Overview of hemodialysis arteriovenous graft maintenance and thrombosis prevention
- Michael Allon, MD
Michael Allon, MD
- Professor of Medicine
- University of Alabama at Birmingham
- Section Editors
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
- David L Cull, MD
David L Cull, MD
- Section Editor — Arterial and Venous Access
- Clinical Professor, Department of Surgery
- University of South Carolina School of Medicine
This topic review provides an overview of general issues regarding arteriovenous (AV) graft maintenance, including measures to prevent AV graft thrombosis and management of the high-risk AV graft. These same considerations with respect to AV fistulas are reviewed separately. (See "Overview of hemodialysis arteriovenous fistula maintenance and thrombosis prevention".)
RISK FACTORS FOR AV GRAFT THROMBOSIS
Arteriovenous (AV) graft thrombosis can occur immediately following AV graft creation, usually related to technical issues, or later after using the access for a variable period of time predominantly due to stenotic lesions that develop from intimal hyperplasia. More than 90 percent of thrombosed grafts have a stenotic lesion. (See "Hemodialysis arteriovenous graft dysfunction and failure".)
Stenosis of a hemodialysis AV graft is initiated by endothelial cell injury, which leads to the upregulation of adhesion molecules on the endothelial cell surface. Subsequent leukocyte adherence to damaged and activated endothelium causes the release of chemotactic and mitogenic factors for vascular smooth muscle cells, thereby enhancing smooth muscle cell migration and proliferation [1-3]. Additional factors that contribute to the neointimal proliferation and fibromuscular hyperplasia include shear stress generated by the turbulent blood flow [4,5] and the mismatch in elastic properties around the anastomosis leading to excessive mechanical stretch . Activated platelets and inflammatory cells also secrete oxidants and other toxins that directly injure the vessel wall . Measures aimed at reducing neointimal hyperplasia as well as other pharmacologic agents that address other elements underlying vascular stenosis may help prevent stenosis. (See 'High-risk AV grafts' below.)
Other factors that can lead to AV graft dysfunction and thrombosis include:
●Preexisting stenotic lesions
- Swedberg SH, Brown BG, Sigley R, et al. Intimal fibromuscular hyperplasia at the venous anastomosis of PTFE grafts in hemodialysis patients. Clinical, immunocytochemical, light and electron microscopic assessment. Circulation 1989; 80:1726.
- Rekhter M, Nicholls S, Ferguson M, Gordon D. Cell proliferation in human arteriovenous fistulas used for hemodialysis. Arterioscler Thromb 1993; 13:609.
- Stracke S, Konner K, Köstlin I, et al. Increased expression of TGF-beta1 and IGF-I in inflammatory stenotic lesions of hemodialysis fistulas. Kidney Int 2002; 61:1011.
- Sterpetti AV, Cucina A, Santoro L, et al. Modulation of arterial smooth muscle cell growth by haemodynamic forces. Eur J Vasc Surg 1992; 6:16.
- Hsieh HJ, Li NQ, Frangos JA. Shear stress increases endothelial platelet-derived growth factor mRNA levels. Am J Physiol 1991; 260:H642.
- Hofstra L, Bergmans DC, Hoeks AP, et al. Mismatch in elastic properties around anastomoses of interposition grafts for hemodialysis access. J Am Soc Nephrol 1994; 5:1243.
- Himmelfarb J. Pharmacologic prevention of vascular access stenosis. Curr Opin Nephrol Hypertens 1999; 8:569.
- https://www.kidney.org/sites/default/files/docs/12-50-0210_jag_dcp_guidelines-va_oct06_sectionc_ofc.pdf (Accessed on March 13, 2017).
- https://www.pennmedicine.org/departments-and-centers/department-of-radiology/patient-care/radiology/interventional-radiology/procedures-and-services/hemodialysis-access (Accessed on March 13, 2017).
- Saran R, Dykstra DM, Pisoni RL, et al. Timing of first cannulation and vascular access failure in haemodialysis: an analysis of practice patterns at dialysis facilities in the DOPPS. Nephrol Dial Transplant 2004; 19:2334.
- Sottiurai VS, Stephens A, Champagne L, et al. Comparative results of early and delayed cannulation of arteriovenous graft in haemodialysis. Eur J Vasc Endovasc Surg 1997; 13:139.
- Schild AF, Schuman ES, Noicely K, et al. Early cannulation prosthetic graft (Flixene™) for arteriovenous access. J Vasc Access 2011; 12:248.
- Jayanti A, Foden P, Wearden A, et al. Self-cannulation for haemodialysis: patient attributes, clinical correlates and self-cannulation predilection models. PLoS One 2015; 10:e0125606.
- Donato-Moore S. Self cannulation for home hemodialysis: strategies for success. Nephrol Nurs J 2013; 40:37.
- Tokars JI, Arduino MJ, Alter MJ. Infection control in hemodialysis units. Infect Dis Clin North Am 2001; 15:797.
- https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm (Accessed on March 13, 2017).
- Arenas MD, Sánchez-Payá J, Barril G, et al. A multicentric survey of the practice of hand hygiene in haemodialysis units: factors affecting compliance. Nephrol Dial Transplant 2005; 20:1164.
- Chang CJ, Ko PJ, Hsu LA, et al. Highly increased cell proliferation activity in the restenotic hemodialysis vascular access after percutaneous transluminal angioplasty: implication in prevention of restenosis. Am J Kidney Dis 2004; 43:74.
- Crowther MA, Clase CM, Margetts PJ, et al. Low-intensity warfarin is ineffective for the prevention of PTFE graft failure in patients on hemodialysis: a randomized controlled trial. J Am Soc Nephrol 2002; 13:2331.
- D'Ayala M, Smith RM, Martone C, et al. The effect of systemic anticoagulation in patients undergoing angioaccess surgery. Ann Vasc Surg 2008; 22:11.
- Chan KE, Lazarus JM, Thadhani R, Hakim RM. Anticoagulant and antiplatelet usage associates with mortality among hemodialysis patients. J Am Soc Nephrol 2009; 20:872.
- Morgan CL, McEwan P, Tukiendorf A, et al. Warfarin treatment in patients with atrial fibrillation: observing outcomes associated with varying levels of INR control. Thromb Res 2009; 124:37.
- O'shea SI, Lawson JH, Reddan D, et al. Hypercoagulable states and antithrombotic strategies in recurrent vascular access site thrombosis. J Vasc Surg 2003; 38:541.
- Brunet P, Aillaud MF, San Marco M, et al. Antiphospholipids in hemodialysis patients: relationship between lupus anticoagulant and thrombosis. Kidney Int 1995; 48:794.
- Prakash R, Miller CC 3rd, Suki WN. Anticardiolipin antibody in patients on maintenance hemodialysis and its association with recurrent arteriovenous graft thrombosis. Am J Kidney Dis 1995; 26:347.
- Molino D, De Lucia D, Marotta R, et al. In uremia, plasma levels of anti-protein C and anti-protein S antibodies are associated with thrombosis. Kidney Int 2005; 68:1223.
- Knoll GA, Wells PS, Young D, et al. Thrombophilia and the risk for hemodialysis vascular access thrombosis. J Am Soc Nephrol 2005; 16:1108.
- Schwab SJ, Harrington JT, Singh A, et al. Vascular access for hemodialysis. Kidney Int 1999; 55:2078.
- Allon M. A Patient with Recurrent Arteriovenous Graft Thrombosis. Clin J Am Soc Nephrol 2015; 10:2255.
- Sreedhara R, Himmelfarb J, Lazarus JM, Hakim RM. Anti-platelet therapy in graft thrombosis: results of a prospective, randomized, double-blind study. Kidney Int 1994; 45:1477.
- Dixon BS, Beck GJ, Vazquez MA, et al. Effect of dipyridamole plus aspirin on hemodialysis graft patency. N Engl J Med 2009; 360:2191.
- Dixon BS, Beck GJ, Dember LM, et al. Use of aspirin associates with longer primary patency of hemodialysis grafts. J Am Soc Nephrol 2011; 22:773.
- Harker LA, Kadatz RA. Mechanism of action of dipyridamole. Thromb Res Suppl 1983; 4:39.
- Himmelfarb J, Couper L. Dipyridamole inhibits PDGF- and bFGF-induced vascular smooth muscle cell proliferation. Kidney Int 1997; 52:1671.
- Tanner NC, Da Silva A. Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts. Cochrane Database Syst Rev 2015; :CD002786.
- Domoto DT, Bauman JE, Joist JH. Combined aspirin and sulfinpyrazone in the prevention of recurrent hemodialysis vascular access thrombosis. Thromb Res 1991; 62:737.
- Kaufman JS, O'Connor TZ, Zhang JH, et al. Randomized controlled trial of clopidogrel plus aspirin to prevent hemodialysis access graft thrombosis. J Am Soc Nephrol 2003; 14:2313.
- Hung AM, Booker C, Ellis CD, et al. Omega-3 fatty acids inhibit the up-regulation of endothelial chemokines in maintenance hemodialysis patients. Nephrol Dial Transplant 2015; 30:266.
- Dixon BS. Fish oil and hemodialysis graft patency: does time matter? JAMA 2012; 307:1859.
- He L, Li MS, Lin M, et al. Effect of fish oil supplement in maintenance hemodialysis patients: a systematic review and meta-analysis of published randomized controlled trials. Eur J Clin Pharmacol 2016; 72:129.
- Bowden RG, Wilson RL, Gentile M, et al. Effects of omega-3 fatty acid supplementation on vascular access thrombosis in polytetrafluorethylene grafts. J Ren Nutr 2007; 17:126.
- Lok CE, Moist L, Hemmelgarn BR, et al. Effect of fish oil supplementation on graft patency and cardiovascular events among patients with new synthetic arteriovenous hemodialysis grafts: a randomized controlled trial. JAMA 2012; 307:1809.
- Schmitz PG, McCloud LK, Reikes ST, et al. Prophylaxis of hemodialysis graft thrombosis with fish oil: double-blind, randomized, prospective trial. J Am Soc Nephrol 2002; 13:184.
- Irish AB, Viecelli AK, Hawley CM, et al. Effect of Fish Oil Supplementation and Aspirin Use on Arteriovenous Fistula Failure in Patients Requiring Hemodialysis: A Randomized Clinical Trial. JAMA Intern Med 2017; 177:184.
- Shemin D, Lapane KL, Bausserman L, et al. Plasma total homocysteine and hemodialysis access thrombosis: a prospective study. J Am Soc Nephrol 1999; 10:1095.
- Wrone EM, Hornberger JM, Zehnder JL, et al. Randomized trial of folic acid for prevention of cardiovascular events in end-stage renal disease. J Am Soc Nephrol 2004; 15:420.
- Jamison RL, Hartigan P, Kaufman JS, et al. Effect of homocysteine lowering on mortality and vascular disease in advanced chronic kidney disease and end-stage renal disease: a randomized controlled trial. JAMA 2007; 298:1163.
- Rotmans JI, Pattynama PM, Verhagen HJ, et al. Sirolimus-eluting stents to abolish intimal hyperplasia and improve flow in porcine arteriovenous grafts: a 4-week follow-up study. Circulation 2005; 111:1537.
- Cheung AK, Terry C, Li L. Pathogenesis and local drug delivery for prevention of vascular access stenosis. J Ren Nutr 2008; 18:140.
- RISK FACTORS FOR AV GRAFT THROMBOSIS
- ROUTINE GRAFT MAINTENANCE AND CARE
- Cannulation and decannulation
- - Inspection prior to initial cannulation
- - General procedure
- - Decannulating the AV graft
- - Cannulation difficulty or failure
- Care between dialysis sessions
- PRIMARY THROMBOSIS PREVENTION IN NEWLY CREATED GRAFTS
- Angioplasty/stenting of underlying stenosis
- Prophylactic antithrombotic therapy
- HIGH-RISK AV GRAFTS
- Immediate graft thrombosis
- - Evaluation for hypercoagulable state
- - Anticoagulation for hypercoagulabity
- Early graft thrombosis
- - Dipyramidole and aspirin
- - Other antiplatelet agents
- - Fish oil
- RECURRENT THROMBOSIS
- Recurrent stenotic lesions
- Recurrence in the absence of a stenotic lesion
- EXPERIMENTAL THERAPIES
- SUMMARY AND RECOMMENDATIONS