The Clotted Access

A functional hemodialysis vascular access is the lifeline for patients with end stage kidney disease (ESKD). The appropriate dialysis access, whether peritoneal dialysis, arteriovenous fistulas (AVFs), arteriovenous grafts (AVGs) or central venous catheters (CVCs) is chosen based on the life plan of this population. Following dialysis access creation, the interplay between several pathologic mechanisms can lead to vascular luminal compromise due to neointimal hyperplasia (NIH) with subsequent stenosis, stasis, and eventually access thrombosis. It is crucial to restore the blood flow within the vascular access circuit in order to avoid the use of CVCs and to prolong the life span of the vascular access conduit. The fundamental principles of access declotting are removal of the thrombus from the clotted access and treatment of the underlying causative lesion. Several endovascular devices have been utilized to perform mechanical declotting and have shown comparable outcomes. Standard angioplasty balloons remain the cornerstone for the treatment of stenotic vascular lesions. The utility of drug coated balloons (DCBs) in dialysis vascular access remains unsettled due to conflicting results from randomized clinical trials. Stent grafts are used to treat resistant and recurrent stenotic lesions and to control extravasation from a ruptured vessel that is not controlled by conservative measures. Overall, endovascular declotting is the preferred modality of treatment for the thrombosed dialysis vascular conduits.