Zusammenfassung
Hintergrund
Für Patienten, die einer regelmäßigen Hämodialyse bedürfen, stellt ein arteriovenöser Shunt sozusagen die lebenswichtige Nabelschnur dar. Eine kontinuierliche Funktionstüchtigkeit bestimmt über Lebensqualität sowie Morbidität und Mortalität der betroffenen Patienten.
Problem
Nach Shuntetablierung kann eine stenosierende Intimahyperplasie mit meist assoziierter Thrombosierung an verschiedensten Lokalisationen zur Dysfunktion bis hin zum Funktionsverlust des gesamten Shunts führen.
Ziel
Die umgehende Beseitigung von evidenten Stenosen bzw. Rekanalisation von Verschlüssen ist essenziell, um einen künftigen längerfristigen Shunterhalt zu gewährleisten. Die verschiedensten verfügbaren Verfahren der perkutanen endovaskulären Thrombektomie haben das gemeinsame Ziel, das okkludierende Thrombusmaterial zur reduzieren, um die zuvor maskierte zugrundeliegende Stenose zu identifizieren und behandeln zu können.
Methoden
Über die vergangenen Jahrzehnte wurden zahlreiche Thrombektomiesysteme unterschiedlichster Funktionsprinzipien entwickelt mit mehr oder weniger ähnlichen Rekanalisationsraten in der Therapie von thrombotischen Shuntverschlüssen. Dabei ist die Ballonangioplastie ohne/mit Medikamentenbeschichtung ein wichtiges Instrument, um einen dysfunktionalen Dialyseshunt in seiner ursprünglichen Funktion längerfristig wiederherzustellen. Daneben kommen nach frustraner oder auch mehrfach kurzfristiger Verwendung von Thrombektomie und Ballonangioplastie Stents und Stentgrafts zum Einsatz, um resistente oder zentralvenös lokalisierte Stenosen zu behandeln.
Abstract
Background
An arteriovenous fistula is vital for patients who need regular hemodialysis. Continuous patency and sufficient functionality determine quality of life and associated morbidity and mortality of patients.
Problem
Following successful hemodialysis shunt creation, intimal hyperplasia and consecutive thrombosis or complete occlusion may cause different types of shunt dysfunctionality or even critical failure.
Objective
Immediate shunt recanalization and revision by using an endovascular-first approach is crucial for long-term survival of hemodialysis fistula. There are several mechanisms available for catheter-based thrombus removal to unmask the typically underlying shunt stenosis.
Methods
Primary technical recanalization success rates are very similar for clot cleaning. Treatment of intimal hyperplasia is preferably addressed by using drug-coated balloon angioplasty to allow for increased shunt patency compared to plain old balloon angioplasty. Stents and stent grafts are only used for resistant or repeated short-term recurrence of severe stenosis. Finally, surgical revision has a classical role in case of repeated failure of endovascular measures.
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A. Maßmann, I. Hammer, M. Ketteler und J. Latus geben an, dass kein Interessenkonflikt besteht.
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Maßmann, A., Hammer, I., Ketteler, M. et al. Akute Interventionen – Rekanalisation von Dialyseshunts. Radiologie 63, 18–23 (2023). https://doi.org/10.1007/s00117-022-01089-1
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DOI: https://doi.org/10.1007/s00117-022-01089-1