Nonoperative salvage of subcutaneous hemodialysis fistulae.

During a 7-month study period 11 chronic hemodialysis patients presented with thrombosis of their arteriovenous grafts or fistulae. They were prospectively entered in a protocol to evaluate the efficacy of low-dose streptokinase and percutaneous angioplasty for reopening the hemodialysis access. All patients were evaluated with a fistulagram and had local, low-dose streptokinase (10,000 U/h) infused directly into the fistula, until the thrombus dissolved or for 36 h. If repeat fistulagram demonstrated stenoses, percutaneous transluminal angioplasty was attempted. 5 patients were successfully treated, and 4 have remained patent without complication for a minimum follow-up of 9 months. 4 patients had the streptokinase stopped prematurely: 1 died (myocardial infarct), 1 was operated upon (perforated diverticulum), and 2 patients had perigraft complications. There were no major complications, although minor complications were common. Significant systemic effects on the coagulation profile did not occur. The regimen of locally infused, low-dose streptokinase and percutaneous transluminal angioplasty was found to be a safe and effective alternative for the treatment of thrombosed hemodialysis arteriovenous grafts or fistulae. If this regimen is unsuccessful, it does not preclude operative revision.