However, the endovascular therapeutic options have largely superseded open surgical techniques for the restoration of a thrombosed dialysis access [88]. The SIR Standards and Practice Committee guidelines suggest that a stenosis with an associated thrombosis that occurs in a dialysis circuit ought to be managed with endovascular techniques when a perianastomotic stenosis is present and when a concomitant venous stenosis is present. In the former case, when a graft thromboses, such perianastomotic lesions should be managed first with combined thrombolysis and/or thrombectomy as well as balloon angioplasty [7]. Dialysis Fistula Malfunction Surgical Consultation According to the SIR Quality Improvement Guidelines, endovascular management is the preferred alternative to open surgery as a first-line therapy for dialysis accesses thrombosis [7]. However, vascular surgery consultation for possible revision for creation of a new fistula may be considered in the setting of clinical failure of endovascular treatment [7]. Vascular surgery consultation for access revision may be performed if thrombosis of the access occurs >2 times within a single month, or if recurrence of a correctable stenosis is delineated in the circuit. In patients with frequent or recurrent thrombotic occlusions of the hemodialysis access, hypercoagulability testing for associated thrombophilia may also be explored [7,89]. While some 90% of access thromboses are secondary to an anatomic stenosis, it should be noted that alternative precipitating processes exist and include hypotension post hemodialysis, hypercoagulable states, decreased cardiac output, and access site infection [7]. Placement of a New Tunneled Dialysis Catheter In the case of a failed declot of an AVF or AVG, a tunneled dialysis catheter may be performed as an interval means for hemodialysis.
Dialysis Fistula Malfunction. However, the endovascular therapeutic options have largely superseded open surgical techniques for the restoration of a thrombosed dialysis access [88]. The SIR Standards and Practice Committee guidelines suggest that a stenosis with an associated thrombosis that occurs in a dialysis circuit ought to be managed with endovascular techniques when a perianastomotic stenosis is present and when a concomitant venous stenosis is present. In the former case, when a graft thromboses, such perianastomotic lesions should be managed first with combined thrombolysis and/or thrombectomy as well as balloon angioplasty [7]. Dialysis Fistula Malfunction Surgical Consultation According to the SIR Quality Improvement Guidelines, endovascular management is the preferred alternative to open surgery as a first-line therapy for dialysis accesses thrombosis [7]. However, vascular surgery consultation for possible revision for creation of a new fistula may be considered in the setting of clinical failure of endovascular treatment [7]. Vascular surgery consultation for access revision may be performed if thrombosis of the access occurs >2 times within a single month, or if recurrence of a correctable stenosis is delineated in the circuit. In patients with frequent or recurrent thrombotic occlusions of the hemodialysis access, hypercoagulability testing for associated thrombophilia may also be explored [7,89]. While some 90% of access thromboses are secondary to an anatomic stenosis, it should be noted that alternative precipitating processes exist and include hypotension post hemodialysis, hypercoagulable states, decreased cardiac output, and access site infection [7]. Placement of a New Tunneled Dialysis Catheter In the case of a failed declot of an AVF or AVG, a tunneled dialysis catheter may be performed as an interval means for hemodialysis.