Time Not An Issue for Percutaneous Thrombectomy

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CHICAGO—Time may not be as serious an issue as previously thought when it comes to image-guided percutaneous thrombectomy in the setting of clotted surgical dialysis access, according to researchers.

Their findings suggest that declotting surgical dialysis access could be handled on an elective rather than an on an emergency basis.

“More patients than ever are dependent on regularly scheduled hemodialysis, and the number of patients requiring hemodialysis is increasing. Therefore, it is very important to determine how emergently these procedures need to be done,” said lead investigator Sonali Mehandru, MD, a fourth-year radiology resident at Case Medical Center in Cleveland.

“Our results support the idea that these procedures do not have to be emergent procedures. This is actually very important clinically. There have been no studies before ours to look at this issue. There has only been anecdotal evidence that they did not have to be done as an emergent procedure. That was the word on the street, but we wanted to support that statement with some actual quantitative research.”

Dr. Mehandru, who presented the study findings at the 2011 Annual Scientific Meeting of the Society of Interventional Radiology, said vascular access dysfunction is a leading cause of hospitalization in dialysis patients. Most surgical access sites are ultimately lost due to thrombotic events that cannot be resolved, she said. Until now, however, the optimal time window for intervention in the setting of an occluded surgical access had not been defined.

Patients' need for emergent dialysis should govern the triage of thrombectomy procedures performed in interventional radiology, Dr. Mehandru said, adding that the assumption of “sooner is better” may not be the case.

She and her colleagues retrospectively reviewed the records from patients who underwent percutaneous thrombectomy of occluded surgical hemodialysis access sites in the interventional radiology departments of two medical centers from 2004 through early 2011. At both centers, the initial request for thrombectomy of a clotted surgical access was documented by electronic order entry.

A total of 377 procedures were performed on 363 access sites (348 synthetic grafts and 29 fistulae): 290 were performed within 24 hours of the initial request and 87 were performed after 24 hours. Overall, the success rate was 94.4% (95.5% for grafts and 75.8% for fistulae).

The researchers found no significant difference in success rates between thrombectomies performed within 24 hours or those performed after 24 hours. It is unknown if these procedures can be delayed safely for several days or weeks, she said.

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