Work

Thrombus burden-stratified catheter-directed thrombolysis combined with percutaneous transluminal angioplasty for acute arteriovenous graft thrombosis in hemodialysis patients: a comparison of single-session versus extended infusion protocols

Year: 2026

Type: article

Abstract: Purpose To compare single session (SS) versus extended infusion (EI) catheter-directed thrombolysis (CDT) combined with PTA for acute AVG thrombosis, with allocation based on thrombus burden and lesion morphology. Methods This study included hemodialysis patients with acute AVG thrombosis treated between April 2020 and September 2023. All patients underwent angiographic classification of AVG stenosis/occlusion into two morphological types: Type I (isolated venous anastomotic stenosis/occlusion) and Type II (complex, multi-segment occlusion involving the arterial anastomosis, graft lumen, and/or venous anastomosis). Based on this classification and thrombus burden assessment, patients with Type I lesions or low thrombus burden received SS-CDT + PTA, while those with Type II lesions or high thrombus burden received EI-CDT + PTA. The primary endpoint was primary patency. Secondary endpoints included technical success rate, procedure-related complications, and secondary patency. Kaplan–Meier survival analysis and multivariate Cox proportional hazards regression were performed. A shared-frailty model and patient-level sensitivity analysis were used to account for within-patient clustering. Results A total of 105 procedures in 89 patients were analyzed (SS-CDT, n = 73; EI-CDT, n = 32). Median primary patency was comparable: SS-CDT 183 days vs. EI-CDT 183 days (log-rank p = 0.867). The proportion of Type II lesions was 80.8% (59/73) in the SS-CDT group and 90.6% (29/32) in the EI-CDT group ( p = 0.261). On multivariate Cox regression, graft age >24 months was associated with improved patency (HR 0.59, p = 0.023), while Type II morphology (HR 0.80, p = 0.428) and CDT protocol (HR 0.91, p = 0.79). Technical success was 100% in both groups (excluding 7 crossover procedures). One major complication (septic shock) occurred in the EI-CDT group. Minor complications were comparable, except puncture-site bleeding (EI-CDT: 18.8% vs. SS-CDT: 0%, p < 0.001). Urokinase infusion was interrupted in 2 EI-CDT procedures due to bleeding. Conclusions Patency outcomes were not significantly influenced by CDT protocol duration or lesion morphology, suggesting that the stratified treatment approach effectively equalized outcomes across clinical contexts; notably, graft age >24 months was independently associated with improved primary patency (HR 0.59, p = 0.023), a finding most plausibly reflecting survivor-graft bias rather than a true treatment effect.

Source: Frontiers in Cardiovascular Medicine

DOI: 10.3389/fcvm.2026.1919383