Figure 1
Teaching Case
SectionInterventional radiology
Case TypeClinical Cases
AuthorsD.Vorwerk
Connected authors
69 years, male
Combined stenosis and thrombosis of a brachiocephalic fistula
Successful trhombectomy and balloon dilation of a brachiocephalic fistula
Patient was admitted because of acute insufficiency of a right brachiocephalic fistula. Clinical investigation revealed a postanastomotic narrowing of the cephalic vein with an adjacent aneurysmal deformation of the vein. The aneurysm was only partially compressible probably due to thrombosis.
Antegrade angiography revealed partial thrombosis of the aneurysmatic venous segment (Fig. 1a,b) and a multisegmental stenosis of the distal cephalic vein close to the av anastomosis.
Thrombectomy was performed mechanically by use of a motor-driven nitinol basket (Trerotola thrombectomy device, Arrow Inc.) that was sufficent to clear the vein from thrombus (Fig,. 2a, b). The device was introduced via an antegrade venous puncture using a 6 F sheath.
A second retrograde venous puncture was performed and a coated guidewire was inserted into the brachial artery. Balloon dilation was performed on the stenotic segment by use of a 6 mm 40 mm high-pressure balloon (Centurion, Bard Inc.) with sufficient but not full opening of the stenosis (Fig. 2c). The procedure reestablished flow into the fistula that was sufficient for successful dialysis.
There are many techniques to perform mechanical thrombectomy from native venous fistulas. The devices used include aspiration, hydrodynamic systems, mechanical macerating systems such as the clot buster or the Trerotola basket. These devices are usable to perform thrombectomy from clotted fistulas because in most incidents, the thrombus material is fresh and easy to destruct. In almost all cases, a preexisting stenosis is responsible for low flow and clot formation which makes an additional balloon dilatation necessary.
When using mechanical devices, there might be some residual clot remaining into the vein but in the presence of high fistula flow this might be tolerable. Some authors, however, believe that patency may be compromised if residual clot is present. However, no firm data are available on this point of discussion
References
[1]
Uflacker R
Mechanical thrombectomy in acute
and subacute thrombosis with use of the
Amplatz device: arterial and venous applications.
J Vasc Interv Radiol. 1997 Nov-Dec;8(6):923-32. (PMID: 9399460)
[2]
Uflacker R, Rajagopalan PR, Vujic I, Stutley JE
Treatment of thrombosed dialysis access grafts:
randomized trial of surgical thrombectomy versus
mechanical thrombectomy with the Amplatz device. (PMID: 9007796)
[3]
17 :
Turmel-Rodrigues L, Sapoval M, Pengloan J, Billaux L, Testou
D, Hauss S, Mouton A, Blanchard D.
Related Articles
Manual thromboaspiration and dilation of thrombosed dialysis access:
mid-term results of a simple concept.
J Vasc Interv Radiol. 1997 Sep-Oct;8(5):813-24. (PMID: 9314373)
[4]
28 :
Vorwerk D, Schurmann K, Muller-Leisse C, Adam G, Bucker
A, Sohn M, Kierdorf H, Gunther RW.
Related Articles
Hydrodynamic thrombectomy of haemodialysis grafts and fistulae: results
of 51 procedures.
Nephrol Dial Transplant. 1996 Jun;11(6):1058-64. (PMID: 8671969)
Case information
| URL: | https://eurorad.org/case/510 |
| DOI: | 10.1594/EURORAD/CASE.510 |
| ISSN: | 1563-4086 |
