Fistula Thrombolysis & Thrombectomy in Cyprus
The kidneys are vital organs necessary for the removal of waste products and drugs from the body, balancing of body fluids and regulation of blood pressure. In patients whose kidneys do not work properly, dialysis allows removal of blood from the body using special tubing directing it to a special machine that filters it of waste and extra fluid and then returns it back to the body. Essentially, dialysis is a process aiming at replacing kidney function to sustain and prolong life.
A number of different methods can be used for dialysis including the use of a:
- Fistula Vein (connecting a vein to an artery to create a high-flow blood vessel)
- Fistula Graft (connecting a synthetic plastic tube to an artery and a vein)
- Central Venous Catheter (plastic tube inserted into a large vein in the chest or abdomen)
When a narrowing develops within a fistula vein or a graft, there is disruption to the high blood flow required for a successful and complete dialysis session. In some patients there may be complete cessation of blood flow which leads to clot (thrombus) formation within the fistula vein or graft.
Fistula thrombolysis & thrombectomy is a procedure in which Dr Zertalis uses ultrasound (US) and
X-Rays (fluoroscopy) to place a fine plastic tube (vascular sheath) into the fistula vein or graft followed by the injection of a chemical to dissolve the clot (thrombolysis) and the use of an angioplasty balloon and/or device to break and remove the clot (thrombectomy).
Following thrombolysis and thrombectomy the area of narrowing or blockage responsible for clot (thrombus) formation is identified by Dr Zertalis and an angioplasty balloon will be used to stretch the area (fistuloplasty). If the angioplasty balloon does not improve the narrowing or blockage,
Dr Zertalis will insert a stent (flexible mesh tube) to keep the fistula vein open.
The purpose of fistula thrombolysis and thrombectomy is to restore blood flow so that you can continue to have dialysis through the fistula vein or graft.
The procedure can be successful if performed within two weeks of clot (thrombus) formation with a higher success rate when performed during the first week. If clot (thrombus) has been present for more than two weeks then it is unlikely that you will benefit from thrombolysis and thrombectomy.
Fistula thrombolysis & thrombectomy is a safe, effective and accurate procedure, but as with any medical procedure there are some risks and complications that you may uncommonly experience.
Pain: Some patients experience tightness when the balloon is inflated. The sensation wears off once the balloon is deflated.
Bleeding: Risk of bleeding that is significant is rare. Uncommonly, you may get a small bruise at the needle entry point in the skin. There is a small risk of injury to the fistula vein or graft and as a result the fistula may fail and not be suitable for dialysis. There is also the rare risk of life-threatening haemorrhage (brain, chest, abdomen) due to the chemical used for dissolving the clot (thrombolysis). Dr Zertalis will discuss this with you in detail. When considering this risk, it is important to note that if clot (thrombus) in the fistula is left untreated, your fistula will stop working.
Infection: This is an uncommon complication however you will be monitored during and after the procedure to check for signs of infection.
Allergy to contrast (X-ray dye): Most adverse events are mild and can be managed safely in our department. A major life-threatening contrast reaction is rare (< 0.005%).
Radiation Risk: Immediate harmful effects such as skin burns, or radiation sickness are extremely rare. The radiation dose you receive during the procedure is monitored to prevent this. On rare occasions the procedure will have to be stopped if the threshold for immediate harmful effects is reached. Increase in lifetime risk of cancer due to radiation per examination is also rare (< 0.001%).
Failure: Very rarely, Dr Zertalis will be unable to restore blood flow or despite treatment, symptoms may recure in the long term and a repeat procedure will be necessary. If a stent is used, the stent can move out of position or become blocked.
Dr Zertalis will explain the procedure and ask you to sign a consent form. Please feel free to ask any questions that you may have and remember that even at this stage, you can still decide not to go ahead with procedure if you choose to do so.
Before the procedure
The procedure is performed under local anaesthetic and sedation. You will be asked not to eat or drink for 6 hours before the procedure. Where necessary a blood test may be required. A short and thin plastic tube (cannula) may be placed into a vein in your arm.
Please let Dr Zertalis know about any medications you take, any allergies you may have and if you previously have had a reaction to the x-ray dye (contrast).
You will be asked to change into a hospital gown and lie on the X-ray table flat on your back. You will have devices attached to your chest, arm and finger to monitor you pulse, blood pressure and oxygen levels. You will be given a sedative to relieve anxiety if required. This is standard for all minimally invasive interventional radiology procedures performed in Cyprus.
The procedure is performed under sterile conditions and Dr Zertalis will wear sterile gowns and gloves. The skin near the point of insertion in the fistula will be cleaned with antiseptic and you will be covered with sterile drapes.
Dr Zertalis will use ultrasound to inject local anaesthetic and place a fine plastic tube (vascular sheath) into the fistula vein or graft. Dr Zertalis will use X-ray equipment to navigate and guide another fine plastic tube (catheter) across the area containing clot (thrombus) over a guidewire.
A special chemical will be injected in the fistula vein or graft followed by a 20-minute pause to allow enough time for the chemical to work (thrombolysis).
A balloon will be used to dilate (stretch) the fistula vein or graft and to break and remove (aspirate) the clot. You may experience tightness in the arm or forearm while the balloon is inflated. The sensation wears off once the balloon is deflated. X-ray dye (contrast) will be injected through the sheath to define the anatomy of the fistula and identify areas of narrowing or blockage. You may experience a warm feeling in your hand – this is normal. Depending on the number and complexity of narrowings or blockages, more often than not, multiple and different types of balloons will be necessary to stretch the fistula vein or graft. If the balloon does not improve the narrowing or blockage, Dr Zertalis will insert a stent (flexible mesh tube) to keep the fistula vein or graft open.
At the end of the procedure the catheter and vascular sheath are removed and pressure is applied to the fistula for 10-15 minutes to prevent bleeding. Sometimes sutures (stiches) will be necessary to stop the bleeding and will be removed after 45 minutes.
Every patient is different, however, expect to be in the radiology department up to 1 hour.
After the procedure
You will be transferred to your ward where your pulse, blood pressure, oxygen levels and the entry site in the fistula will be checked by our team at regular intervals. You should expect to be in bed for
6 hours and to stay in hospital for up to 24 hours if there is a plan for dialysis on the same day.
Please discuss driving, return to work and exercise with Dr Zertalis as this varies between patients. Dr Zertalis may organise a follow-up US scan in 4-6 weeks.