The use of tissue plasminogen activator as continuous infusion into an arteriovenous hemodialysis access in the hemodialysis unit: a case series

BACKGROUND: Thrombolytics such as tissue plasminogen activator are often used by interventional radiologists in the radiology suite to salvage thrombosed hemodialysis arteriovenous fistulae. Thrombolytics are also commonly used in dialysis facilities as a dialysis catheter lock solution or as an infusion into a dialysis catheter when dysfunctional. However, the use of tissue plasminogen activator as a continuous infusion into an arteriovenous fistula in the dialysis facility to treat clot burden is not commonly done. OBJECTIVE: The aim of our case series is to demonstrate the successful use of tissue plasminogen activator to decrease clot burden in an arteriovenous fistula in the dialysis unit. DESIGN: Observational case series. SETTING: An outpatient dialysis facility in a tertiary care hospital. PATIENTS: Three non- consecutive patients were diagnosed with an acute thrombosed arteriovenous fistula either on physical exam or by imaging. MEASUREMENTS: A thrombosed fistula as well as successful resolution of clot was illustrated by either physical exam, fistulogram or ultrasound. A functioning fistula demonstrated successful continuation of dialysis and adequate access flow measurements in follow up. METHOD: This is a case series that describes the technique of using an infusion of tissue plasminogen activator into an arteriovenous fistula on the dialysis unit by vascular access nurses to treat or diminish clot burden. RESULTS: We have described three separate cases where treatments with tissue plasminogen activator infusions on the dialysis unit resulted in objective evidence of decrease in clot burden on ultrasound or fistulogram. LIMITATIONS: The small numbers of our case series requires that the results need to be verified in a larger study. Inclusion and exclusion criteria need to be defined before widespread application of this technique. CONCLUSIONS: To our knowledge this small case series is the first to describe the procedure whereby low dose tissue plasminogen activator is directly infused into the fistula by the vascular access nurse in the dialysis unit during dialysis and not in the interventional suite. This provides additional information to the existing literature that there is an alternative option for dialysis units to diminish clot burden until a more permanent solution is established through angioplasty.