Declot

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

Positioning

• 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

Access

Many different techniques when declotting a fistula or graft.

Give local 1% lidocaine in tissues over the inflow near the arterial anastomosis.
Access toward the venous anastomosis.
• Many operators use US for access
• Many operators 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

Treat Outflow Stenoses

• 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

Administer TPA

• 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

Fistulagram

• 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.

Circuit Imaging

• 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