VS6. Percutaneous Thrombectomy of a Dialysis Graft in the Office Setting

With the advent of endovascular techniques thrombectomy of occluded dialysis graft can be carried out percutaneously. Over the last few years various devices have been approved for mechanical thrombectomy of dialysis graft. We describe a technique that we have developed without using these devices, in our office based endovascular suite. Patient is given hydrocodone 5 mg, Diazepam 5 mg and Cefazolin 500 mg orally before the procedure. Patient is not fasting. After prepping and draping the extremity Xylocaine 1% is infiltrated in the skin. Crossing micro puncture needles are introduced into the graft pointing towards each anastomosis. Guide wires are threaded through the needles. Needles are removed and micro puncture sheaths are threaded over the guide wires. Fistulogram is done to confirm the thrombosis and to make sure the catheters are in the lumen. Two ml of tissue plasminogen activator is introduced through each catheter. After 15 minutes glide wires are threaded through each sheath and these are switched to 6 French sheaths. The glidewires should cross both anastomoses. Five French embolectomy catheter is threaded over the arterial wire and clot is pulled out of the arterial side and flushed out of the side port of the sheath. Same procedure is carried out on venous side. Fistulogram is performed and the procedure is repeated until there is no residual clot. Invariably there is stenosis present at the graft vein anastomosis or in the graft circuit. Rarely there is arterial stenosis. If it is a 6mm graft 8mm balloon is used to dilate the area of stenosis at the graft vein anastomosis. The sheaths and guide wires are removed and puncture sites are closed with nylon suture. the graft can be used immediately. A similar procedure can be used for a fistula.