Thrombolysis of clotted hemodialysis grafts with tissue-type plasminogen activator

PURPOSE: To evaluate prospectively the efficacy of treating thrombosed hemodialysis arteriovenous polytetrafluoroethylene (PTFE) grafts using tissue-type plasminogen activator (tPA) and percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: Forty-two sequential thrombosed PTFE dialysis grafts in 33 patients presented for declotting. All 42 grafts were treated with a modified lysis and PTA technique with use of 2 mg tPA and 3,000-5,000 U heparin in a total volume of 5 mL, administered into the graft via an angiocatheter. The elapsed time from tPA injection until completion was recorded. Prospective data collection included demographic information, technical details of the procedure, immediate outcomes, complications, and patency rates. RESULTS: Technical success, defined as complete graft recanalization with a palpable thrill after treatment plus successful hemodialysis, was achieved in all cases, except five. These five cases were deliberate graft closures due to inadequacy of the outflow veins to support an arteriovenous graft after successful lysis. Mean lysis time was 40.8 minutes and mean room procedure time after the lysis period was 65.4 minutes. Eight procedure-related complications occurred (two major and six minor). The follow-up period was 4-241 days, with an estimated mean of 157 days. The 30-day and 90-day primary patency rates were 57% and 50%, respectively. CONCLUSIONS: Treatment of thrombosed PTFE dialysis grafts with use of 2 mg tPA and 3,000 U of heparin is safe and effective. Use of this modified lysis and PTA technique allows an expeditious procedure in the angiography suite. However, this technique precludes imaging of the outflow veins before treatment, so that grafts entering diffusely diseased veins may need to be closed after successful lysis.