Dear Editor:
Massage of an arteriovenous fistula following thrombosis can restore blood flow and avoid the comorbidity associated with catheters. However, this practice carries significant risks. We present the case of a male with thrombosis of the humero-cephalic arteriovenous fistula who, following massage, showed an acute ischaemia of the left upper extremity due to
embolisation of the humeral artery.
The patient is 53 years old with chronic renal failure secondary to IgA nephropathy, in substitutive renal treatment for the last 19 years: 10 in haemodialysis and 9 in renal transplant. At present, the patient is on a regime of four haemodialysis sessions per week. The patient has chronic obstructive pulmonary disease and obstructive sleep apnoea syndrome. A diagnosis of myocardial ischaemia (acute myocardial infarction six years previously) and advanced peripheral vasculopathy was made. The patient had undergone multiple failed vascular accesses: right and left radiocephalic thrombosed fistulae, right humerocephalic fistula and a thrombosed polytetrafluoroethylene (PTFE) humerobasilic graft. At present, dialysis is carried out by means of a left humerocephalic fistula, created two years ago.
The patient showed elevated haematocrit levels (44%). Phlebotomies were periodically performed to reduce the risk of thrombosis, accentuated by low arterial pressures and regular systolic pressures of around 85 or 90 mmHg.
He attended his haemodialysis session with low arterial pressure, and a short time following connection, the fistula thrombosed. On examination neither thrill nor bruit was found; the fistula had been functioning normally during the dialysis session one day previously. A fistula massage was performed, without recovering function. Immediately following the treatment the patient began complaining of pain in his hand and feeling cold, as well as cutaneous pallor. A colour Doppler sonography showed an absence of distal flow.
Both humeral and distal vessel thrombectomies were performed and a large amount of thrombotic material was extracted. The radial and humeral pulse were eventually restored. Although limb infusion had been adequate in previous vascular surgical reviews, it poses a difficulty in wound healing.
Late-stage vascular access thromboses are of multifactorial etiology, with predisposing factors such as hypotension, haemoconcentration and hypercoagulable states.1,2
For treatment of vascular access thromboses, clinical practice guidelines recommend surgical thrombectomy or mechanical or pharmacomechanical thrombolysis, depending on experience, with good results3,4. None of the guidelines either recommend or advise against massage as an immediate treatment of thrombosis of an arteriovenous fistula. However, in practice this technique is applied with a view to performing a fistulography within subsequent hours.
There are no publications in the scientific literature that approach this subject. Only a case of embolisation following massage of a PTFE graft is described. Our case is similar, only with an autologous fistula. Both cases demonstrate one of the potential negative onsequences of practising massage: distal embolisation of the extremity, for which an early diagnosis of acute ischaemia is necessary. Other possible consequences, such as pulmonary embolism, also cannot be ruled out. Unfortunately, there is no evidence to quantify the favourable results of internal fistula massage in correcting a thrombosis, meaning we are unable to establish a balance between its risks and benefits. It is possible that the benefit is greater in radiocephalic fistulae, owing to their distal location and presence of the palmar arch. Despite this, to the extent that established therapeutic options exist for the correction of a vascular access thrombosis (surgical thrombectomy and thrombolysis), we believe that the practice of massage should be advised against due to its potential complications.
