Indications

• Thrombosed AVF or AVG (absence of thrill/pulse/bruit)

Contraindications

• Infected access site (may cause septic emboli)

• Recent (<4 wk) creation of access (risk of rupturing anastomoses)

• Right-to-left shunt (risk of stroke)

• Large thrombus burden or poor cardiopulmonary reserve

• Ipsilateral “steal syndrome” where access is stealing too much flow

• Hyperkalemia, especially with EKG changes

• Contrast allergy that cannot be premedicated

• Uncorrectable coagulopathy (rare)

• Contraindication to tPA, heparin (relative)

Imaging Review

• Review prior shunt studies or Dopplers to evaluate the type of access device and the location of prior stenoses and stents.

• Bedside or pre-procedure US to eval extent of clot and location of anastomoses

Tips for Workup

• Rarely emergent, as temp HD cath can be placed for dialysis in interval

  • • AVF should be declotted within 48 hours for optimal results.

    • AVG can be successfully declotted days or weeks after thrombosis

• When was last dialysis? Is temp HD needed more urgently to improve stability prior to declot?

• Consent:

  • • Failure of declot, arterial thromboembolism à ischemic limb, PE, paradoxical embolism (stroke), vessel rupture, worsening thrombosis, infection.

    • Include “possible tunneled dialysis catheter placement” in case the declot is unsuccessful.