Cardiovasc Intervent Radiol DOI 10.1007/s00270-014-0847-8
TECHNICAL NOTE
Balloon Catheter Looping Technique for Entry Site Angioplasty During Endovascular Management of Thrombosed Arteriovenous Grafts by Single Access Sung Il Park • Il Jung Kim • Shin Jae Lee • Man Deuk Kim • Jong Yun Won • Do Yun Lee Shin-Wook Kang • Kyu Hun Choi
•
Received: 16 October 2013 / Accepted: 6 January 2014 Ó Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2014
Abstract Purpose This study was designed to evaluate the feasibility of balloon catheter looping technique for angioplasty of entry site lesions of stenosis or thrombi that could not be aspirated during endovascular treatment of thrombosed arteriovenous grafts by single access. Methods Balloon catheter looping technique was used for angioplasty of entry site lesions in 13 sessions of treatment of thrombosed arteriovenous grafts by single access in 11 patients (M:F = 7:4, mean age: 70.7 years, 9 brachio-axillary straight and 2 brachio-antecubital loop grafts) and were S. I. Park (&) I. J. Kim S. J. Lee M. D. Kim J. Y. Won D. Y. Lee Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea e-mail: [email protected] I. J. Kim e-mail: [email protected] S. J. Lee e-mail: [email protected] M. D. Kim e-mail: [email protected] J. Y. Won e-mail: [email protected] D. Y. Lee e-mail: [email protected] S.-W. Kang K. H. Choi Division of Nephrology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 501, Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea e-mail: [email protected] K. H. Choi e-mail: [email protected]
retrospectively evaluated. Middle equator of the graft was punctured and a 7F Desilets-Hoffman introducer sheath was inserted for aspiration thrombectomy and angioplasty. For entry site angioplasty, the balloon catheter was positioned 4–5 cm beyond the tip of the sheath. The sheath was retrieved to the entry site and was redirected into the contralateral limb, so the balloon catheter would form a loop. The introducer sheath was advanced to pull the balloon back to cover the entry site for angioplasty. Radiological images and medical records were evaluated for feasibility, success rate, and complications. Results Technical success of treatment of thrombosed graft and balloon catheter looping for entry site angioplasty could be achieved in all 13 cases (100 %), without requiring second access. Completion fistulography revealed no access complication. Patency rate at 3 and 6 months were 80 and 68.6 %, respectively. Conclusions Balloon catheter looping technique for angioplasty of entry site lesions during endovascular treatment of thrombosed arteriovenous graft is a feasible alternative technique to obtaining a second access. Keywords Dialysis shunts Grafts Thrombolysis Thrombectomy
Introduction The classic method of access for thrombosed AV graft was the crossed-catheter technique [1–9], until the apex-puncture technique was introduced [10]. The apex-puncture technique gains single entry into the apex of the loop graft, providing access to the entire graft and both anastomoses for thrombectomy and angioplasty. The concept of apexpuncture technique was further extended to bidirectional angioplasty in the native fistulas [11].
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S. I. Park et al.: PTA for Entry Site Lesions
Since the prior reports [10, 11], the concept of bidirectional angioplasty has been extended by the authors, and we have been treating the thrombosed hemodialysis grafts and fistulas by single access including straight grafts. However, the ‘‘peri-sheath protected area’’ exists in the apex puncture technique. When a stenosis or residual thrombi reside adjacent to the entry site of the introducer sheath, angioplasty through the single access can be difficult. In this circumstance, an additional access has to be obtained for the treatment. In this study, the results of using an alternative method of balloon catheter looping technique is reported, which allows balloon angioplasty of the entry site by single access during endovascular management of thrombosed AV graft.
Materials and Methods Patient Population This retrospective study was approved by the institutional review board, and written informed consent for the procedure was obtained from all patients. Due to the retrospective nature of the study, informed consent for inclusion in the study was waived. From March 2013 to December 2013, balloon catheter looping technique was performed for the entry site lesions, including a stenosis or acute and chronic thrombi, which could not be aspirated in 13 sessions of endovascular treatment for thrombosed AV grafts in 11 patients, and was retrospectively evaluated. The patients were seven men and four women with ages ranging from 58 to 85 years (mean, 70.7 ± 7.6 years). The AV grafts were in right upper extremity in one and in left upper extremity in ten patients and were: brachio-axillary straight graft in nine and brachio-antecubital loop graft in two patients. Cumulative duration of hemodialysis ranged 9–264 months (mean, 60.8 ± 76.4 months), and the duration of implantation of the thrombosed graft ranged 9–48 months (mean, 22.3 ± 13.0 months). Thrombectomy and Angioplasty Procedure Thorough physical examination and sonographic evaluation of the AV grafts preceded fistulography to confirm and determine the extent of the thrombosis and to determine the location of access. The location of access was determined as: lateral equator of the middle segment in the straight grafts and the caudal equator of the apex in loop grafts. After sterile preparation, the predetermined access site was anesthetized using 1 % lidocaine hydrochloride. Under ultrasonographic guide, the middle equator of the graft was punctured using an 18G Angiocath. A 0.035-inch
123
hydrophilic guidewire (Radiofocus M; Terumo, Tokyo, Japan) was advanced into the venous limb, and a 7F DesiletsHoffman introducer sheath (Cook, Bloomington, IN) was inserted. The guidewire was passed through the venous anastomosis, followed by the Desilets-Hoffman introducer sheath or a conventional balloon catheter, and 3,000–5,000 IU of heparin was injected. Then aspiration thrombectomy was done using the Desilets-Hoffman introducer sheath. The Desilets-Hoffman introducer sheath has a radio-opaque marker at the tip of the shaft, which is used to identify the position of the tip. Also, the proximal hub can be separated from the shaft. After separation, the thrombi can be aspirated by applying negative pressure directly to the rear end of the sheath using a syringe. After complete removal of the thrombi in the venous limb, balloon angioplasty of the stenoses in the venous anastomosis and venous limb were done as required. Then the Desilets-Hoffman introducer sheath was redirected toward the arterial limb for aspiration thrombectomy and angioplasty as required. Balloon Catheter Looping Procedure When AV fistulography after treatment of both the venous and arterial limbs revealed an entry site lesion, including a stenosis or acute and chronic thrombi that could not be aspirated, the balloon catheter looping technique was used. The technique of balloon catheter looping is shown in Fig. 1. In all cases of balloon catheter looping, the introducer sheath used was 7F Desilets-Hoffman introducer sheath with a length of 13 cm, and the hydrophilic guidewire used was Radiofocus M. Balloon catheters used were Mustang (Boston Scientific, Natick, MA) (n = 10), Reef HPTM (Invatec, Bethlehem, PA) (n = 1), and Conquest (Bard, Karlsruhe, Germany) (n = 2), with balloon diameter of 7 mm (n = 12) and 8 mm (n = 1). Balloon catheter looping was performed without a support in the initial five cases, but a support was used in the latter eight cases (Figs. 2, 3): the proximal end of a Lunderquist extra stiff wire guide (Cook) (n = 1) and the innermost needle of a multipurpose drainage catheter (Dawson-Mueller Drainage Catheter; Cook) (n = 7). The innermost needle of the drainage catheter was collected during prior drainage procedure and was prepared in advance, by ethylene oxide gas sterilization. Radiological images and medical records were evaluated for success rate and complications. Definition and Statistics Technical success was defined as successful endovascular treatment of the thrombosed graft with less than 30 % residual stenosis, to undergo at least one subsequent session of hemodialysis, and successful balloon catheter
S. I. Park et al.: PTA for Entry Site Lesions
Fig. 1 Balloon catheter looping technique. A The balloon catheter is advanced into a limb of the graft so that the proximal marker is approximately 4–5 cm beyond the tip of the introducer sheath. Then, the supporting metal rod (arrows) is inserted and advanced to the tip of the introducer sheath. B The introducer sheath, the balloon catheter, and the supporting metal rod as a whole is retrieved so that the tip of the introducer sheath would lie immediately inside the entry site. C With a light push toward the lesser curvature side of the graft, the introducer sheath, the balloon catheter, and the supporting metal rod are redirected toward the contralateral limb so that the balloon
catheter is looped and the introducer sheath would be directed toward the graft to be entered. D The introducer sheath, the balloon catheter, and the supporting metal rod as a whole is gently pushed into the contralateral limb of the graft. After the introducer sheath has entered the limb and balloon catheter looping has succeeded, the support is retrieved. E With the looped balloon catheter acting as a J-tip guidewire, the introducer sheath is advanced so that the balloon is pulled back to be positioned over the entry site. F Balloon angioplasty of the entry site is performed in the usual manner
looping for angioplasty of the entry site lesion. Patency rates were obtained by Kaplan–Meier survival analysis using SPSS 12.0 for Windows (SPSS Inc., Chicago, IL). Mean values are provided as mean ± standard deviations.
Completion fistulography revealed no access site complication, including bleeding. Follow-up was performed by physical examination in outpatient basis in five patients and by fistulography during reintervention in three patients, at 16–217 days after the initial endovascular treatment. There was no follow-up in three patients. Four sessions of repeated thrombectomy and angioplasty was performed in three patients at 16, 55, 109, and 217 days, respectively, after the initial treatment, which revealed no late access site complication. The early rethrombosis at 16 days occurred in a patient due to hypotensive event during treatment of pneumonia. Patency rates at 3- and 6-month were 80 and 68.6 %, respectively.
Results Technical success could be achieved in all 13 cases (100 %) without need for a second access. In the three types of balloon used, all balloons could be inflated to the maximum burst pressure. There was no balloon catheter bending or fracture after using the looping technique.
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Fig. 2 Images of a 64-year-old female with thrombosed left brachioantecubital loop graft. A Spot radiography obtained during aspiration thrombectomy reveals residual thrombi at both the arterial and venous limbs and the entry site. The thrombi in both the limbs were macerated by balloon angioplasty, but the thrombi at the entry site could not be aspirated. B Balloon catheter looping technique is performed to place the balloon over the entry site and angioplasty is
performed to macerate the thrombi. Note the supporting metal rod (arrows). C Fistulography performed after angioplasty of the entry site reveals small residual thrombi (arrowhead) adjacent to the entry site, in the direction of balloon catheter looping. Balloon catheter looping and maceration in the contralateral direction can be performed to completely remove the residual thrombi
Discussion
usually discarded after a drainage procedure, was sufficiently stiff to prevent bending of the introducer sheath and provide support during looping and redirecting the introducer sheath, but it was not sharp enough to penetrate the introducer sheath. Using the support has made looping the balloon catheter considerably easier, especially in the straight grafts (Fig. 3), and the time required for looping usually required less than 5 s, as measured by the captured fluoroscopy images provided by the angiography equipment. Endovascular techniques to remove residual thrombi or stenosis at entry site using the apex puncture technique have been reported previously, using Fogarty balloon catheters [12] and angioplasty balloon catheters [13]. The Fogarty balloon catheters were used to dislodge residual thrombi caught by the introducer sheath at the apex, but intimal hyperplasia at the apex could not be treated and additional access was recommended. Various angioplasty balloons also were used for angioplasty of apex puncture site using the T-shaped balloon angioplasty technique. The T-shaped balloon angioplasty technique removes the guidewire during redirection, resulting in folding of the balloon catheter. Once the balloon catheter is folded, reinsertion of the guidewire may be difficult as the inner lumens of the balloon catheter are collapsed. Subsequently, the technique should be performed only at the end of the
The apex-puncture technique enables thrombectomy and angioplasty of both the venous and arterial limbs of a thrombosed loop graft through single access. But the technique has the disadvantage that when an intragraft stenosis or treatment-resistant clot are present adjacent to the sheath entry site, a second access is required for the treatment [10]. The technique of balloon catheter looping was developed to allow angioplasty of the entry site when a stenosis or treatment-resistant clot is present, without obtaining additional access. Initially, manual approximation of the introducer sheath and the graft in a pinching manner was performed to loop the balloon catheter. But manual looping occasionally required considerable amount of time, especially in obese patients, and the possibility of access loss and exposure of the operator’s hand into the radiation field could not be excluded. Subsequently, the method of looping the balloon catheter was modified and a support was used. Proximal end of a Lunderquist extra stiff wire guide was used in one case but was abandoned because the wire guide was not stiff enough as a support during looping. Subsequently, the support was substituted to the innermost needle of a multipurpose drainage catheter. The innermost needle of the multipurpose drainage catheter, which is
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S. I. Park et al.: PTA for Entry Site Lesions
Fig. 3 Images of a 75-year-old female with thrombosed left brachioaxillary straight graft. A Fistulography after aspiration thrombectomy and balloon angioplasty reveals residual thrombi at the entry site, which could not be aspirated. B Balloon catheter looping technique is
performed to place the balloon over the entry site and angioplasty is performed to macerate the thrombi. C Fistulography performed immediately after angioplasty of the entry site reveals resolved thrombi in the entry site
procedure. In using the balloon catheter looping technique, the entry site angioplasty can be performed any time during the procedure, such as treating stenosis in another location. Furthermore, although balloon catheter fracture during the T-shaped balloon angioplasty was not reported, the possibility cannot be excluded, which may result in balloon catheter embolization. For the use of the balloon catheter looping technique, the authors recommend accessing the graft with shortest subcutaneous tunnel as possible. A long subcutaneous tunnel may promote bending of the introducer sheath within the subcutaneous layer during the looping procedure, especially in obese patients. Second, when balloons of 8 mm in diameter or larger is used for angioplasty, exchange of the introducer sheath to larger size is recommended. In the one case in which the balloon catheter looping was performed with a balloon of 8-mm diameter, insertion of the supporting metal rod was difficult. Third, although the looped balloon catheter can be advanced to any limb of the graft according to the operator’s preference, we recommend the loop to be advanced toward the arterial limb. By looping toward the arterial limb, fistulography can be performed immediately after the angioplasty to confirm the result of treatment. Finally, angioplasty of the entry site by balloon catheter looping does not completely eliminate the ‘‘peri-sheath protected area.’’ Small residual thrombi may persist (Fig. 2) at the greater curvature side of the graft in the direction of
balloon catheter looping. For complete removal of the residual thrombi, additional balloon maceration after balloon catheter looping in the contralateral direction may be required. In conclusion, the balloon catheter looping technique for treatment of entry site lesions, including a stenosis or acute and chronic thrombi that could not be aspirated, is an alternative technique to obtaining an additional access during endovascular management of thrombosed hemodialysis grafts, obviating the need for an additional access. Conflict of interest Sung Il Park, Il Jung Kim, Shin Jae Lee, Man Deuk Kim, Jong Yun Won, Do Yun Lee, Shin-Wook Kang, and Kyu Hun Choi have no conflict of interest to disclose.
References 1. Davis GB, Dowd CF, Bookstein JJ, Maroney TP, Lang EV, Halasz N (1987) Thrombosed dialysis grafts: efficacy of intrathrombic deposition of concentrated urokinase, clot maceration, and angioplasty. AJR Am J Roentgenol 149(1):177–181 2. Valji K, Bookstein JJ, Roberts AC, Oglevie SB, Pittman C, O’Neill MP (1995) Pulse-spray pharmacomechanical thrombolysis of thrombosed hemodialysis access grafts: long-term experience and comparison of original and current techniques. AJR Am J Roentgenol 164(6):1495–1500 discussion 1501–1503 3. Beathard GA, Welch BR, Maidment HJ (1996) Mechanical thrombolysis for the treatment of thrombosed hemodialysis access grafts. Radiology 200(3):711–716
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S. I. Park et al.: PTA for Entry Site Lesions 4. Trerotola SO, Lund GB, Scheel PJ Jr, Savader SJ, Venbrux AC, Osterman FA Jr (1994) Thrombosed dialysis access grafts: percutaneous mechanical declotting without urokinase. Radiology 191(3):721–726 5. Trerotola SO, Vesely TM, Lund GB, Soulen MC, Ehrman KO, Cardella JF (1998) Treatment of thrombosed hemodialysis access grafts: arrow-trerotola percutaneous thrombolytic device versus pulse-spray thrombolysis. Arrow-trerotola percutaneous thrombolytic device clinical trial. Radiology 206(2):403–414 6. Cooper SG (2003) Pulse-spray thrombolysis of thrombosed hemodialysis grafts with tissue plasminogen activator. AJR Am J Roentgenol 180(4):1063–1066 7. Goodwin SC, Arora LC, Razavi MK, Sayre J, McNamara TO, Yoon C (1998) Dialysis access graft thrombolysis: randomized study of pulse-spray versus continuous urokinase infusion. Cardiovasc Interv Radiol 21(2):135–137 8. Sahni V, Kaniyur S, Malhotra A, Fan S, Blakeney C, Fotheringham T et al (2005) Mechanical thrombectomy of occluded hemodialysis native fistulas and grafts using a hydrodynamic
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9.
10.
11.
12.
13.
thrombectomy catheter: preliminary experience. Cardiovasc Interv Radiol 28(6):714–721 Patel AA, Tuite CM, Trerotola SO (2005) Mechanical thrombectomy of hemodialysis fistulae and grafts. Cardiovasc Interv Radiol 28(6):704–713 Hathaway PB, Vesely TM (1999) The apex-puncture technique for mechanical thrombolysis of loop hemodialysis grafts. J Vasc Interv Radiol 10(6):775–779 Kim BM, Goo DE, Park SI (2007) Bidirectional angioplasty with single vascular access in autogenous arteriovenous fistula. J Vasc Interv Radiol 18(7):868–874 Goo DE, Yang SB, Kim YJ, Moon C, Song D, Yoon SC et al (2013) Fogarty balloon application technique in dislodging residual thrombus on the single sheath entry point at the apex of thrombosed loop grafts. Diagn Interv Radiol 19(2):150–153 Oh JS, Choi BG, Chun HJ, Lee HG (2013) T-shaped angioplasty with apex puncture of thrombosed looped hemodialysis grafts. J Vasc Interv Radiol 24(3):406–409
TECHNICAL NOTE
Balloon Catheter Looping Technique for Entry Site Angioplasty During Endovascular Management of Thrombosed Arteriovenous Grafts by Single Access Sung Il Park • Il Jung Kim • Shin Jae Lee • Man Deuk Kim • Jong Yun Won • Do Yun Lee Shin-Wook Kang • Kyu Hun Choi
•
Received: 16 October 2013 / Accepted: 6 January 2014 Ó Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2014
Abstract Purpose This study was designed to evaluate the feasibility of balloon catheter looping technique for angioplasty of entry site lesions of stenosis or thrombi that could not be aspirated during endovascular treatment of thrombosed arteriovenous grafts by single access. Methods Balloon catheter looping technique was used for angioplasty of entry site lesions in 13 sessions of treatment of thrombosed arteriovenous grafts by single access in 11 patients (M:F = 7:4, mean age: 70.7 years, 9 brachio-axillary straight and 2 brachio-antecubital loop grafts) and were S. I. Park (&) I. J. Kim S. J. Lee M. D. Kim J. Y. Won D. Y. Lee Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea e-mail: [email protected] I. J. Kim e-mail: [email protected] S. J. Lee e-mail: [email protected] M. D. Kim e-mail: [email protected] J. Y. Won e-mail: [email protected] D. Y. Lee e-mail: [email protected] S.-W. Kang K. H. Choi Division of Nephrology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 501, Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea e-mail: [email protected] K. H. Choi e-mail: [email protected]
retrospectively evaluated. Middle equator of the graft was punctured and a 7F Desilets-Hoffman introducer sheath was inserted for aspiration thrombectomy and angioplasty. For entry site angioplasty, the balloon catheter was positioned 4–5 cm beyond the tip of the sheath. The sheath was retrieved to the entry site and was redirected into the contralateral limb, so the balloon catheter would form a loop. The introducer sheath was advanced to pull the balloon back to cover the entry site for angioplasty. Radiological images and medical records were evaluated for feasibility, success rate, and complications. Results Technical success of treatment of thrombosed graft and balloon catheter looping for entry site angioplasty could be achieved in all 13 cases (100 %), without requiring second access. Completion fistulography revealed no access complication. Patency rate at 3 and 6 months were 80 and 68.6 %, respectively. Conclusions Balloon catheter looping technique for angioplasty of entry site lesions during endovascular treatment of thrombosed arteriovenous graft is a feasible alternative technique to obtaining a second access. Keywords Dialysis shunts Grafts Thrombolysis Thrombectomy
Introduction The classic method of access for thrombosed AV graft was the crossed-catheter technique [1–9], until the apex-puncture technique was introduced [10]. The apex-puncture technique gains single entry into the apex of the loop graft, providing access to the entire graft and both anastomoses for thrombectomy and angioplasty. The concept of apexpuncture technique was further extended to bidirectional angioplasty in the native fistulas [11].
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S. I. Park et al.: PTA for Entry Site Lesions
Since the prior reports [10, 11], the concept of bidirectional angioplasty has been extended by the authors, and we have been treating the thrombosed hemodialysis grafts and fistulas by single access including straight grafts. However, the ‘‘peri-sheath protected area’’ exists in the apex puncture technique. When a stenosis or residual thrombi reside adjacent to the entry site of the introducer sheath, angioplasty through the single access can be difficult. In this circumstance, an additional access has to be obtained for the treatment. In this study, the results of using an alternative method of balloon catheter looping technique is reported, which allows balloon angioplasty of the entry site by single access during endovascular management of thrombosed AV graft.
Materials and Methods Patient Population This retrospective study was approved by the institutional review board, and written informed consent for the procedure was obtained from all patients. Due to the retrospective nature of the study, informed consent for inclusion in the study was waived. From March 2013 to December 2013, balloon catheter looping technique was performed for the entry site lesions, including a stenosis or acute and chronic thrombi, which could not be aspirated in 13 sessions of endovascular treatment for thrombosed AV grafts in 11 patients, and was retrospectively evaluated. The patients were seven men and four women with ages ranging from 58 to 85 years (mean, 70.7 ± 7.6 years). The AV grafts were in right upper extremity in one and in left upper extremity in ten patients and were: brachio-axillary straight graft in nine and brachio-antecubital loop graft in two patients. Cumulative duration of hemodialysis ranged 9–264 months (mean, 60.8 ± 76.4 months), and the duration of implantation of the thrombosed graft ranged 9–48 months (mean, 22.3 ± 13.0 months). Thrombectomy and Angioplasty Procedure Thorough physical examination and sonographic evaluation of the AV grafts preceded fistulography to confirm and determine the extent of the thrombosis and to determine the location of access. The location of access was determined as: lateral equator of the middle segment in the straight grafts and the caudal equator of the apex in loop grafts. After sterile preparation, the predetermined access site was anesthetized using 1 % lidocaine hydrochloride. Under ultrasonographic guide, the middle equator of the graft was punctured using an 18G Angiocath. A 0.035-inch
123
hydrophilic guidewire (Radiofocus M; Terumo, Tokyo, Japan) was advanced into the venous limb, and a 7F DesiletsHoffman introducer sheath (Cook, Bloomington, IN) was inserted. The guidewire was passed through the venous anastomosis, followed by the Desilets-Hoffman introducer sheath or a conventional balloon catheter, and 3,000–5,000 IU of heparin was injected. Then aspiration thrombectomy was done using the Desilets-Hoffman introducer sheath. The Desilets-Hoffman introducer sheath has a radio-opaque marker at the tip of the shaft, which is used to identify the position of the tip. Also, the proximal hub can be separated from the shaft. After separation, the thrombi can be aspirated by applying negative pressure directly to the rear end of the sheath using a syringe. After complete removal of the thrombi in the venous limb, balloon angioplasty of the stenoses in the venous anastomosis and venous limb were done as required. Then the Desilets-Hoffman introducer sheath was redirected toward the arterial limb for aspiration thrombectomy and angioplasty as required. Balloon Catheter Looping Procedure When AV fistulography after treatment of both the venous and arterial limbs revealed an entry site lesion, including a stenosis or acute and chronic thrombi that could not be aspirated, the balloon catheter looping technique was used. The technique of balloon catheter looping is shown in Fig. 1. In all cases of balloon catheter looping, the introducer sheath used was 7F Desilets-Hoffman introducer sheath with a length of 13 cm, and the hydrophilic guidewire used was Radiofocus M. Balloon catheters used were Mustang (Boston Scientific, Natick, MA) (n = 10), Reef HPTM (Invatec, Bethlehem, PA) (n = 1), and Conquest (Bard, Karlsruhe, Germany) (n = 2), with balloon diameter of 7 mm (n = 12) and 8 mm (n = 1). Balloon catheter looping was performed without a support in the initial five cases, but a support was used in the latter eight cases (Figs. 2, 3): the proximal end of a Lunderquist extra stiff wire guide (Cook) (n = 1) and the innermost needle of a multipurpose drainage catheter (Dawson-Mueller Drainage Catheter; Cook) (n = 7). The innermost needle of the drainage catheter was collected during prior drainage procedure and was prepared in advance, by ethylene oxide gas sterilization. Radiological images and medical records were evaluated for success rate and complications. Definition and Statistics Technical success was defined as successful endovascular treatment of the thrombosed graft with less than 30 % residual stenosis, to undergo at least one subsequent session of hemodialysis, and successful balloon catheter
S. I. Park et al.: PTA for Entry Site Lesions
Fig. 1 Balloon catheter looping technique. A The balloon catheter is advanced into a limb of the graft so that the proximal marker is approximately 4–5 cm beyond the tip of the introducer sheath. Then, the supporting metal rod (arrows) is inserted and advanced to the tip of the introducer sheath. B The introducer sheath, the balloon catheter, and the supporting metal rod as a whole is retrieved so that the tip of the introducer sheath would lie immediately inside the entry site. C With a light push toward the lesser curvature side of the graft, the introducer sheath, the balloon catheter, and the supporting metal rod are redirected toward the contralateral limb so that the balloon
catheter is looped and the introducer sheath would be directed toward the graft to be entered. D The introducer sheath, the balloon catheter, and the supporting metal rod as a whole is gently pushed into the contralateral limb of the graft. After the introducer sheath has entered the limb and balloon catheter looping has succeeded, the support is retrieved. E With the looped balloon catheter acting as a J-tip guidewire, the introducer sheath is advanced so that the balloon is pulled back to be positioned over the entry site. F Balloon angioplasty of the entry site is performed in the usual manner
looping for angioplasty of the entry site lesion. Patency rates were obtained by Kaplan–Meier survival analysis using SPSS 12.0 for Windows (SPSS Inc., Chicago, IL). Mean values are provided as mean ± standard deviations.
Completion fistulography revealed no access site complication, including bleeding. Follow-up was performed by physical examination in outpatient basis in five patients and by fistulography during reintervention in three patients, at 16–217 days after the initial endovascular treatment. There was no follow-up in three patients. Four sessions of repeated thrombectomy and angioplasty was performed in three patients at 16, 55, 109, and 217 days, respectively, after the initial treatment, which revealed no late access site complication. The early rethrombosis at 16 days occurred in a patient due to hypotensive event during treatment of pneumonia. Patency rates at 3- and 6-month were 80 and 68.6 %, respectively.
Results Technical success could be achieved in all 13 cases (100 %) without need for a second access. In the three types of balloon used, all balloons could be inflated to the maximum burst pressure. There was no balloon catheter bending or fracture after using the looping technique.
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S. I. Park et al.: PTA for Entry Site Lesions
Fig. 2 Images of a 64-year-old female with thrombosed left brachioantecubital loop graft. A Spot radiography obtained during aspiration thrombectomy reveals residual thrombi at both the arterial and venous limbs and the entry site. The thrombi in both the limbs were macerated by balloon angioplasty, but the thrombi at the entry site could not be aspirated. B Balloon catheter looping technique is performed to place the balloon over the entry site and angioplasty is
performed to macerate the thrombi. Note the supporting metal rod (arrows). C Fistulography performed after angioplasty of the entry site reveals small residual thrombi (arrowhead) adjacent to the entry site, in the direction of balloon catheter looping. Balloon catheter looping and maceration in the contralateral direction can be performed to completely remove the residual thrombi
Discussion
usually discarded after a drainage procedure, was sufficiently stiff to prevent bending of the introducer sheath and provide support during looping and redirecting the introducer sheath, but it was not sharp enough to penetrate the introducer sheath. Using the support has made looping the balloon catheter considerably easier, especially in the straight grafts (Fig. 3), and the time required for looping usually required less than 5 s, as measured by the captured fluoroscopy images provided by the angiography equipment. Endovascular techniques to remove residual thrombi or stenosis at entry site using the apex puncture technique have been reported previously, using Fogarty balloon catheters [12] and angioplasty balloon catheters [13]. The Fogarty balloon catheters were used to dislodge residual thrombi caught by the introducer sheath at the apex, but intimal hyperplasia at the apex could not be treated and additional access was recommended. Various angioplasty balloons also were used for angioplasty of apex puncture site using the T-shaped balloon angioplasty technique. The T-shaped balloon angioplasty technique removes the guidewire during redirection, resulting in folding of the balloon catheter. Once the balloon catheter is folded, reinsertion of the guidewire may be difficult as the inner lumens of the balloon catheter are collapsed. Subsequently, the technique should be performed only at the end of the
The apex-puncture technique enables thrombectomy and angioplasty of both the venous and arterial limbs of a thrombosed loop graft through single access. But the technique has the disadvantage that when an intragraft stenosis or treatment-resistant clot are present adjacent to the sheath entry site, a second access is required for the treatment [10]. The technique of balloon catheter looping was developed to allow angioplasty of the entry site when a stenosis or treatment-resistant clot is present, without obtaining additional access. Initially, manual approximation of the introducer sheath and the graft in a pinching manner was performed to loop the balloon catheter. But manual looping occasionally required considerable amount of time, especially in obese patients, and the possibility of access loss and exposure of the operator’s hand into the radiation field could not be excluded. Subsequently, the method of looping the balloon catheter was modified and a support was used. Proximal end of a Lunderquist extra stiff wire guide was used in one case but was abandoned because the wire guide was not stiff enough as a support during looping. Subsequently, the support was substituted to the innermost needle of a multipurpose drainage catheter. The innermost needle of the multipurpose drainage catheter, which is
123
S. I. Park et al.: PTA for Entry Site Lesions
Fig. 3 Images of a 75-year-old female with thrombosed left brachioaxillary straight graft. A Fistulography after aspiration thrombectomy and balloon angioplasty reveals residual thrombi at the entry site, which could not be aspirated. B Balloon catheter looping technique is
performed to place the balloon over the entry site and angioplasty is performed to macerate the thrombi. C Fistulography performed immediately after angioplasty of the entry site reveals resolved thrombi in the entry site
procedure. In using the balloon catheter looping technique, the entry site angioplasty can be performed any time during the procedure, such as treating stenosis in another location. Furthermore, although balloon catheter fracture during the T-shaped balloon angioplasty was not reported, the possibility cannot be excluded, which may result in balloon catheter embolization. For the use of the balloon catheter looping technique, the authors recommend accessing the graft with shortest subcutaneous tunnel as possible. A long subcutaneous tunnel may promote bending of the introducer sheath within the subcutaneous layer during the looping procedure, especially in obese patients. Second, when balloons of 8 mm in diameter or larger is used for angioplasty, exchange of the introducer sheath to larger size is recommended. In the one case in which the balloon catheter looping was performed with a balloon of 8-mm diameter, insertion of the supporting metal rod was difficult. Third, although the looped balloon catheter can be advanced to any limb of the graft according to the operator’s preference, we recommend the loop to be advanced toward the arterial limb. By looping toward the arterial limb, fistulography can be performed immediately after the angioplasty to confirm the result of treatment. Finally, angioplasty of the entry site by balloon catheter looping does not completely eliminate the ‘‘peri-sheath protected area.’’ Small residual thrombi may persist (Fig. 2) at the greater curvature side of the graft in the direction of
balloon catheter looping. For complete removal of the residual thrombi, additional balloon maceration after balloon catheter looping in the contralateral direction may be required. In conclusion, the balloon catheter looping technique for treatment of entry site lesions, including a stenosis or acute and chronic thrombi that could not be aspirated, is an alternative technique to obtaining an additional access during endovascular management of thrombosed hemodialysis grafts, obviating the need for an additional access. Conflict of interest Sung Il Park, Il Jung Kim, Shin Jae Lee, Man Deuk Kim, Jong Yun Won, Do Yun Lee, Shin-Wook Kang, and Kyu Hun Choi have no conflict of interest to disclose.
References 1. Davis GB, Dowd CF, Bookstein JJ, Maroney TP, Lang EV, Halasz N (1987) Thrombosed dialysis grafts: efficacy of intrathrombic deposition of concentrated urokinase, clot maceration, and angioplasty. AJR Am J Roentgenol 149(1):177–181 2. Valji K, Bookstein JJ, Roberts AC, Oglevie SB, Pittman C, O’Neill MP (1995) Pulse-spray pharmacomechanical thrombolysis of thrombosed hemodialysis access grafts: long-term experience and comparison of original and current techniques. AJR Am J Roentgenol 164(6):1495–1500 discussion 1501–1503 3. Beathard GA, Welch BR, Maidment HJ (1996) Mechanical thrombolysis for the treatment of thrombosed hemodialysis access grafts. Radiology 200(3):711–716
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S. I. Park et al.: PTA for Entry Site Lesions 4. Trerotola SO, Lund GB, Scheel PJ Jr, Savader SJ, Venbrux AC, Osterman FA Jr (1994) Thrombosed dialysis access grafts: percutaneous mechanical declotting without urokinase. Radiology 191(3):721–726 5. Trerotola SO, Vesely TM, Lund GB, Soulen MC, Ehrman KO, Cardella JF (1998) Treatment of thrombosed hemodialysis access grafts: arrow-trerotola percutaneous thrombolytic device versus pulse-spray thrombolysis. Arrow-trerotola percutaneous thrombolytic device clinical trial. Radiology 206(2):403–414 6. Cooper SG (2003) Pulse-spray thrombolysis of thrombosed hemodialysis grafts with tissue plasminogen activator. AJR Am J Roentgenol 180(4):1063–1066 7. Goodwin SC, Arora LC, Razavi MK, Sayre J, McNamara TO, Yoon C (1998) Dialysis access graft thrombolysis: randomized study of pulse-spray versus continuous urokinase infusion. Cardiovasc Interv Radiol 21(2):135–137 8. Sahni V, Kaniyur S, Malhotra A, Fan S, Blakeney C, Fotheringham T et al (2005) Mechanical thrombectomy of occluded hemodialysis native fistulas and grafts using a hydrodynamic
123
9.
10.
11.
12.
13.
thrombectomy catheter: preliminary experience. Cardiovasc Interv Radiol 28(6):714–721 Patel AA, Tuite CM, Trerotola SO (2005) Mechanical thrombectomy of hemodialysis fistulae and grafts. Cardiovasc Interv Radiol 28(6):704–713 Hathaway PB, Vesely TM (1999) The apex-puncture technique for mechanical thrombolysis of loop hemodialysis grafts. J Vasc Interv Radiol 10(6):775–779 Kim BM, Goo DE, Park SI (2007) Bidirectional angioplasty with single vascular access in autogenous arteriovenous fistula. J Vasc Interv Radiol 18(7):868–874 Goo DE, Yang SB, Kim YJ, Moon C, Song D, Yoon SC et al (2013) Fogarty balloon application technique in dislodging residual thrombus on the single sheath entry point at the apex of thrombosed loop grafts. Diagn Interv Radiol 19(2):150–153 Oh JS, Choi BG, Chun HJ, Lee HG (2013) T-shaped angioplasty with apex puncture of thrombosed looped hemodialysis grafts. J Vasc Interv Radiol 24(3):406–409
