BackTable / VI / Podcast / Transcript #117

Podcast Transcript: Successful (and Quick!) Declots for AV Access

with Dr. Neghae Mawla

Interventional Radiologist Christopher Beck talks with Interventional Nephrologist Neghae Mawla about how to perform successful Declot procedures for AV fistulae and grafts, including tips and tricks to make this procedure safe and efficient. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Declot Procedure Workup

(2) Declot Technique: Outflow Then Inflow

(3) Treating Anastomoses

(4) Sheath Placement in Declot Procedures

(5) Dealing with Residual Clot

(6) Declot Procedure Time

(7) Declot Complications

(8) Drug-Coated Balloons for Declots

(9) Follow-Up Care for Declots

(10) Declot Tips and Tricks

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Successful (and Quick!) Declots for AV Access with Dr. Neghae Mawla on the BackTable VI Podcast)
Ep 117 Successful (and Quick!) Declots for AV Access with Dr. Neghae Mawla
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[Chris Beck]
Ladies and gentlemen, welcome to the BackTable Podcast, your source for all things endovascular and minimally invasive. If you're a new listener, welcome. For all of our regular listeners, welcome back, and thank you for listening. You can find all the previous episodes of the podcast on iTunes, Spotify, or our website, which is backtable.com. Subscribe to the podcast. Leave us a review or reach out to us on Twitter, or send us an email. Let us know how we can make this podcast a more valuable resource for you, the IR and endovascular community.

[Chris Beck]
Today's BackTable Podcast is sponsored by Mermaid Medical. Mermaid Medical Group is an international provider of medical devices focused on technologies for patients in the vascular interventional dialysis and critical care settings. Mermaid Medical's newly released D-Clot Rotational Thrombectomy System is raising the standard of safe and effective thrombectomy by integrating several purpose build features to include manual aspiration, a single piece tip design, tip reverse rotation and enhanced safety torque. D-Clot's HD-engineered advancements provide both effective and safe thrombectomy. Visit mermaidmedical.com, or contact customer care at mermaidmedical.com for information on the D-Clot HD Rotational Thrombectomy System. Let them know that you heard it from the BackTable Podcast.

I'm Chris Beck. I'll be your host today. I'm a private practice interventional radiologist based out of New Orleans. We're going to be talking about declots today, so dialysis access maintenance. We have today Neghae Mawla. Man, welcome back to the show.

[Neghae Mawla]
Thank you so much for having me, guys. I enjoyed last time. I'm looking forward to talking this time.

[Chris Beck]
Can you talk about your practice and why you’re talking about declots today?

[Neghae Mawla]
I'm an interventional nephrologist out of Dallas. I work in an ASC setting. All I do is interventional work, and so it's dialysis access maintenance. We do about 2,500 cases a year at our center. We have two centers in the practice, one downtown and one up in North Dallas, and I'm basically there. We do about 50 declots a month on average. We've streamlined the efficiency. I like talking to people to see how other people do things. My partner who joined me 10 years ago does declots differently, and we've swapped ideas and shared and modified our technique along the way based off of each other and watching each other do it and talking to each other.

[Neghae Mawla]
I think it's fun to be able to exchange ideas on how things are done. I really hope that we get a lot of that today. I want to hear how you guys do it. I'll tell you what I do and see what happens along the way.

[Chris Beck]
Absolutely. We also have with us Aaron Fritts. He's on mute right now, but Fritts is going to be jumping in periodically to throw in some color commentary. Is that right, Fritts?

[Aaron Fritts]
Yes. Thanks, Chris. Thanks for having me.

(1) Declot Procedure Workup

[Chris Beck]
All right. All right, let's jump into it. Let's get into the procedure. When patients come to you, and it's a declot procedure, you know it's a declot, what does your workup look like beforehand in the center? Do you ultrasound the arm? Do you already... Let's just say it's one that you've never seen before. Do you do anything ahead of time as far as physical exam or ultrasound evaluation to get an idea of the landscape that you're going to be working on?

[Neghae Mawla]
I don't do an ultrasound evaluation. I just do a quick physical exam, usually just looking at the skin, making sure there's nothing there, trying to assess aneurysm sizes that may be complicated along the way. But assuming it's a standard PTFE graft, either straight in the upper arm or loop in the forearm, is really just trying to figure out where the arterial side is. Every now and then, I have a patient that can't tell me which one's their arterial side. I always like to get my venous access in first. That's the only reason it matters, but it's not a deal breaker if I can't figure it out.

[Neghae Mawla]
I've always been a two sheath kind of guy. I know there's a couple of people that do a single sheath thrombectomy. I just don't like flipping back and forth if I need to, so I've always done the two sheaths anyway. Really, that's the only thing I'm trying to figure out. Then other basic things: When was the last time you had an intervention? If you're at our center before, I usually go back and review previous films, but assuming that someone who's here the first time, I ask them, "When was your last intervention?" those kinds of things. The pre-op visit is pretty quick.

[Chris Beck]
Is there anyone that you will not perform a declot on in terms of either they just recently had their graft or fistula placed, or do you check any labs beforehand, where like someone's potassium hits a certain level where you won't go after a declot? Is there ever a situation where you believe to place the catheter, get dialysis, then bring them back after things have settled down.

[Neghae Mawla]
I don't have access to labs, so that's an easy answer. I don't. I don't worry about potassium. I never worry about INR or platelet counts or anything like that. We just go as far as: Is it quicker to put a catheter in? I mean, the ultimate answer is I gotta get them dialyzed, and so whatever is quicker to dialyze. Most of the time, I can do the declot just as quickly as I can do the catheter. Again, dialysis is not always accessible for them. Most of the time, they leave me and go back to their home facility to get their dialysis treatment. I don't do the catheter then.

[Neghae Mawla]
The only time would be if they say they absolutely cannot lie flat on the table because they're just so overloaded. Then I would say, "Okay, fine, maybe I can keep them propped up, do a quick femoral catheter, get them dialysis and bring them back in a couple of days and do the declot.

[Chris Beck]
Okay, that's fair. As far as anesthesia requirements for the procedure, are you doing local, moderate sedation, something deeper?

[Neghae Mawla]
No, just moderate sedation and local.

[Chris Beck]
So fentanyl and Versed pretty much?

[Neghae Mawla]
Pretty much, and they do fine with that.

[Chris Beck]
All right, so the patient makes it out of the preoperative area, and they're on the table for you. What are some of the things that you're considering as far as room setup? One of the things that I feel like sometimes I struggled with, especially early on, was making sure that my techs had the area prepped appropriately, and had enough access where you're not just putting one sheath in. I'm also a two sheaths kind of guy, so sometimes they have to prep a little higher up than they think. Can you talk about room setup and things that you have prepped and ready to go to create those efficiencies for the procedure?

[Neghae Mawla]
Usually, my setup is pretty standard across all of my cases, whether it's an angiogram or a declot, and so the room setup is pretty straightforward. I typically like to stand where the armpit is with the arms extended out. I'll stand to where the armpit is for a left arm, and I'll stand at the head of the patient for a right arm. I just stand opposite. That way, basically, my right hand is doing most of the work driving centrally.

[Chris Beck]
I see. We talked a little bit about your room setup. Do you have a fixed system? Is it like a movable C-arm? That's one of the things you hear a lot of complaints about. If you have a fixed system that sometimes I feel like the declot can become a little bit cumbersome, because you're either having to break the table or you always feel like you're in the way as the operator.

[Neghae Mawla]
I have a movable C-arm. That way, my table is pretty much centered and fixed, and all of the movement is with the II. That makes it much easier. My monitors are mounted on the ceiling, so they're easy to swing around to whatever position I need to.

[Chris Beck]
No matter where you stand, you're always able to get the monitors right in front of you, and basically, the C-arm is extremely mobile and a bit nimble. That's a huge advantage.

[Neghae Mawla]
Those are things I would never think about. Those are things I would never think about, because this is all I have and all I know.

(2) Declot Technique: Outflow Then Inflow

[Chris Beck]
That's right. I mean, you make what you have work. All right, so you're starting the procedure. Any preoperative medications? Do you give heparin? What's the first thing you do?

[Neghae Mawla]
I don't do an IV in preop, because these patients, it's just so hard to get sometimes. I'm going to be in there anyway. I do all the sedation and medications myself, so we don't have separate IV access for any rare cases. First, I will do the arterial limb. Let's say it's closer to the arterial anastomosis. I'll put my seven French sheath in directed towards the outflow, and then usually a Kumpe catheter straight up into the central veins, do my central run, conscious sedation, 5,000 of heparin. That's how I start.

[Chris Beck]
Well, let me also back you up on whenever you're getting access, just by palpation, just by feel, do you like ultrasound guidance?

[Neghae Mawla]
I do it just by field because I've just always done it that way. Merit has a seven French with a micro wire and a micro access needle, and so that's the kit that I use. It's a short four-centimeter sheath. One of my nuisances and pet peeves are when my sheaths are overlapping, so I keep it with a four-centimeter sheath for my declot, and I just do it by palpation. If it's somebody that is a fistula that is difficult to palpate, then I'll bring in the ultrasound, and do it under ultrasound guidance. But let's say a PTFE or a very well established fistula, I'll just go in by feel.

[Chris Beck]
Gotcha. All right, so you do your central run. Let's say you do have a central stenosis. Do you go ahead and treat that right after you've done your central run, or do you reserve that for later?

[Neghae Mawla]
I reserve that for the end, assuming there's no thrombus burden all the way up to the centrals, but I would say it's there but it's not the reason for the thrombotic episode. That's why I say I reserve that for the end. Let me just go do the declot first. Then it's basically looking at a central angiogram and angioplasty at that point.

[Chris Beck]
Sure. All right, so you have your seven French in. You've done your central run, looks clear centrally. At that point, are you getting arterial access?

[Neghae Mawla]
No, so then I'll do a pullback with contrast. I'll just look at the outflow veins to identify the level of the stenosis. With your graft, it's usually at the venous anastomosis. We look at the outflow vein and how much clot burden there is in the outflow vein. Most of the time, it's not that much. It's all in the graft. Once I identify that and I see my thrombus, I stop with my pullback. I'll take the Kumpe out. The way I was always taught was outflow, inflow, polish.

I mean, if you can do that, then you're good. My partner used to always do inflow. He would get up to this point, do the central, sedate, pullback, and then he would get his arterial sheath and then do the inflow. That works, too. I mean, at the end of the day, I don't think it matters how you do it, but it's just different ways of doing it, but I was always taught if there's no outflow and you can't get an outflow, why did you bother with the inflow? I treat the outflow first.

[Chris Beck]
How do you treat the outflow? Is it a combination of Fogarty? Do you use any thrombectomy devices, either aspiration or mechanical? This is where everyone has their own signature.

[Neghae Mawla]
There's a couple of ways of doing it. There's really two ways that I do it. One is either just balloon maceration. I'll take a seven by eight centimeter balloon, and I'll just balloon from lesion all the way back to the sheath, or I will do a rotational thrombectomy device. Which one I decide varies based on two factors. One is how much length of the circuit there is. The longer the circuit or the bigger the clot burden, the more likely I am to grab a device as opposed to just a balloon.

[Neghae Mawla]
If it's an older graft, and there's a lot of age and I know their history, and not only is the venous anastomosis going to be a problem but their venous cannulation side, their arterial cannulation side, and I'm expecting and I know multiple disease points along the way, then I'll just balloon it at that point, because then you can macerate and treat it all at the same time.

[Chris Beck]
Gotcha. As far as devices, do you have a preferred device if you are going to go to the device route?

[Neghae Mawla]
I have three devices in house. I have an over the wire trerotola. The only reason I don't use it very often is because of cost. For an ASC, it's the most expensive having that over wired device. But on that rare occasion, where I feel like I don't want to lose my wire, just because for whatever reason it took so long to get across the venous anastomosis that I just don't want to lose it, I'll grab that. Then I have the Argon Cleaner thrombectomy device. There's actually two sizes. There's a six French XT, and there's a seven French 15 that has a larger diameter, and then I have the D-Clot thrombectomy device by Mermaid Medical, which is also a rotational thrombectomy device. Actually, I have four because I have two different Argons.

[Chris Beck]
I guess this might be getting a little bit into the weeds, but putting the trerotola aside where you're trying to maintain your wire access, how do you decide between whether or not you're going to go either your seven or six French Argon Cleaner?

[Neghae Mawla]
Between the six and the seven French argon is based on the size. If I've got a big fistula with a large pseudoaneurysm, then I will grab the seven French usually. The Cleaner XT, I think the maximum diameter is 10 maybe 11 millimeters versus the 15 millimeter diameter, so it's a stronger battery and rotational force or whatever they're doing there. For a larger and reasonable fistula, I'll grab the 15 first.

[Chris Beck]
It seems like you're either going with a balloon macerate or with a device. Is there any situation where you just go Fogarty and just push the clot with a little Fogarty balloon or?

[Neghae Mawla]
If it's a brand new graft, and I expect everything to be healthy, then sometimes I'll do just the Fogarty on the arterial side. I'll put the sheath for the arterial side very close to the venous anastomosis. If it's three, four weeks old and D-clotted off, then a lot of times, you can start with that. I just get a lot of clot clearance that way, and I'm not expecting anything else. Sometimes it's just easier to do the Fogarty that way.

[Chris Beck]
If you do decide to go device like the Cleaner, are you using any thrombolytics with that? I mean, I know that you had already said that you do the heparin after you do your central run, but any TPA?

[Neghae Mawla]
I don't use TPA as a norm. It's not my standard. I'll use it when I'm stuck, when I'm seeing resistant clots, or if I've got a large aneurysm burden. Also, I may take one of my Kumpes in there. In the early step, I may drop a little bit, usually two milligrams of TPA, but TPA is not a standard step inside my thrombectomy. Usually, what I do is when I grab my device, either the Cleaner or the D-Clot, if it's a standard graft, I alternate back and forth. Sometimes I feel like a Cleaner. Sometimes I feel like a Clot. I basically will just turn it on, and I'll pull. Then through the side port, I will just slowly inject a little bit of contrast.

[Neghae Mawla]
That way, I can see if I've macerated thrombus burden as I'm doing the pullback. That way, I've got the entire pullback. I’ve not even used 10 CCs of contrast, usually, to inject, and I can see what my outflow looks like and where all my lesions are. The other thing I like about these devices is you will actually see the tip or the rotational component getting narrower as you come across a stenotic lesion, and so even without a contrast injection. If you're following it, you can usually identify where you're going to come across a lesion along the way.

[Chris Beck]
Gotcha. All right. You mentioned doing a little bit of injection through the side port, and you're talking about the side port of the device and not the side port of the of the device, not the sheath.

[Chris Beck]
All right, so you handled the outflow with whether it be a balloon maceration or thrombectomy, and you feel pretty good that you've macerated the clot burden. What do you move to next?

[Neghae Mawla]
If I've done the device, then I'll go do my angioplasty of the outflow. If I'm doing balloon maceration, angioplasty is all done in one step. If I'm doing the device, then I'll go to my angioplasty. I usually start with a seven millimeter balloon as my standard for anything and everybody, unless it's a really small fistula or something I worry about, but usually a graft, I'll start with a seven millimeter balloon. Most of our grafts here in the Dallas area are the tapered four to seven, and so most of the venous outflow is a seven.

[Chris Beck]
That's also partly knowing your referring docs and what people are putting in.

[Neghae Mawla]
But even if you don't know, you're safe to upsize by one usually. That's why I say even if it's a six millimeter straight graft, a seven millimeter balloon is going to be fine. That's why I always start with the seven.

[Chris Beck]
All right. You've either done a combination of device and angioplasty or a straight balloon maceration, and then do you move to placing your arterial sheath?

[Neghae Mawla]
Yeah. After I do the angioplasty, then I'll aspirate from that sheath. Then I can basically establish back bleeding. From my venous outflow, I've gotten the clot out, and then whatever, I may pick up a few bits and pieces of clot from the aspiration from that sheath at that point. It's all through a back bleeding process. I'll do a quick little injection to what the outflow looks like, if that all looks good, then I'll put my second sheath in.

[Chris Beck]
Will you just go into a little bit briefly about, for those who don't know, what do you mean by the back bleeding technique and how you're aspirating from that venous sheath?

[Neghae Mawla]
Once your outflow is reestablished, and there's no significant clot burden, or even if there's a little bit, you're basically going to pull from your venous outflow. If it's an upper arm vein, let's say you're pulling from the axillary, then that will actually pull really well usually. I can usually just aspirate a syringe, maybe two syringes, just to make sure that it's clean, and so I feel like I've gotten the outflow completely cleared of any remaining clot.

[Chris Beck]
All right, so then you go to the arterial sheath. To recap, you did seven French for the venous outflow, and then arterial inflow, in what size sheath?

[Neghae Mawla]
Six French sheath here.

[Chris Beck]
You have a six French, a short sheath directed towards the arterial inflow, and then it's another Kumpe and Glidewire across the anastomosis?

[Neghae Mawla]
Yep. That's basically it. The first time I'm doing everything, I will use a Kumpe to guide me. Once I know the patient's anatomy and what they're comfortable with, if I'm doing the outflow, I'll just take the balloon and do my central imaging with the balloon, and then I pull back with the balloon. Then I just angioplasty with the balloon, so I'm not having to swap out everything. The same thing on the arterial side. Most of the time, if the wire goes straight up into the artery, then I'll just go in with the Fogarty.

(3) Treating Anastomoses

[Neghae Mawla]
I like having the wire proximal to the anastomosis in the artery, so into the brachial artery going up towards the axilla. That way, I can pull, and I can go back and inject. But if it doesn't work, and it goes down the arm towards the hand, I'm okay with that too, usually.

[Chris Beck]
This is something that I wanted to talk about a little bit. There are a lot of anastomosis out there that I think you can spend a lot of time trying to get central, meaning that you cross the anastomosis, but it's going distally easily, but it's not able to come up until the brachial artery. You're still able to get the same results just by pulling the Fogarty from the mid radial artery across the anastomosis.

[Neghae Mawla]
Usually, I'll go for the ulnar side, because the ulnar artery is a little bit bigger, but you don't have to get that far. Usually, if it's an upper arm, it's high enough away from the bifurcation. I like going up just because I think it saves me a little step down the line, but if it doesn't, because of whatever reason--You're doing this blind, so you can't figure out why it's not going up and why it only goes down, and maybe the way it's hooked around in the anastomosis created. Then if it constantly keeps going distal down the forearm, then I say, "Okay, fine. Let's just do it that way." Do the Fogarty. I always use an over wire Fogarty.

[Chris Beck]
Can you talk about, for the audience who may not do as many of these, or maybe we have plenty of trainees who listen, the difference between having your wire in the brachial or having your wire go distal and what the difference is and why it matters for you for either a subsequent step?

[Neghae Mawla]
I'm going to pull with the Fogarty across the arterial anastomosis. I've got a syringe on each sheath. The one on the arterial sheath, the first, the seven French sheath towards the venous outflow is just hooked up, and it's just passive. My tech is aspirating on the venous sheath. That one is a little bit more active. I'll usually do two passes with the Fogarty balloon. The reason I have the syringe on the seven French sheath is because usually, once I clear to that level, that syringe will open up on its own. So it gives me an indication that, "Okay, I've cleared up until this point," but if I'm unable to aspirate at the sheath where the Fogarty is in, then there's probably some clot right around there. Usually, that's what happens that there's clot right around the sheath and it doesn't aspirate, but the other one will aspirate.

[Chris Beck]
All right, that makes sense.

[Neghae Mawla]
Two passes there. If my wire's in the brachial artery, then I just take the Fogarty up into the brachial artery, and I do my injection. I just do an arteriogram. That's the only reason I really like having it up there if it goes up that way.

[Chris Beck]
Say it's the other situation where you're only able to get your wire to go distally, and then you've made your two Fogarty passes, do you then take a catheter and try and renegotiate that wire up into the brachial? You're nodding, but I just want to cue the audience.

[Neghae Mawla]
Yes. Because then, at least what I will do is I'll just do a very slow injection through my sheath, and let it go retrograde, and I can get a little silhouette of what the arterial anastomosis anatomy looks like. I do it slowly. Just in case there's still a little bit of clot there, a little plug there that I haven't fully cleared. I don't want to push that, go so heavily that I'm going to push that into the artery, but usually, you can do it gradually just to see what the anatomy of the anastomosis looks like. That way, I can manipulate my company and my wire, and steer and get up into the brachial artery.

[Chris Beck]
I just wanted to drill down on that for a second for some of maybe the uninitiated that whenever you're dealing with some clot that hasn't been cleared from your dialysis circuit, you don't want to blow in a whole bunch of contrast at the risk of blowing clot into the arterial into your inflow or outflow radial/ulnar artery.

[Neghae Mawla]
Right. That's why I do that part really slowly. If I do see some clot there, I'll do a couple more passes with the Fogarty, but most of the time, that clot is still there because there's probably a stenosis there as well. If I'm unable to clear the clot with the Fogarty, I will just do an angioplasty balloon.

[Chris Beck]
Which size? Do you start with a particular size, or do you have an injection that you're sizing it to the stenosis?

[Neghae Mawla]
Either I'll do a five or a six millimeter at the arterial anastomosis.

[Chris Beck]
Do you have any balloons that you like for this area, because I feel like sometimes your high pressure balloons... I didn't even ask you that. Are there any particular balloons that you like for declots, or you'll just take anything?

[Neghae Mawla]
I just take anything. Our standard balloon is the gladiator, which I think is the Mustang in the hospital. I think it's the same balloon. They just market it for outpatient versus inpatient differently.

[Chris Beck]
I had no idea.

[Neghae Mawla]
I believe it's basically the exact same balloon. That's my standard go-to balloon for everything. I will use a Conquest if I don't get full effacement with that balloon. Then at the arterial side, I will use the Ultraverse if it's a very tight band, because sometimes, that Gladiator doesn't want to make that U turn up. The Ultraverse has been really nice for that. Everything I do is over an 035. I think once a year, I may grab an 018 balloon system just to make that bend into a radial artery that the 035 system wasn't doing, but everything is 035.

[Chris Beck]
Yeah, but few and far between if you have to downsize far, right?

[Neghae Mawla]
Right.

[Chris Beck]
Can you talk a little bit about angioplasty of the arterial anastomosis in the arterial segment? It's been my experience that sometimes this can be a very delicate area to work in, and if you're overly aggressive that you can actually shut down or dissect. You can dissect inflow. You can call a spasm. Can you talk about some technique things there or how careful you have to be if you're going to be working in that spot?

[Neghae Mawla]
I think the biggest issue there is really making sure you don't oversize it. If you've got the ultrasound, use the ultrasound so you can size it according to the artery, and you should be fine. Most of the time, I keep the arterial anastomosis around 10 or 12 atmospheres. I typically don't go higher than that. That's usually sufficient. I don't do long inflations. Most of my inflations, venous or arterial, are an up-down. I'm happy with the way the balloon looks. Let's take it down and another picture.

[Chris Beck]
I think that's something that can vary from operator to operator. I think that if you're doing these a lot like an up-down technique, you realize it is totally sufficient for dialysis work. I think, on the other hand, if you're someone who dabbles a lot in arterial revascularization, you think about these prolonged inflations and how you have to keep the catheter, or you have to keep the balloon up.

[Neghae Mawla]
I think I saw something several years ago that showed short inflation versus a three-minute inflation. I think the end conclusion was, "The final image looks good, but the reintervention rate was unchanged."

[Neghae Mawla]
You bring up a good point. I mean, for dialysis access, these are big vessels. These are really mostly compliant vessels. All you gotta do is break the balloon open. Once it's open, I don't believe that you need to sit there and hold it open to change. I go up-down. I do everything. You guys are the fluoro experts. I do everything with a low dose and pulse on my image intensifier, so I can keep my fluoro times quicker just because it's a six, seven millimeter vein graft dropping into a 10 millimeter vessel. Why do I need full dose fluoro for that?

[Chris Beck]
All right, so at this point, you've tuned up the arterial anastomosis or the juxta-arterial segment. Do you ever, at any point, use any devices in the arterial limb or across the anastomosis?

[Neghae Mawla]
No. I've never done that. If there's an aneurysm or an aneurysmal segment in that juxta anastomotic region, I'll put the device into there, but I'm very particular about not crossing the device into the artery.

(4) Sheath Placement in Declot Procedures

[Chris Beck]
Okay, fair. Can you talk a little bit... This is something that I think only comes up when you're in the procedure, but talk about sheath placement and why it's important to have a little bit of physical distance between the tips of your sheaths. What I'm basically talking about is how to avoid the dueling sheath situation where you have overlapping sheaths, and why that's such a pain in the ass.

[Neghae Mawla]
Sometimes that's hard to do, but I always try to keep them away from each other because inevitably, when you're doing the Fogarty, a lot of times, that clot will come and get stuck behind the sheaths or between the sheaths. Then I'm pulling the sheath back or pulling one of the sheaths out just so I can address the other one. It's like this little web of stuff that just slows the flow down. That's why I always try to make sure my sheaths are far enough away from each other. Typically, the places I will avoid are the cannulation zones, because I expect to find disease there or right around there.

[Neghae Mawla]
I try not to get near each anastomosis. I will stay proximal, but in the event that there's a juxta anastomotic stenosis or a swing segment stenosis, I try not to put my seven French sheath into any of that either.

[Chris Beck]
I access most of the time with ultrasound, but I'll take it on a case by case basis. What I've found is, especially in fistula work, if you access too close into the juxta-arterial segment where the vessel really narrows, then the sheath can become flow limiting.

[Neghae Mawla]
Yes, and so that's the problem. Then you got two sheaths that are touching and overlapping. Then it's just a hot mess.

(5) Dealing with Residual Clot

[Chris Beck]
I agree. I agree. All right, so you've treated the venous side. Now you've treated the arterial side. What's next?

[Neghae Mawla]
Then you take a look into what the rest of it looks like. If I'm happy, then I'm happy. If there's a little recoil, I go address that, so this is that polish stage, right? If there's a little recoil, if there's a little extra clot burden, maybe go after it with the cleaner or the balloon or the Fogarty and just polish up what the outflow looks like. Then you're pretty much done. If there's a central lesion, now's the time to go assess the central again, and see if I decide this to be a clinically important central lesion that I want to balloon. I have had the scenario where patients did not have arm swelling before the declot, and then I see something centrally during the declot.

[Neghae Mawla]
I say, "Well, they were asymptomatic before," so I leave it alone. Then two weeks later, they come back. That was probably more indicative of the fact that they were really low flow headed towards failure type of dialysis access, that the central lesion was not able to be symptomatic. Once I fully restored flow, then that central lesion became symptomatic. It's one of those things that I go case by case. If I know the history, I may go ahead and treat it. If not, usually, I tell them, "Hey, there was something there. Let's see how it does, but since you weren't having symptoms before, then I would assume that you won't have symptoms after."

[Neghae Mawla]
But if they do develop symptoms after, it's probably because that dialysis access was putzing along for a long time anyway.

[Chris Beck]
Gotcha. Now that you've got it tuned up and highly flowing, then I can see where that would become problematic with the central stenosis. Talking about the last section of the procedure, basically, what you're calling the polish portion. Are you trying to evacuate every piece of clot that you see? I know it's hard to quantify the clot, the residual clot burden that you're comfortable with, but how much clot burden are you comfortable with at the end, and does it change whether you have a fistula that you're declotting versus a graft that you're declotting?

[Neghae Mawla]
For a graft, no. Most of the time, it depends on where it is, but if it hangs out at the venous anastomosis, I might think that there's residual or recoil that's there. A lot of times, what I'll do is I'll take my Fogarty and just use it as a diagnostic feel. If you inflate the Fogarty and go forward, if it crosses the venous anastomosis without any difficulty, and you're not getting a lot of resistance, I'll usually just say, "Okay, we're happy. We're good." But if I'm getting resistance pushing that Fogarty, then I'll say, "You know what? There's probably some recoil here that maybe it doesn't look as bad on imaging."

[Neghae Mawla]
That's when you want to say, "Okay, do I want to come back and upsize the balloon, Conquest the balloon, or stent the outflow?"

[Neghae Mawla]
I mean, really, if you think about how much clot is in a dialysis circuit, I mean, you're looking at five mls, maybe seven mls. There's not a lot of clot burden in there. To say that I'm leaving a little bit behind, I mean, how much am I leaving behind?

[Chris Beck]
I've run across different people with different schools of thought, and I've seen some people who believe that it's sacrilege to leave any amount of clot in grafts because they think that that clot is thrombogenic. Then if you leave anything in the circuit, that clot then seeds the rest of the clot, and it creates a clot bomb. Then I've seen some people who are just more forgiving of the fistula. They say, "It's an aneurysm segment. It's sometimes difficult to clean out the whole thing." You would spend your whole day trying to clean out an aneurysmal fistula segment.

[Neghae Mawla]
I go a lot by exam here, because if I've got a good thrill, and it's not pulsatile and I don't feel that resistant pulsatile outflow, then I say, "You know what? This is probably not a hemodynamically significant residual clot." You're absolutely right. These large ones are hard to open up, and there's actually a handful of nephrologists that will do a mini open thrombectomy, where they'll just make a little cut down into that aneurysm, squeeze it all out, and then close it off. They will basically put a balloon on each end, and so they've got hemostasis and control, proximal and distal controls. They'll put a Fogarty up. They'll put a balloon up, and then you can cut down to the aneurysm, express out all the clot, close that up, and then continue on with your percutaneous side of it. A “mini open” is what they call it. That's a really fascinating technique. I'll tell you, the times that I struggle are there. The ones that I struggle with are the big aneurysms, and making sure I've got adequate clearance of all that. That's why I like the Cleaner 15 for that. I think it does really well with that.

[Neghae Mawla]
That's why I'll use TPA there. The other one I'll struggle with is with a patient that had a, for example, brachiocephalic fistula that then got converted into a graft, and the surgeon has decided to anastomose the PTFE to the original AV fistula as opposed to making a new or true arterial anastomosis. You've got this dilated vein stump between the artery and the PTFE, and a lot of times, the graft segment opens up really easily. The outflow is easy. It's that little segment that I sit there, and I spend a lot of time on, and that may be an additional 10, 15, 20 minutes just working on that little segment.

(6) Declot Procedure Time

[Chris Beck]
All in all, and one thing that I deliberately haven't asked you is what is your average time in starting and ending a declot? How long does it take you?

[Neghae Mawla]
I would say 15 minutes, 10 to 15 minutes, for a graft. Fistulas take a little bit longer, sometimes a little more unexpected, so 15 to 20 for a fistula. HeROs actually can be really quick. HeROs, you can get open in under 10 minutes. Sometimes those things are very blood pressure dependent, so there's no even lesion. A HeRO graft, because it's so long, I will always use a rotational device. I'll do a rotational device through the outflow, Fogarty on the inflow. Sometimes that's it. I mean, for a HeRO, that's all it takes.

[Chris Beck]
Just for some of our audience, can you tell everyone what a HeRO is and why they're so much easier?

[Neghae Mawla]
A HeRO is a combination of a graft and a catheter in concept. Half of it is a five millimeter covered stent, basically, but it goes through one of the veins. Usually, it's an IJ, but I've seen some through the axillary vein as well. Just like a perm cath, the tip of it is positioned in the right atrium, and then usually near the shoulder joint is where the graft, instead of being anastomosed to the vein, it is anastomosed to this HeRO outflow component.

[Neghae Mawla]
Usually, you've got a six or seven millimeter graft from your arterial anastomosis to your HeRO transition, and then it's a five millimeter outflow component all the way into the right atrium. You've got no venous outflow at all.

[Chris Beck]
All right, so aside from that segue into the HeRO category, it takes you, you said, about 15, 20 minutes for a graft. Maybe you said 20 or 25 minutes for a fistula?

[Neghae Mawla]
Somewhere around there. Usually, I mean, if I'm pushing 20 minutes, then my staff are starting to get antsy with me. Usually, it's because there is one residual. I mean, it's usually in the polish stage, where it's just this one little piece that I feel like I need to get either in the inflow or less often in the outflow. In the outflow, if I get annoyed, I'll just put a stent graft across it, and I'm done. But a lot of times, it's just one little clot in the inflow that I think is still impeding flow that I just have to address over and over again.

[Neghae Mawla]
I think most of my time is spent in the polishing stage. The outflow is a couple of minutes. The inflow is a couple of minutes, and then it's just a matter of getting flow established adequately and comfortably.

[Chris Beck]
One of the things that I felt like was an unlocked for me in terms of getting my procedure time down is if I know which way is inflow and if I know which way is outflow, I will go ahead and place my seven French sheath with a seven to six venous and arterial respectively. I'll put my seven French sheath in access with ultrasound. I get my seven French in, and then also get my six French in at the same time. That way, I've just taken care of the sheath work. I've taken care of most of my ultrasound work, and then I can just start going to work on the procedure. But in your situation, it sounds like you're always treating outflow, then coming back, doing inflow and then polishing up the rest. Is that right?

[Neghae Mawla]
That's it. I will sometimes put in both sheaths. Before I put that second sheath in, I want to make sure that whole segment is cleared. If that sheath is there, then that slows down how long it takes me, or sometimes it gets in the way of me clearing it, especially if I'm using a rotational device. Balloon, you can do comfortably. You can balloon around the sheath, and it's fine, but if you're doing a rotational device, and that gets in the way, or if there's a wire there that gets in the way. That's why I don't put that second sheath in right away.

[Chris Beck]
This is fair. Have you ever snagged the trerotola on one of the sheaths?

[Neghae Mawla]
I have. None of them are fun. If there's anything in the way of these rotational devices, it will win. I always say, "If it's a rotational device versus the wire, the wire is going to win." The Argon gets tangled up around it. The D-Clot still gets in the way of it being able to do what it needs to do. I always try to keep that clean. That's unclear and nothing else in there.

[Chris Beck]
That's fair. Aaron, you want to jump in with something?

[Aaron Fritts]
Yeah. Neghae, you already touched on this, but quick question about timing and the devices. Do you find that the devices help decrease procedure time? Are you just balancing that with the cost in terms of your decision to use a device?

[Neghae Mawla]
It usually does decrease the procedure time, and it depends on the length and the disease circuit, right? If I've got a loop graph that's stented all the way up to the axilla, it's just going to be faster for me to grab the device and just pull that all the way through the outflow. That way, I just balloon in one location of the two locations that I see, as opposed to going and ballooning the entire different segment. I think that's a little bit faster. I think I get a little bit better clearance of thrombus burden using the device than using the balloon.

[Neghae Mawla]
I don't know that there's actually any data that suggests that one is actually better than the other as far as balloon versus these rotational devices or these catheter aspiration. You guys have this Cat6, Cat8 stuff that looks really cool. I don't know that one device actually performs better than another device. For me, it's a matter of what I think is going to be faster and a little bit safer. With patients who have a large clot burden, I tend to reach the device first.

[Aaron Fritts]
I mean, my next question is other than devices being cost prohibitive in certain settings, are there any other disadvantages to using a device, or is it really just the time saver?

[Neghae Mawla]
If there's a lot of disease in the circuit, and I pulled a device all the way through, and then I've got my final image, my pre-angioplasty image, and I've got balloon here, here, here, here, here, then I sit there and say, "Well, if I knew I was going to balloon all of that anyway, I could have ballooned it and do the maceration all in one step.

[Aaron Fritts]
Gotcha.

[Neghae Mawla]
That's why I tend to only do it when there's a long circuit where I anticipate one or two balloon locations for angioplasty.

[Aaron Fritts]
Gotcha. That makes sense.

(7) Declot Complications

[Chris Beck]
One of the things that I wanted to get into the troubleshooting component of things that I think can hang people up, and that's if you have a recalcitrant stenosis. You mentioned it, but I have a feeling it'll get glossed over. If a stenosis doesn't efface with the Mustang, you mentioned that you would go to another balloon. Would you talk about that, and why you go to that balloon?

[Neghae Mawla]
Usually, I'll go to a Conquest. My Conquest goes to 40. I usually have a 30 also, I think, but I have the Conquest 40. I can go up to 40 atmospheres there. Usually, I'll keep that at the same size. Sometimes if that waste is really tight, I may actually downsize my Conquest first just to avoid the extravasation, because let's say it's a seven millimeter balloon, and it's still at 25 or 30 atmospheres because I'll push these balloons. I'll get up to 25 comfortably and sometimes even 30. Let's say I still look like what I think is a 50% waste, then I may grab a six millimeter Conquest, get that fully effaced and then come back with my seven millimeter again. It's probably just as safe to grab a seven Conquest and just do it. I just feel like sometimes, you want to be cautious and you think, "I'm being much more cautious if I grab a six versus a seven." The reality is that it probably doesn't make any difference, but it makes us feel better.

[Chris Beck]
Sometimes you have to treat the operator. My next thing that I wanted to bring up is what happens if you do injure the vessel? It's, like you said, a venous outflow stenosis. You do your post run, and you see some extrav. Will you talk about your protocols, how you work through that?

[Neghae Mawla]
Then I will just take the balloon up there, and I'll hold it for three minutes or so, and just do another run and see. Most of the time, that takes care of it. If I have a massive extrav and a very large one, especially something that I can see a hematoma forming in the arm is when I'll grab a stent graft. But most of the time, it's small enough that if you just hold the balloon up there, it'll tamponade off on its own. You're just holding pressure. Whether you do it from the outside or inside, it doesn't matter.

[Chris Beck]
No, that's also been my experience. It's funny that we did a lot of these in fellowship, and I don't remember ever rupturing a fistula or a graft, and then it happened to me twice in my first year. They tell you the trick. I'll say another thing that I do is whenever I pull a balloon out to do a run, I always keep the balloon on the wire very close to the sheath. I mean, that was something that was drilled into me. My techs are always very quick. They want to get that balloon off, but I just hold it right there near the sheath. That way, you're always in a position to run that balloon right off and tamponade something.

[Neghae Mawla]
The balloon, just pull it just off to the side of the sheath, and you're done. I will say for this tamponading, I mean, it's just usually six to eight atmospheres just to get the minimum pressure.

[Aaron Fritts]
Chris, that was the first dialysis case I did with Peter Bream, and he drilled that into me. Always keep your balloon right here just in case. You know why? Because that first case, it ruptured, and we threw the balloon right back in and blew it up. I always remember that. Even though I don't think I've had any instances of it either, but it's just the smart thing to do.

[Neghae Mawla]
The other thing you can do in case you don't have balloon access and if it is off the table, and you're waiting, you just put your thumb on the graft right behind that sheath. Just control the inflow, and then it's not going to bleed either. There's lots of ways to do it. I think the easiest way is to take the balloon in there and go. There have been a few instances where I have lost wire access, and I'm trying to get the wire back across. At that point, I will get my Fogarty back into the proximal graft, and I'll do proximal control with the Fogarty. Then that way, I'm not flowing out while I'm trying to wire back across the outflow, do I've got time to get my wire back across the outflow.

[Neghae Mawla]
Most of the time, I do it with a single wire. I'll pull the wire, and I just use the vents, and I'll pull the vents in, and then I'll go on the arterial side and pull the vents, and unless it was something really tight where I say, "You know what? I don't want to lose this wire or lesion that was really difficult to cross," to where I say, "I don't want... I spent a couple minutes trying to cross that. I won't do that again. I'll leave the wire." But if the wire goes up very quickly and easily, and the outflow opens up the way I expect, then I just pull that wire, and I use it on the arterial side also.

[Chris Beck]
That's a good question, Fritts. Do you do something similar? I'm always in a two-wire system.

[Aaron Fritts]
For sure. I was always taught to keep the wire across no matter what. It goes up easily.

[Neghae Mawla]
Right. I mean, if it goes up and if you've done an angioplasty, and you've done an image, and you know there's an extravasation--I did a cross while it was almost 95% occluded. You're going to have to cross it afterwards also, so I just pulled the wire, used it on the other side, because usually, once I've done the Fogarty and I'm happy with my inflow, I never go back to it. I usually would go back to the outflow and readdress the outflow, but I never go back to the inflow. You can also make the argument that, "You know what? I'm going to go back to the outflow anyway, so leave the wire up there."

[Neghae Mawla]
I think this is one of those things that everybody's done their own way and their own thing, and it's fine either way. There's no real advantage one way or the other.

[Chris Beck]
Agreed. Let's talk about lesions where you decide to stent. I mean, taking extrav off the table, which lesions and at what point do you decide to stent, and when you are stenting, does it depend on location whether you're going to use bare metal versus stent graft?

[Neghae Mawla]
Always the stent graft. Bare metal is gone, so always the stent graft. I think the bare metal... I mean, the data is there just to show that the bare metal is just not that good. For me, it's always a stent graft, and I'm choosing between the Viabahn and the Covera. Usually, the costs are pretty comparable for me there. The Covera has a flared option, which I like, and so when you've got a graft, a seven millimeter that opens up into a 10 or 11 millimeter axillary, then the Covera there is actually what I prefer, because it opens up into that larger vein. I'll use the flared Covera there.

[Neghae Mawla]
But otherwise, I think the use of them are pretty much the same, but it really boils down to how resistant that lesion is. The other thing to keep in mind that's in the workflow now is the drug-coated balloons.

(8) Drug-Coated Balloons for Declots

[Chris Beck]
No, man, jump in. Let's talk about the DCB's for the Dallas circuit. Do you use them during a declot, or do you declot, then bring them back?

[Neghae Mawla]
No, if I want to do it, I'll use it during a declot. The problem with the DCB is that there's no reimbursement for it, but the advantages of both the Lutonix and the IN.PACT balloon, they've given me a 12-month guarantee that if I need to reintervene. At least, that way, it helps to offset it if I feel like it didn't work. It makes me feel better that, "All right, I've tried it, and it didn't work." I've got this 12-month guarantee, and I just tell them, and they replace the balloon, right? No harm done that way. I think that actually is coming in before the stent graft. I’m trying to figure out where that's going to fall into the algorithm, but I think normally I would say that falls into the algorithm before the stent graft does or should, particularly in lesions and in areas where we're cannulating and it's hard to stent, because I don't like cannulating a stented region.

[Neghae Mawla]
I've seen too many stent fractures from that, so I try to avoid cannulating in the graft or in the fistula, where they're going to be using it. For there, I'll lean definitely towards the drug-coated balloon. If I feel like it's resistant or going to come back, I will lean towards the DCB more on a repeat procedure than on a first procedure.

[Neghae Mawla]
Let's say I'm doing the declot, and it's their first time here, and I've got recoil like crazy, then stent graft can't be done, because I'm afraid they're going to come back. Usually, let's say I've done it. I was happy with the outcome, but if they come back in two or three weeks, I will upsize it. Let's say they come back a third time within a month, because my final images look good, they just are not holding. Then I'll say, "Okay, you know what? This is the scenario for a DCB."

[Chris Beck]
Gotcha. There's two more things that I want to cover before we wrap things up. One I should also ask is so the only anticoagulation you give is the 5,000 of heparin in the beginning. I assume you're not doing intermittent heparin.

[Neghae Mawla]
I always do a little heparin at the end. I don't know. I give another 5,000 at the end, so the total will be 10,000.

[Chris Beck]
Gotcha. Then what do you do for either closure hemostasis once you're all finished?

[Neghae Mawla]
Oh, we just take the sheaths out and pull. I use the StatSeal, which has the hemostatic disc, and so usually about five minutes of pressure with that. I'll use that for six, seven and eight French sheath. If I'm going bigger than an eight French, I'll put a purse string around it and send them home with that, but otherwise, I do the StatSeal. That way, it's just the disc and addressing over it, and they take it off the next day, and there's no more sutures to worry about. The dialysis clinics around the area are very reluctant to remove the suture sometimes, and so some of these patients that have to come back just to get a suture removal. I think it’s silly.

[Neghae Mawla]
Put the StatSeal, manual hemostasis. They're in recovery 30 minutes, and they're out the door.

(9) Follow-Up Care for Declots

[Chris Beck]
Nice. Very nice. Very quick. In terms of the follow-up, is it up to the dialysis clinics to be doing some basic surveillance on these patients either with recirculation, or they're doing physical exams? How do people get fed back into you so you avoid the declot, so you catch them with some fistulogram maintenance when you're just tuning up?

[Neghae Mawla]
That's at the dialysis level, so they're doing surveillance with flow studies. There's a couple of different devices to measure flow studies out there that each clinic has, or each dialysis provider, I should say, have. They do physical examinations and they have symptoms. Patients say, "I'm bleeding too long after dialysis. It can't stop," so they know to come back. The dialysis clinic and the patients are usually the ones that are responsible. Depending on the disease severity, I might say, "Come back. Let me just do a physical exam myself."

[Neghae Mawla]
I may bring them back just for a physical examination a month after a declot just to say, "Let me take a look and see what it feels like, and make sure that it's not acting up again." But most of the time, I leave it up to the dialysis center.

[Chris Beck]
Let me ask you a specific scenario that may or may not come up in your practice. But say you're seeing someone on a semi regular basis like every month, or you can even take it down to every week or two weeks where you're having to do a declot, at what point do you say, "This isn't working. Let's have this either surgically revised or put in a catheter," or what do you do with that scenario where you feel like you're having to see that patient over and over for declot?

[Neghae Mawla]
That's always the tricky one, right? That's the one we don't like talking about. Usually, at that point, I'm coordinating with the surgeons and saying, "All right, I've done this guy three times this month. What's our next plan of action? If it's an outflow one that I can stand, I will do that. If it's an inflow that I think I need patched, then I coordinate with the surgeon, and I say, "All right, how are we going to do this? Are we going to do this now, next week, or should I put in the catheter and let you deal with it?"

[Neghae Mawla]
Usually, if I can coordinate something pretty quick like in the next week or so, and I think that they're holding open for that week, then I'll go ahead and just do the declot again. I'll say, "Okay, fine, let me open you up," and then let him revise you as an outpatient. They'll just schedule them straight to the OR. That's usually when I'm calling the surgeon and say, "All right, don't see this guy in the office. Just let me declot him. You take him to the OR. Patch the arterial anastomosis, and we're good." It's the ones where we don't know what's happening that we struggle where we start adding in Plavix and Eliquis.

[Neghae Mawla]
It may treat us more than it treats the patient. Typically, I don't put anybody on any coagulation only for repeated thrombotic episodes. Generally, three or four thrombectomies inside of a month, that's when I may say, "You know what? Either this one is done, and we've just been trying to salvage it, and then put in a catheter, or it's a specific focal lesion every time that isn't holding, and I want a surgical revision of that, or it's the venous outflow that I just need a bypass segment of that."

[Neghae Mawla]
If it's something that looks like a relatively easy surgical fix, where I anticipate, "Hey, if you just do this little bit, and we should be fine,” then I'll declot him again, and let the surgeon do their picks. But if it's a failing, it's a five years old, seven years old kind of thing, then at that point, I say, "Look, it's done. Let's just put it in a catheter and go."

(10) Declot Tips and Tricks

[Neghae Mawla]
Aaron, you came and spent the day with me. What did you think?

[Aaron Fritts]
I was telling Chris some of the tricks that I picked up. One was the aspiration from the sheath as you're pulling the Fogarty back. That, I had never seen before, and I thought that was a really cool trick. It helped get some of that clot out, because then you showed it. You showed how much clot you pulled out. I was used to always just pulling the Fogarty back and then letting it flow with everything else, but I think that that makes a significant difference. I mean, the official speed by which you do it, and the techs all know your next move, I mean, that all makes a huge difference, right?

[Aaron Fritts]
Like I said, for somebody like myself--guys that do them once a month in labs, more importantly, labs that only do them once a month slows everything way down, because they forget how to set everything up. They're just standing there and handing you wires and stuff, but I think part of it is just well trained staff. I think that's a huge part of it.

[Neghae Mawla]
Staff makes a huge difference. We always underestimate how important the staff are, because if they can anticipate your next move, right?

[Aaron Fritts]
With imaging too, right? I mean, you have somebody that's they've got it squared away for a year. You're really just focusing on where you gotta go, and they're taking care of the rest. I mean, that's a big difference. Those are the main things that stuck out to me. Then being able to do all that without TPA using the devices. Chris and I trained similarly where I was training just Kumpe catheters, four milligrams of TPA, lace the clot as you pull back and then go in and balloon macerate everything. Push it out. Pull with the Fogarty, but that still took forever. I mean, it's felt like it took two hours to do a declot.

[Neghae Mawla]
That's the basic declot.

[Neghae Mawla]
You just said it, outflow, inflow, polish.

[Chris Beck]
I will say that I get bogged down. One, I'll throw a tip out there for the audience. I don't know how other people run their practice, but for some reason, if I get impatient, I start wanting to do more things myself. I'll start grabbing for things. I'm loading things up on the wire, and that's out of my frustration, but for declots, you really have to be a general. I'll tell my techs before we get started, I'm like, "I'm going to bark a lot of orders, and I'm going to expect you to be on your game.” It's declots when I want to really move fast.

[Chris Beck]
I really stay in one position and let everything come to me because whenever I start flailing around is when I think I get sloppy. The other thing that I learned from Aaron after he went and worked with you, Neghae, was the amount of polish that I'm putting on afterwards. Sometimes, I'm just going after every little small piece of clot. I guess I was just like, "Oh, I don't have to do that," and then it was like someone took a burden off me.

[Aaron Fritts]
Well, you showed me, Neghae, either you watch this little piece of clot and then you do a run two minutes later, and it's gone, because the flow helps get rid of it, right? You don't have to go in there and balloon every little piece of clot that's hanging on.

[Neghae Mawla]
I will take the Fogarty. I take the Fogarty towards the outflow as part of the polish stage. That's one of the reasons I like the over-the-wire Fogarty is because I can lock it. I'll just inflate it and lock it. I'll just polish or floss with it. If it goes all the way into the outflow, and I don't feel any resistance, it's fine. If the graft is not pulsatile, and the fistula is not pulsatile, you can get used to examining the fistula after each stage and each step that you do it and see how that exam changes, because that will guide you also.

[Neghae Mawla]
Then suddenly, you get this great thrill, and all the resistance is gone. Everything feels great. Well, at that point, you can say, "All right, we're done. You do a quick run to correspond with it," but that becomes a good guide for you also more than the images. If you've got a clot, but it feels great, and it's just a little piece of clot that's hanging out, a lot of times the heparin takes care of that.

[Chris Beck]
There's actually a good expression. A guy who taught me how to do declots and talking about examining the fistula after each stage of the decline, he would say, "Treat the patient, not the pictures." That applies to so much of what we do in interventional radiology, but I think that point really distills it. All right, well, I feel like we covered a lot as far as the declots. Neghae, I really appreciate you coming on again, and sharing some of your insight and your expertise on the procedure. We always like having you on.

Podcast Contributors

Dr. Neghae Mawla discusses Successful (and Quick!) Declots for AV Access on the BackTable 117 Podcast

Dr. Neghae Mawla

Dr. Neghae Mawla is an Interventional Nephrologist with Dallas Nephrology Associates in Texas.

Dr. Christopher Beck discusses Successful (and Quick!) Declots for AV Access on the BackTable 117 Podcast

Dr. Christopher Beck

Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.

Cite This Podcast

BackTable, LLC (Producer). (2021, March 22). Ep. 117 – Successful (and Quick!) Declots for AV Access [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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DEB vs. Balloon Angioplasty Alone for Dysfunctional Hemodialysis Access with Dr. Eric Therasse on the BackTable VI Podcast)
AV Fistula & Graft Maintenance with Dr. Ari Kramer on the BackTable VI Podcast)
New Tools to Treat Severe Distal Femoropopliteal Disease with Dr. John Rundback on the BackTable VI Podcast)

Articles

Right thigh loop graft with stented segments at the venous anastomosis and graft

Tips & Tricks for AV Fistula & Graft Declots

Fistula with arterial and venous directed sheaths for declot procedure

How to Declot AV Fistulas & Grafts Part 2: Finishing Touches & Follow-Up Care

Loop graft with arterial and venous directed sheaths for declot procedure

How to Declot AV Fistulas & Grafts Part 1: Patient Prep, Access, Outflow

Topics

Declot Procedure in Arteriovenous Fistulae & Grafts
Dialysis Access Procedure Prep