Strategies other than treatment of stenosis to prevent thrombosis of hemodialysis arteriovenous access
- Michael Allon, MD
Michael Allon, MD
- Professor of Medicine
- University of Alabama at Birmingham
- Section Editor
- 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
Hemodialysis requires access to blood vessels capable of providing rapid extracorporeal blood flow. These requirements are currently best met by both primary arteriovenous (AV) fistulas and AV grafts. (See "Overview of chronic hemodialysis vascular access".)
Hemodialysis AV access failure is primary due to irreversible thrombosis. More than 90 percent of thrombosed grafts have a stenotic lesion, which is commonly treated with percutaneous transluminal angioplasty and/or surgery. However, mechanical approaches that rely upon preemptive angioplasty to treat stenosis to help graft failure are associated with disappointing results. Thus, alternative strategies to prevent graft thrombosis may be beneficial.
Strategies to prevent thrombosis of hemodialysis AV grafts other than treatment of the stenosis are presented in this topic review. Management of stenosis of hemodialysis access is presented separately. (See "Percutaneous intervention for the treatment of stenosis in the arteriovenous access" and "Techniques for angioplasty of the arteriovenous hemodialysis access".)
Vascular access stenosis of hemodialysis AV fistulas and grafts 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 . Finally, angioplasty of stenotic lesions exacerbates neointimal hyperplasia, resulting in accelerated restenosis .
- 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.
- 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.
- Domoto DT, Bauman JE, Joist JH. Combined aspirin and sulfinpyrazone in the prevention of recurrent hemodialysis vascular access thrombosis. Thromb Res 1991; 62:737.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Dixon BS. Fish oil and hemodialysis graft patency: does time matter? JAMA 2012; 307:1859.
- Twardowski ZJ, Harper G. Buttonhole method of needle insertion into arteriovenous fistulas. 1997.
- Twardowski Z, Kubara H. Different sites versus constant sites of needle insertion into arteriovenous fistulas for treatment by repeated dialysis. Dial Transpl 1979; 8:978.
- Hashmi A, Cheema MQ, Moss AH. Hemodialysis patients' experience with and attitudes toward the buttonhole technique for arteriovenous fistula cannulation. Clin Nephrol 2010; 74:346.
- Nesrallah GE, Cuerden M, Wong JH, Pierratos A. Staphylococcus aureus bacteremia and buttonhole cannulation: long-term safety and efficacy of mupirocin prophylaxis. Clin J Am Soc Nephrol 2010; 5:1047.
- Vaux E, King J, Lloyd S, et al. Effect of buttonhole cannulation with a polycarbonate PEG on in-center hemodialysis fistula outcomes: a randomized controlled trial. Am J Kidney Dis 2013; 62:81.
- MacRae JM, Ahmed SB, Atkar R, Hemmelgarn BR. A randomized trial comparing buttonhole with rope ladder needling in conventional hemodialysis patients. Clin J Am Soc Nephrol 2012; 7:1632.
- Macrae JM, Ahmed SB, Hemmelgarn BR, Alberta Kidney Disease Network. Arteriovenous fistula survival and needling technique: long-term results from a randomized buttonhole trial. Am J Kidney Dis 2014; 63:636.