Outpatient use of tPA to recanalize thrombosed native fistulas a case series and discussion of literature

Background: The present study aims to evaluate the effectiveness of ultrasound-guided percutaneous alteplase (t-PA) injection for the treatment of long segment ( ≥14cm) thrombi in the efferent veins of native arteriovenous fistulas in hemodialysis patients. Methods: A total of 9 patients who underwent t-PA application under ultrasound guidance in the interventional radiology clinic between 2019 and 2021 were included in the study. During the intervention, information such as thrombosed segment length, t-PA dose, number of sessions, presence of aneurysmal segment, bleeding after the intervention and the need for percutaneous transluminal angioplasty (PTA) were recorded. Restoring the flow in the fistula was considered the successful outcome. All statistical evaluations were performed with the IBM SPSS Statistics 21 software (version 21.0; SPSS Inc, Chicago, Illinois) for Windows. Results: Mean age of the patients was 48.7±14 years, the fistula age was 28.7±11 months, the thrombosis age was 3.5±2 days, and the thrombosed segment length was 17.7±2.9 cm. Post-intervention bleeding that did not require treatment was encountered in 2 patients, and stenosis in the proximal fistula was encountered in 6 patients. PTA was applied to 7 patients after t-PA. After the interventions, effective flow was provided in all patients. Conclusion: Ultrasound-guided percutaneous t-PA injection should be considered as an effective intervention which is less invasive, can be performed as an outpatient intervention and has fewer complications, even if the thrombi segments are long (>10 cm). This technique avoids the potential endothelial damage and saves the cost of the mechanical devices.