Thrombolysis for the treatment of thrombosed hemodialysis access grafts

Maintaining the patency of hemodialysis access grafts remains problematic. It is best to recognize the failing graft before its thrombosis by noting an increase in recirculation time, changes in Doppler ultrasound findings, elevation of venous pressures, or arm swelling. If a failing graft is suspected, an angiogram should be performed to evaluate the graft. Percutaneous declotting has been evolving since its introduction in the early 1980s. At first, a low dose thrombolytic infusion through a single catheter was used. Crossing catheters with a higher dose infusion was then introduced. The current method is a pharmacomechanical thrombolysis which uses crossing catheters and pulse-spray technique. Several mechanical devices have proven to be efficacious as well. Recently, the "lyse and wait" technique, a simpler and quicker technique, has been used to declot thrombosed grafts and the initial success has been similar to the previously described techniques. After the graft is successfully declotted, the arterial plug must be mobilized and the stenotic lesion must be addressed either by angioplasty, stent placement, surgery, or any combination of these interventions.