A 70 year old patient presents with acute thrombosis of his Cimino dialysis shunt. He has successfully been transplanted a kidney 7 months ago, therefore he does not need dialysis any more. The shunt worked properly for 5 years. Would you do a revision and thrombectomize the shunt or would you simply ligate it?
The patient does not require any shunt, besides, the possibility of a successful thrombectomy of a 5 years autologous AV shunt is small as the cause of thrombosis is usually vein wall degeneration by multiple iatrogenic trauma. Ligation at the point, distal to vein trhombosis is an option for PE prevention. However, if throbosis has been occured days before, ligation is not required. In case thrombosed vein presents with signs of infection or tenderness, vein excision is advisable.
Thank you for your opinion. Thrombosis ocurred one day ago, clinical findings showed swelling and pain of the affected area. Conservative treatment by topic application of heparine ointment and cold pack was initiated. We decided not to operate.
I would suggest to salvage AVF and keep it patent. Ligation is unwarranted as Thromboembolism is not expected as a complication.
Intervention would depend upon the transplant function. Progressive deterioration of transplant function with possibility of requirement of dialysis, would mandate salvage of the AV fistula. Otherwise, I would leave it alone. Aseptic inflammation from thrombosis should be managed with analgesics. Be on a lookout for infection!!!
In general, management of remaining dialysis access during renal transplantation depends on transplant function, type of access and access blood volume.
Others already said that if Tx function deteriorates, access function should be salvaged for upcoming dialysis.
Graft accesses would be nice to be withdrawn but this is complicated due to a large inner wound surface. Such procedures only will be performed if there is evidence for the graft to be a source of bacterial spreading if chronically infected. In fistulas, volume accessment by i.e. dupley ultrasound is mandatory in my eyes to estimate the steal and the impact of shunt flow to heart beat capacity. If the flow is higher than 1400ml/hour ("high volume shunt"), ligation should be considered if the transplant is stable.
Generally, shunts thrombose spontaneously after transpants due to improvement of platelet function. So, this is expected, perhaps, even desired (reduced risk of high-output cardiac failure).
Why would you even consider salvaging it with working kidney?
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