the Argon Cleaner Device [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

Join The Discussion

 

Demos

Demos are not yet available for this procedure.

Please check back soon.

Basic Concepts In Fistula Graft Declotting

Dr. Leo Valentin discusses IR treatment of AV fistula grafts for hemodialysis.

Thrombectomy of Dialysis AVG

This demo description is not yet available.

 

Tools

Tools are not yet available for this procedure.

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Literature

Literature is not yet available for this procedure.

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Seminars in Interventional Radiology (Jun 2004)

Problematic Declots: Complications and Irritations

This article summarizes common complications and pitfalls encountered with percutaneous graft declotting. Management options are reviewed with an emphasis on those problems that can be successfully managed in the interventional radiology suite.

Endovascular Today (Jun 2013)

Addressing the Clotted Access

An esteemed panel of interventional experts shares viewpoints on optimal methods for identifying and treating clotted AV fistulas and grafts.

Seminars in Interventional Radiology (Jun 2004)

Declotting Maintenance and Avoiding Procedural Complications of Native Arteriovenous Fistulae

This article reviews approaches to declotting and maintaining fistulae. Common procedural complications and their treatment or follow-up are also reviewed.

 

Podcasts

Podcasts are not yet available for this procedure.

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Declots with the Argon Cleaner Podcast with Dr. Sabeen Dhand

Dr. Sabeen Dhand

Dr. Christopher Beck

Dr. Christopher Beck and Dr. Sabeen Dhand describe their declot techniques, with an emphasis on when and how they use the Argon Cleaner device for these cases.

&

 

Blog Articles

Blog articles are not yet available for this procedure.

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bt-procedure-feed-arterial-revasculariza

Pros & Cons of the Argon Cleaner Thrombectomy System for Dialysis Access Declots

If you’re looking at upgrading your declot procedure kit and simplifying your dialysis access cases, you may want to consider the Argon Cleaner thrombectomy ...

bt-procedure-feed-arterial-revasculariza

Shorter Declot Procedure Time Using the Argon Cleaner Thrombectomy System

Declots are typically added to the case schedule on short notice and can require a substantial amount of time depending on the treatment modality you utilize...