Vascular Medicine

Percutaneous Trans-Radial Intervention for

Acute Thrombosis of Upper Arm Grafts: An

Outpatient-Based, Effective, and Feasible Option

Lung-Sheng Wu,1 Yu-Shen Lin,1 Chang-Min Chung,2 Jen-Te Hsu,2 Shih-Tai Chang,2

Teng-Yao Yang,2 Hui-Wen Chen,2 Chi-Tai Kuo1 and Pi-Chi Lin2

Purpose: To evaluate the efficacy, safety, and feasibility of an outpatient-based trans-radial intervention for acute

thrombosis of upper arm graft.

Materials and methods: A total of 101 trans-radial balloon angioplasty was performed in 63 patients with acute

thrombosis of upper arm graft (29 males, 34 females; age: 69 � 10 years). Thrombus was macerated and pushed into

the central circulation with a balloon catheter. Low-dose urokinase injection was given as an adjunctive therapy in

17 interventions. Procedure time, anatomical and clinical success, and complications were analyzed.

Results: The procedural time was 56+/-29 minutes. Anatomic success (< 30% residual stenosis) was obtained in

87.2% of cases and clinical success in 79.2%. There was no major bleeding or symptomatic pulmonary embolism.

Other complications were distal arterial embolism with or without clinical symptoms in 2% and 5.9% of cases,

respectively. The complication rate of axillary extravasations was 3%.

Conclusion: Trans-radial intervention for acute thrombosis of upper arm graft as an outpatient procedure had

comparable success and complications compared to the results reported earlier. Therefore, outpatient-based trans-

radial intervention should be considered a feasible therapy for acute thrombosis of upper arm graft.

Key Words: Trans-radial approach � Angioplasty � Hemodialysis access

INTRODUCTION

Maintaining adequate patency of arterio-venous (AV)

access is very important for patients on hemodialysis.

AV access often gets occluded and contributes signifi-

cantly to morbidity and hospitalization for such pa-

tients.1 Acute occlusion of an AV access in patients on

hemodialysis necessitates immediate restoration of pa-

tency. The treatment of an AV graft thrombosis has tradi-

tionally been surgical, i.e. incision of the graft with

Fogarty balloon, thrombectomy and revision as neces-

sary. However, percutaneous methods are also an effec-

tive alternative to surgical thrombectomy.1-3 Transve-

nous4-7 or trans-brachial8 approaches are common tech-

niques in endovascular intervention for thrombosed ac-

cess. Both trans-brachial and trans-venous approaches

(crossed catheter technique) are commonly used to in-

crease success rate.5,9-12

The trans-radial approach is widely used for per-

cutaneous coronary intervention because of fewer com-

plications related to the puncture site, and early ambula-

tion.13 Recently, it has also been applied for non-coro-

nary interventions such as renal artery stenting, mesen-

teric artery stenting or cerebral artery stenting.14-17 How-

Acta Cardiol Sin 2008;24:86�91 86

Original Article Acta Cardiol Sin 2008;24:86�91

Received: October 29, 2007 Accepted: January 30, 20081First Cardiovascular Division, Department of Internal Medicine,

Chang Gung Memorial Hospital, Chang Gung University College of

Medicine, Taipei; 2Section of Cardiology, Department of Medicine,

Chang Gung Memorial Hospital at Chiayi, Chiayi, Taiwan.

Address correspondence and reprint requests to: Dr. Pi-Chi Lin,

Section of Cardiology, Department of Medicine, Chang Gung Memo-

rial Hospital at Chiayi, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi

County 613, Taiwan. Tel: 886-5-362-1000 ext. 2854; Fax: 886-

5-362-3002; E-mail: Bonbong.Lin@gmail.com.

ever, there are very few studies on trans-radial interven-

tion for managing thrombosis of AV access in hemo-

dialysis patients; only two studies related to radio-ce-

phalic fistula18-19 have been reported.

This study was an analysis of a single center’s experi-

ence with endovascular intervention using trans-radial ap-

proach for acute thrombosis of upper arm grafts over a

three-year period. We sought to examine the feasibility, ef-

ficacy and complications of this outpatient-based approach.

METHOD

Patient population

This study was conducted in Chang Gung Memorial

Hospital, Chia Yi, Taiwan. All patients from January

2004 to July 2007 with acute occlusion of upper arm

graft due to thrombosis and normal Allen’s test that were

referred to the interventional cardiology department

were included in this study. They underwent treatment

within 72 hours of no palpable thrill. Grafts with evi-

dence of infection were excluded. All grafts were made

with polytetrafluoroethylene (Gore-Tex; W.L. Core, Elk-

ton, MD). Patients underwent treatment on an outpatient

basis and were hospitalized only if necessary for other

reasons. Written informed consent was obtained from all

patients prior to the procedure.

Interventional procedure

The radial artery was punctured with a 30-mm 20-G

sheathed needle, under local anesthesia (2% lidocaine).

After successful access and free flow of blood, the nee-

dle was removed from the sheath and a 150-cm 0.025-in

angled hydrophilic guidewire (Terumo) was inserted

through the soft sheath. The wire was advanced until se-

cured, then the 20-G soft sheath was removed, leaving

the guidewire in place. A 6-Fr 10-cmsheath (Terumo)

was then introduced into the radial artery. Heparin

(3000IU) was given in all cases in order to prevent intra-

procedural thrombus formation. Midazolam (5 mg) was

administered intravenously for anxiolysis and amnesia as

needed. Nitroglycerin (0.2 mg) was administered intra-

arterially if brachial artery spasm occurred.

A diagnostic fistulogram was conducted through the

sheath. Upon fluoroscopy of a thrombosed upper arm

graft, in most of the cases, only a small stump was visu-

alized. A 6Fr right Judkins 4 (JR4) catheter (Boston Sci-

entific, Maple Grove, MN) was used for better support

to guide the hydrophilic guidewire. If the 0.025-in an-

gled hydrophilic guidewire was unable to pass through

the lesion, a 0.014-in coronary wire with a soft hydro-

philic coating on the tip was employed. After the guide-

wire was passed through the lesion or the entire graft,

the JR4 was withdrawn, and a 6-mm peripheral Wanda

balloon (Boston Scientific Ireland, Galway, Ireland) was

advanced over the wire. The balloon was inflated over

the stump and then withdrawn with the guidewire left in

place. The Wanda balloon was again advanced over the

wire and inflated over the identified lesions under re-

peated imaging. The inflation pressure was increased

gradually until no “waist” remained or the maximal rated

balloon pressure was reached. The balloon catheter size

was 6-7mm � 20 or 40 mm. The balloon was usually in-

flated to 8-16 atmospheres (atm) for 30-40 seconds at a

time. The balloon was inflated for up to 2 minutes as re-

coil was encountered. If the lesion revealed significant

stenosis after initial ballooning, a non-compliant Con-

quest balloon (Bard, Crawley, UK) with a 1:1 balloon-

vessel ratio was employed and inflated to 20-24 atm.

When significant residual thrombus was demonstrated in

the occluded segment, the same Wanda balloon was se-

quentially inflated downstream over the entire graft (6-8

atm) and for a shorter duration of inflation, usually 10- 15

seconds a time. If thrombus was persistent, 60,000~

120,000 U of urokinase was directly injected into the

graft from the peripheral Wanda balloon catheter placed

near the inflow anastomotic area. Contrast medium was

injected 10-15 minutes thereafter to evaluate the effect of

urokinase injection. Finally, the balloon was sequentially

inflated downstream over the entire graft again at a low

pressure of 6-8 atm and for a short duration of inflation to

macerate residual clot or the inflated balloon maintained

at 4-6 atm was used to push the residual clot into the cen-

tral venous system. The declotting procedure was consid-

ered complete when fluoroscopy revealed restored blood

flow and palpable thrill was detected (Figure 1).

At the end of the intervention, the sheath was removed

and the puncture site was manually compressed for approx-

imately 1~2 minutes before compression with gauze and

pressure bandage. The bandage was removed two hours

later. All procedures were performed on an outpatient basis

unless the patient was already admitted to hospital.

87 Acta Cardiol Sin 2008;24:86�91

Trans-Radial PTA for Thrombosed Graft

Study definitions

Procedural time was measured from the start of per-

cutaneous trans-radial puncture to completion of the en-

dovascular procedure. In our laboratory, the procedure

time also includes the time to achieve hemostasis of the

puncture site. Anatomic success for thrombosed lesion

was defined as restoration of flow with less than 30%

maximal residual stenosis. Clinical success was defined

as presence of palpable thrill and the ability to carry out

hemodialysis for at least one week via treated AV graft.

Major complications included symptomatic distal arte-

rial embolization, remote site hematoma or bleeding,

vascular perforation or rupture, death, symptomatic pul-

monary embolism and puncture site complication.33 Mi-

nor complications included additional drug therapy or

short hospital stay for observation.28

RESULTS

From January 2004 to July 2007, 101 interventions

of trans-radial balloon angioplasty were performed in 63

patients with normal Allen test (29 males, 34 females;

age range: 20-90 years; average: 69 � 10 years). The re-

sults of procedural time, anatomical and clinical success,

and complications are shown in Table 1. Anatomic suc-

cess was achieved in 88 of 101 interventions (87.2%).

One intervention failed because of inaccessibility due to

tortuosity of the radial artery. No trans-radial approach

was hindered by unrelievable radial artery spasm. Twelve

interventions failed due to residual stenosis exceeding

Acta Cardiol Sin 2008;24:86�91 88

Lung-Sheng Wu et al.

Table 1.

Intervention N = 101

Procedural time (min) 56+/-29

Anatomic success rate 88/101 (87.2%)

Clinical success rate 80/101 (79.2%)

Major complications

Symptomatic distal arterial embolism 2/101 (2.0%)

Minor complications

Asymptomatic distal arterial embolism 6/101 (5.9%)

Axillary vein focal dissection or extravasation 3/101 (3.0%)

Figure 1. a. This fistulogram was taken trans-radial approach before percutaneous transluminal angioplasty (PTA) and revealed total occlusion

near the ostium of the brachio-axillary graft. b. After the guidewire passed through the thrombosed graft, the first ballooning at the stump of

thrombosed graft was performed. c. Sequential ballooning the entire graft was performed and the figure showed the last ballooning at the graft-ve-

nous junction. d. This fistulogram was taken after the PTA and revealed a successful result.

30% with excessive persistent thrombus. In 9 of the 12

failed interventions, PTA was done more than two days

after onset. In 8 patients re-thrombosis occurred within 7

days of the intervention. All of them had lesions both at

the venous and arterial junctions. Clinical success was

achieved in 79.2% of interventions (80 of 101). Adjunc-

tive therapy with urokinase (Abbokinase; Abbott La-

boratories, North Chicago, IL) at doses ranging from

60,000 U to 120,000 U was used in 17 of 101 interven-

tions at the discretion of the operating physician. The av-

erage procedure time was 56 � 29 minutes.

Complications occurred in 10.5% of procedures.

The major complications were two episodes of distal

embolism in the ulnar artery with pain and coldness. Mi-

nor complication included six episodes of smaller distal

arterial embolism without clinical symptoms, one epi-

sode of axillary vein focal dissection, two episodes of

axillary vein extravasations, and no patient experienced

bleeding complications or clinically detectable pulmo-

nary embolism.

DISCUSSION

Trans-radial percutaneous transluminal angioplasty

with or without urokinase restore the function of throm-

bosed upper arm graft, with acceptable anatomic (87.2%),

clinical (79.2%) success rates. Previous studies related

to salvaging thrombosed AV fistulae or grafts for hemo-

dialysis access, including surgical thrombectomy and

endovascular thrombectomy by various devices coupled

with or without thrombolytic agents, have reported suc-

cess ranging from 71~95%.1,5,7,10,12,21-23 In our series of

patients, the major anatomic failure was resulted from

massive residual thrombus even after performance of

several courses of angioplasty with higher pressure, lar-

ger balloon size, longer inflation time, non-compliant

balloon or low-dose urokinase injection. The potential

factors contributing to the persistence of thrombosis af-

ter PTA include venous limb stenosis,34 clotting disorder,

compromised arterial inflow35 and the age of thrombus.

In 9 of 13 cases with anatomical failure, PTA was done

more than two days after onset. Organization of the rela-

tively old thrombus might hamper effective fragmenta-

tion of the thrombus by PTA. Early intervention after on-

set may increase the success rate. In this study, only one

patient had tortuous radial artery and resulted in a failed

trans-radial intervention.

There were 8 episodes of early re-thrombosis. Hy-

percoaguloability, hypotension, and significant residual

stenosis were the assumed causes of early thrombosis.36

Reviewing the fistulograms of these cases, all of them

had lesions both at the venous and arterial junctions. Re-

coil after PTA at venous junction was noted in three pa-

tients. However, as early recoil occurs commonly in le-

sion at the graft junction, the anatomical locations of

these lesions suggest that recoil after PTA with insuffi-

cient flow may have contributed to the early rethrom-

bosis in these cases. None of them was treated with

low-dose urokinase. However, it was beyond this study

to answer whether routinely using low-dose urokinase

could achieve lower re-thrombosis rate or not.

In some cases with large thrombus burden, inflated

balloons were used at low-pressure status to push the re-

sidual clot to the central venous system after administer-

ing Urokinase injection for 10~15 minutes. We used

lower dose of urokinase (60,000~120,000 U) instead of

the full dose (250,000~500,000 U) as reported in some

reports.11,26 Fifteen out of 17 times, urokinase injection

helped the balloon angioplasty get optimal results. No

bleeding complication occurred in this subgroup of pa-

tients. Low-dose urokinase injection could be an effec-

tive adjunctive therapy in patients with large thrombus

burden. Further study is necessary to prove the benefit-

risk ratio of routine usage of this pharmacological ad-

junctive therapy for all lesions.

The trans-radial approach overcomes several limita-

tions of the traditional approach. First, the lesions can be

clearly visualized by antegrade contrast medium injec-

tion. Second, operators can be protected from exposure

to the X-ray generator throughout the procedure. Third,

one sheath is sufficient to treat all lesions from brachial

artery to the central vein, including thrombosed grafts.

The average procedural time for endovascular ma-

nagement of thrombosed hemodialysis access reported

previously was around 1 hour.5,7,21 In addition, more

than 10 minutes were required to achieve hemostasis in

the traditional approach, and often more if a thrombo-

lytic agent was used. Thus, the average time was more

than 1 hour in the traditional approach5,24 compared to

this study, where it was 56 � 29 minutes, which was in-

clusive of time required for hemostasis. In this study,

89 Acta Cardiol Sin 2008;24:86�91

Trans-Radial PTA for Thrombosed Graft

hemostasis was achieved in less than five minutes, whi-

ch minimized the burden on nursing and medical staff.

The possible complications of the trans-radial ap-

proach include radial artery occlusion, radial artery dis-

section and extravasation. Stella PR reported persistent

radial artery occlusion in less than 3% of patients, and

none had clinical symptoms at the time of trans-radial ar-

tery coronary angioplasty with 6-Fr guiding sheath.25 In

this study, 6-Fr guiding sheath was used in all patients,

and no patient complained of cold sensations or numb-

ness in the hand following the procedure, even those who

underwent several interventions.

The overall complication rates in endovascular ma-

nagement for thrombosed lesions as reported earlier

(4~15%)7,10,31,32 are comparable to our results (10.5% in-

cluding 5.9% asymptomatic arterial embolism). The in-

cidence of occurrence of a peripheral artery embolism

was reported to be as high as 6%.31 In several stud-

ies,3,5,31,32 the reported incidence actually reflected the

incidence of ‘symptomatic’ distal embolism. The sug-

gested threshold (%) of symptomatic distal arterial em-

bolization was 2%.33 Early in our experience, two epi-

sodes of symptomatic distal arterial embolism (2%) oc-

curred during vigorous contrast injection after balloon-

ing the thrombosed stump. Subsequently, these two cases

underwent successful surgical thrombectomy. There were

six episodes of asymptomatic distal arterial embolism.

All were related to smaller thrombus. Additionally, three

complications of the axillary vein were treated with local

compression successfully. Another concern with our

technique (clot maceration without removal) was the

possibility of pulmonary embolism. In this study, no pa-

tient had clinical symptoms of pulmonary embolism,

which was consistent with previous studies.3,28,29

Thus, in all aspects, including success rate, compli-

cations and procedural time, the reported result of this

study are not only equal but better in some ways to the

traditional surgical techniques or those reported by pre-

vious authors.

Limitation of study

This was an observational study and did not com-

pare head-to-head with traditional surgical methods. Pe-

ripheral duplex for radial artery before and after a trans-

radial intervention would had shown a better additional

index of success. This was not done in all patients. Pri-

mary and secondary patency rates or complications could

not be evaluated in this study because not all patients

were regularly followed up in this hospital.

CONCLUSION

This study showed that the success rate, procedural

time and complication rate of trans-radial intervention

for acute thrombosis of upper arm graft were comparable

to those reported in previous studies. This study clearly

demonstrated the overall safety, efficacy and feasibility

of outpatient-based trans-radial intervention for acute

thrombosis of upper arm graft.

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