What is the best treatment approach for a patient with a hemodialysis access and an increased rate of thrombosis?

Management of Hemodialysis Access with Increased Rate of Thrombosis

For a hemodialysis patient experiencing recurrent access thrombosis, endovascular intervention with mechanical thrombectomy and/or pharmacologic thrombolysis combined with balloon angioplasty should be performed within 24-48 hours as first-line therapy, followed by systematic evaluation and correction of underlying stenosis, and consideration of anticoagulation with apixaban 2.5 mg twice daily for three months to prevent recurrence. 1, 2, 3

Immediate Management of Acute Thrombosis

Endovascular intervention is superior to open surgery as first-line therapy for dialysis access thrombosis. 1, 2

Timing is Critical

• Intervention must occur within 24-48 hours of thrombosis diagnosis to maximize success rates 1, 2
• Delaying beyond 48 hours significantly decreases success rates and necessitates temporary catheter placement 2

Endovascular Techniques

The following combined approach achieves 75-94% clinical success: 1, 2

• Mechanical thrombectomy using suction thrombectomy, balloon thrombectomy, or clot maceration 1, 2
• Pharmacologic thrombolysis with tissue plasminogen activator (TPA) or alteplase 2
• Balloon angioplasty to treat underlying stenosis—this is critical to prevent immediate re-thrombosis 1, 2
• Stent placement if elastic recoil occurs after angioplasty 2

Expected Outcomes

• Clinical success: 75-94% 1, 2
• 6-month primary patency: 18-39% 1, 2
• 6-month secondary patency: 62-80% 1, 2

Identifying and Correcting Underlying Causes

Since 90% of access thromboses result from anatomic stenosis, fistulography must be performed during the thrombectomy procedure to identify and immediately correct the stenosis. 1, 2

Anatomic Causes to Address

• Perianastomotic stenosis (most common in grafts) 1
• Juxta-anastomotic stenosis (most common in fistulas) 1
• Venous outflow stenosis 1
• Central venous stenosis 1

Non-Anatomic Precipitating Factors

Evaluate and address: 1, 2

• Post-hemodialysis hypotension
• Hypercoagulable states (requires thrombophilia testing in recurrent cases)
• Decreased cardiac output
• Access site infection

Prevention of Recurrent Thrombosis

Anticoagulation Strategy

For patients with recurrent thrombosis after successful thrombectomy, apixaban 2.5 mg twice daily for three months significantly reduces re-thrombosis risk. 3

• Apixaban reduces recurrent access thrombosis from 40.8% to 24.0% at three months (hazard ratio 0.52) 3
• Primary patency failure improves from 49.5% to 32.2% 3
• Minor bleeding increases from 7.5% to 22.6%, but major bleeding rates remain comparable 3
• This represents the most recent (2025) and highest quality evidence for anticoagulation in this specific population 3

Alternative Anticoagulation Considerations

Warfarin is NOT routinely recommended due to safety concerns, despite some efficacy data: 4, 5

• Warfarin use is associated with increased mortality in hemodialysis patients (hazard ratio 1.27) 4
• If warfarin is used on a case-by-case basis, target INR 1.5-2.5 (not higher) 5, 6
• Major bleeding risk increases significantly at INR >2.5 5

Hypercoagulability Workup

In patients with >2 thrombotic episodes within a single month, perform thrombophilia testing: 1, 2

• Factor V Leiden mutation 7
• Prothrombin 20210 gene mutation 8
• Antithrombin deficiency 8
• Protein C and S deficiency 8
• Antiphospholipid antibodies 8
• Factor VIII levels (frequently elevated in hemodialysis patients) 7

Indications for Surgical Consultation

Refer to vascular surgery when: 1, 2

• Endovascular treatment fails clinically
• Thrombosis recurs >2 times within a single month
• Recurrent correctable stenosis is identified despite repeated interventions
• Aneurysms or pseudoaneurysms are present (contain chronic intraluminal thrombus difficult to access endovascularly)

Temporary Access Management

If endovascular declotting fails, place a tunneled cuffed dialysis catheter for interim hemodialysis access (acceptable for <3 months duration). 1, 2

• Place catheter in the extremity opposite to the extremity anticipated for future AV access creation or revision 1
• Consider femoral vein placement to preserve upper extremity vasculature for pending AV access 1

Anticoagulation During Dialysis Sessions

For patients requiring anticoagulation to prevent circuit thrombosis during dialysis (not for systemic anticoagulation), regional citrate is preferred over heparin or non-heparin anticoagulants. 1

• In patients with heparin-induced thrombocytopenia requiring circuit anticoagulation, use argatroban, danaparoid, or bivalirudin rather than fondaparinux or rivaroxaban 1

Critical Pitfalls to Avoid

• Never delay intervention beyond 48 hours—this dramatically decreases success rates 1, 2
• Never perform thrombectomy without addressing underlying stenosis—failure to treat stenosis leads to immediate re-thrombosis 1, 2
• Never place multiple temporary catheters while awaiting definitive treatment—this increases infection risk unnecessarily 2
• Never ignore hypercoagulable workup in patients with >2 episodes per month—treatable thrombophilia may be present 1, 2, 7
• Never use aspirin or clopidogrel routinely for thrombosis prevention—these are associated with increased mortality in hemodialysis patients without proven benefit for access thrombosis 4