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ENDOVASCULAR RECANALIZATION OF AN ACUTE DISTAL AVF THROMBOSIS WITH EKOS®

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Abstract

A woman on hemodialysis for 11 years by a distal radio-cephalic AVF presented a 20cm cephalic vein thrombosis including 2x2 cm two aneurysms at 7 and 18cm from anastomosis (fig. 1a). Thrombosis extension prevented us from performing mechanical thrombolysis or surgical trombectomy. Endovascular treatment with ultrasounds (US) energy combined with thrombolitic infusion deep into the clots can treat artery and peripherical vein thrombosis and pulmonary thromboembolism. No description about this option on AVF thrombosis was reported.

Under US guidance, a 6F introducer sheath was inserted in the cephalic vein just over the AV anastomosis; a 0.025" guidewire was inserted and driven beyond the thrombosis. 5000 units heparin bolus was infused. An EKOS® catheter performing enhanced thrombolysis by US was inserted and placed inside the whole thrombosed vein. Catheter was 106cm long and its treatment area was 24cm long. We administred 75000 IU/hour urokinase infusion for 16 hours, performing Doppler scan every 6 hours. In the first 6 hours, a complete recanalization of the straight cephalic vein between aneurysms occurred. At the end, Doppler scan showed thrombi reduction of 30% in the distal aneurysm and 50% in the proximal one (fig. 1b). No complications occurred and AVF allowed a good dialysis 2 hours later. Then oral anti-coagulation was started. Complete recanalization occurred after a week (fig. 1c). 2 weeks later AVF flow went below 500l/min and angiography detected two hemodynamically significant stenosis: juxta-anastomotic venous stenosis was corrected performing a percutaneous dilatation to 4mm by a cutting balloon; peri-anastomotic arterial stenosis was dilatated by a 6x40mm high-pressure balloon (fig.2). AVF flow increased over 800 ml/min. After 9 months AVF works still well.

It’s the first report describing an endovascular AVF thrombolysis using US energy combined with thrombolitic infusion. EKOS® system permitted a rapid resolution of vein thrombosis, restoring the patency of the forearm superficial venous circle without any injury. This system allowed the immediate use of AVF for dialysis and the reduction of thrombolitic agent and bleeding risk.

L. Buzzi(1), E. Alberghini(1), F. Ferrario(1), I. Baragetti(1), G. Santagostino(1), S. Furiani(1), E. Corghi(1), C. Sarcina(1), V. Terraneo(1), F. Rastelli(1), G. Bacchini(2), C. Pozzi(1)
((1)Nephrology and Dialysis Department, E. Bassini Hospital Cinisello Balsamo, Milan , (2)Nephrology and Dialysis Department, A. Manzoni Hospital Lecco )
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Realizzazione: Tesi S.p.A.

Per assistenza contattare: Claudia Ingrassia, Tesi S.p.A.
0172 476301 — claudia.ingrassia@gruppotesi.com