Salvage of occluded autologous arteriovenous fistulae.

Well-functioning vascular access is essential to optimizing outcomes in hemodialysis patients. Initial placement of greater numbers of autologous arteriovenous fistulae (AVFs) is needed, as is more attention to salvage of such accesses when they become occluded. In this study, thrombolysis with small doses of thrombolytic agents in combination with balloon angioplasty was attempted in 15 patients with 16 autologous AVFs (7 forearm AVFs, 8 upper-arm AVFs). Either urokinase (UK; mean dose, 109,375 U) or tissue plasminogen activator (tPA; mean dose, 7.1 mg) was used for thrombolysis. The technical success rate was 94%, whereas long-term patency was achieved in 81% of the accesses. Failure to achieve long-term patency was caused by the inability to achieve adequate drainage in 2 patients. In 1 patient, technical inability to cannulate the access and penetrate the venous end of a basilic vein transposed fistula occurred. One patient was successfully declotted and angioplastied twice. Successful salvage of thrombosed AVFs can be safely performed with much lower doses of thrombolytic agents than previously reported. In addition, tPA is effective in this setting, in addition to UK. Salvage of occluded autologous AVFs should be attempted more frequently than is currently practiced and would result in improved hemodialysis patient outcomes.