Do you need to treat a clotted Arteriovenous (AV) fistula that isn’t in use?

From the Guidelines

A clotted AV fistula that isn’t in use should not be treated unless it is the patient’s only viable option for future dialysis access, as unnecessary interventions can lead to reductions in patient quality and increased costs to the healthcare system. When considering treatment, the decision should be based on the patient's overall health status, future dialysis needs, and the duration of the clotting. According to the 2019 update of the KDOQI clinical practice guideline for vascular access 1, there is no clear guidance on intervention thresholds, but it suggests that the number of interventions a patient should tolerate before abandoning the current AV access should be part of the vascular access contingency plan.

Key factors to consider in the decision-making process include:

• The patient's potential future need for the AV fistula as a dialysis access site
• The presence of alternative access options
• The patient's overall health status and ability to undergo intervention
• The risk of complications associated with an untreated clotted fistula, such as local inflammation and pain

Treatment options, if deemed necessary, may include surgical thrombectomy or endovascular procedures like catheter-directed thrombolysis using tissue plasminogen activator (tPA), followed by angioplasty to address any underlying stenosis. However, these interventions should be reserved for cases where the AV fistula is crucial for the patient's future dialysis needs, as supported by the guidelines 1. Consultation with a vascular surgeon or interventional nephrologist is essential to determine the optimal approach for each individual case, taking into account the latest clinical practice guidelines and the patient's unique circumstances.

From the Research

Treatment of Clotted AV Fistula

• A clotted Arteriovenous (AV) fistula that isn’t in use may still be treated to restore its functionality, as studies have shown that percutaneous interventions can successfully salvage a significant percentage of failed AV fistulas 2, 3.
• The decision to treat a clotted AV fistula depends on various factors, including the underlying cause of the clot, the presence of any anatomical abnormalities, and the overall condition of the fistula 4, 5.
• Endovascular techniques, such as thrombectomy, angioplasty, and stent placement, can be used to treat clotted AV fistulas and restore blood flow 4, 5, 6.
• The success rate of these procedures can be high, with studies reporting primary patency rates of up to 75% after 3 months and 51% after 12 months 5.
• However, complications can occur, including vessel rupture, arterial embolism, and pulmonary embolism, highlighting the need for careful patient selection and procedure planning 4.

Benefits of Treatment

• Treating a clotted AV fistula can help to minimize the need for dialysis catheter placement and reduce the risk of associated complications 3.
• Successful treatment can also help to maximize AV fistula use in hemodialysis patients, which is a key strategy for improving patient outcomes 3.
• The National Kidney Foundation Dialysis Outcomes Quality Initiative supports the salvage of early and late fistula failure to minimize catheter use and promote AVF use 3.

Procedure Considerations

• The choice of procedure will depend on the individual patient's needs and the specific characteristics of the clotted AV fistula 4, 5, 6.
• A thorough evaluation of the fistula, including angiographic imaging, is necessary to identify any underlying abnormalities and guide treatment decisions 2, 5.
• The use of adjunctive methods, such as cutting balloon angioplasty and drug-coated balloon angioplasty, may be necessary to treat stenoses and promote fistula patency 4, 6.