Management of Thrombosed Dialysis Access: Thrombectomy Versus Thrombolysis

More than 250,000 patients per year with end stage renal disease are maintained on long-term hemodialysis. Because of this large population, hemodialysis access procedures now account for a large percentage of operative interventions in the United States. Prosthetic arteriovenous access thrombosis is a frequent complication that occurs at a rate of 0.5 to 0.8 episodes per year and is a major source of hospital admissions, increasing hospital costs, patient morbidity, and physician frustration. Thrombosed grafts often require rescue procedures to extend the life of the graft and make the most use of the limited available access sites. Such salvage procedures of thrombosed prosthetic dialysis shunts may be performed with either conventional surgical or endovascular techniques. Many techniques for declotting have been used, including open surgical thrombectomy, percutaneous pharmacologic or mechanical thrombectomy, and pharmacomechanical techniques. Despite the various treatment options, no individual declotting modality has proven itself superior. Long-term patencies after a single revascularization procedure are meager, with a median of less than 90 days. This article will review prosthetic hemodialysis access graft declotting mechanisms and supporting literature.