Interventional radiology of the occluded fistula

Scott Trerotola
Scott Trerotola

Scott O Trerotola, Stanley Baum Professor of Radiology, Department of Radiology, University of Pennsylvania, Philadelphia, USA, received the SIR Leader in Innovation Award early this year and received a BSIR honorary membership in November 2011 at the annual meeting in Glasgow, UK. He told Interventional News that fistula declotting has become a mainstay of interventional radiology practices in the USA.

What is the background to the problem of treating occluded fistulae?


Dialysis grafts and fistulae are the lifeline of a haemodialysis patient. When they become thrombosed, it is critical to restore them to function as quickly as possible to allow continued life-sustaining dialysis therapy. Percutaneous declotting of dialysis grafts has been the standard of care for well over a decade. However, only relatively recently have we learned that declotting of fistulae is not only effective, it has better outcomes in terms of patency than graft declotting. With a huge push for more fistulae in the US, and the US fistula prevalence approaching 60%, fistula declotting has become a mainstay of interventional radiology practices. Percutaneous declotting salvages a fistula that would otherwise have been abandoned, conserving venous capital, and allows immediate return to dialysis. Most interventional radiology clinicians offer same day declotting so there is no interruption of the patient’s dialysis.


How effective are these solutions? What does the evidence say on the issue?


Percutaneous declotting has a 90% success rate and roughly 50% six-month primary patency, though reported outcomes vary substantially, and the type of fistula, especially transposed versus in situ, affects these results. The procedure has an extremely high safety margin with very few complications.


What are the key challenges that need to be overcome, in order to improve the clinical results?


At present, restenosis remains the Achilles’ heel of all haemodialysis access interventions. While stentgrafts have been shown to improve patency over percutaneous transluminal angioplasty at the venous anastomosis of grafts, to date no randomised study has shown any device (stent or stent graft) to be better than angioplasty in fistulae.


What does the honorary fellowship from the BSIR mean to you?


I am deeply honoured to receive this recognition, and particularly from such a highly functioning group of interventional radiology clinicians. Interventional radiology in the UK is extremely advanced and often well ahead of the United States, not only because of earlier access to devices but also due to a strong spirit of innovation. Over the years, I have learned great many things from by British interventional radiology colleagues, and I am deeply grateful for that. Further, many of them have been strong advocates of mechanical thrombectomy, both in haemodialysis access and elsewhere, and have helped advance this part of our field in a huge way.


Scott O Trerotola was awarded a BSIR honorary membership on 3 November, 2011 in Glasgow, UK.