{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,25]],"date-time":"2026-10-25T10:35:14Z","timestamp":1792924514420,"version":"4.5.0"},"reference-count":15,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T00:00:00Z","timestamp":1787702400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["J Vasc Access"],"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>The absence of a standardised method for assessing thrombus burden limits endovascular management of thrombosed haemodialysis vascular access. Studies comparing thrombectomy techniques rarely account for lesion complexity, introducing treatment-selection bias. We evaluated the HKL Thrombus Burden Classification, a structured framework designed to stratify thrombus complexity and guide treatment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>This retrospective cohort study included consecutive endovascular thrombectomy procedures for thrombosed haemodialysis access at a tertiary centre (January\u2013June 2025). Thrombus burden was classified prospectively using the HKL Classification (thrombus length, organisation, venous outflow, aneurysmal burden), and treatment followed a predefined classification-guided strategy. The primary outcome was 6-month primary patency. Kaplan-Meier analysis and Cox regression identified independent predictors of access failure; thrombectomy technique was retained as an adjustment variable, multicollinearity was assessed using variance inflation factors, and a post-hoc power calculation contextualised non-significant findings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>\n                      Of 87 procedures in 75 patients (12 contributing more than one procedure), 32 (36.8%) were Grade 1, 38 (43.7%) Grade 2 and 17 (19.5%) Grade 3. Six-month primary patency was 68.8% (95% CI 52.7\u201384.8), 57.9% (42.2\u201373.6), and 52.9% (29.2\u201376.7) respectively (log-rank\n                      <jats:italic toggle=\"yes\">p<\/jats:italic>\n                      \u2009=\u20090.482). Increasing HKL grade independently predicted access failure (adjusted hazard ratio 2.42, 95% CI 1.12\u20135.25;\n                      <jats:italic toggle=\"yes\">p<\/jats:italic>\n                      \u2009=\u20090.025), whereas thrombectomy technique was not independently associated with outcome after adjustment for thrombus burden. Variance inflation factors ranged from 1.12 to 3.47. With 34 events among 87 procedures, the study had 80% power to detect a hazard ratio of approximately 0.31 or 3.27.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>The HKL Classification provides a pragmatic hierarchical framework for pre-procedural assessment of thrombosed haemodialysis access and independently predicts primary patency. These findings support structured thrombus burden assessment to guide treatment planning. Prospective multicentre validation, including interobserver reliability testing, is required before clinical implementation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/11297298261477928","type":"journal-article","created":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T13:20:10Z","timestamp":1787750410000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["Development and initial clinical application of the HKL Thrombus Burden Classification for endovascular salvage of thrombosed haemodialysis access"],"prefix":"10.1177","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1451-7468","authenticated-orcid":false,"given":"Karthigesu","family":"Aimanan","sequence":"first","affiliation":[{"name":"Vascular Surgery Unit, Department of Surgery, Hospital Kuala Lumpur, Malaysia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pradeep Chand","family":"Chandran","sequence":"additional","affiliation":[{"name":"Vascular Surgery Unit, Department of Surgery, Hospital Kuala Lumpur, Malaysia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muhamad Aizat","family":"Tamlikha","sequence":"additional","affiliation":[{"name":"Vascular Surgery Unit, Department of Surgery, Hospital Kuala Lumpur, Malaysia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hanif","family":"Hussein","sequence":"additional","affiliation":[{"name":"Vascular Surgery Unit, Department of Surgery, Hospital Kuala Lumpur, Malaysia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,8,26]]},"reference":[{"key":"e_1_3_3_2_2","doi-asserted-by":"crossref","unstructured":"Aimanan K Idris MAM Safri LS et al. Does systemic heparin reduce thrombosis rate of radiocephalic fistula: a double-blinded randomised study. Vasc Dis Ther 2017; 2(6): 1\u20135. https:\/\/doi.org\/10.15761\/VDT.1000139","DOI":"10.15761\/VDT.1000139"},{"key":"e_1_3_3_3_2","doi-asserted-by":"crossref","unstructured":"Inston N Al Shakarchi J Khawaja A et al. Maintaining patency of vascular access for Haemodialysis. Cardiovasc Eng Technol 2017; 8(3): 240\u2013243. https:\/\/doi.org\/10.1007\/s13239-017-0320-3","DOI":"10.1007\/s13239-017-0320-3"},{"key":"e_1_3_3_4_2","doi-asserted-by":"crossref","unstructured":"Aimanan K Ismail MAT Chandran PC et al. Hussein H. Arteriovenous fistula outcomes in Malaysia: a systematic review and meta-analysis of maturation failure and patency rates. J Vasc Access 2026: 11297298251414687. Epub ahead of print. https:\/\/doi.org\/10.1177\/11297298251414687.","DOI":"10.1177\/11297298251414687"},{"key":"e_1_3_3_5_2","doi-asserted-by":"crossref","unstructured":"Deogaonkar G Thulasidasan N Phulambrikar R et al. Endovascular salvage of thrombosed haemodialysis vascular access. Vasa 2023; 52(1): 63\u201370. https:\/\/doi.org\/10.1024\/0301-1526\/a001043","DOI":"10.1024\/0301-1526\/a001043"},{"key":"e_1_3_3_6_2","doi-asserted-by":"crossref","unstructured":"Lim C Kwan J Lo ZJ et al. Single-centre experience with endovascular rotational thrombectomy for single session salvage of thrombosed arteriovenous fistulas and grafts. J Vasc Access 2023; 24(5): 965\u2013971. https:\/\/doi.org\/10.1177\/11297298211060964","DOI":"10.1177\/11297298211060964"},{"key":"e_1_3_3_7_2","doi-asserted-by":"crossref","unstructured":"Fonseca AV Toledo Barros MG Baptista-Silva JC et al. Interventions for thrombosed haemodialysis arteriovenous fistulas and grafts. Cochrane Database Syst Rev 2024; 2(2): CD013293. https:\/\/doi.org\/10.1002\/14651858.CD013293.pub2","DOI":"10.1002\/14651858.CD013293.pub2"},{"key":"e_1_3_3_8_2","doi-asserted-by":"crossref","unstructured":"Li JY Liu JL Tian X et al. Clinical outcomes of AngioJet pharmacomechanical thrombectomy versus catheter-directed thrombolysis for the treatment of filter-related caval thrombosis. World J Clin Cases 2023; 11(3): 598\u2013609. https:\/\/doi.org\/10.12998\/wjcc.v11.i3.598","DOI":"10.12998\/wjcc.v11.i3.598"},{"key":"e_1_3_3_9_2","doi-asserted-by":"crossref","unstructured":"Wu V Kalva SP Cui J. Thrombectomy approach for access maintenance in the end stage renal disease population: a narrative review. Cardiovasc Diagn Ther 2023; 13(1): 265\u2013280. https:\/\/doi.org\/10.21037\/cdt-21-523","DOI":"10.21037\/cdt-21-523"},{"key":"e_1_3_3_10_2","doi-asserted-by":"crossref","unstructured":"Lee HS Park PJ. Clinical outcome of percutaneous thrombectomy of dialysis access thrombosis by an interventional nephrologist. Kidney Res Clin Pract 2014; 33(4): 204\u2013209. https:\/\/doi.org\/10.1016\/j.krcp.2014.10.004","DOI":"10.1016\/j.krcp.2014.10.004"},{"issue":"9","key":"e_1_3_3_11_2","article-title":"Quality improvement guidelines for percutaneous management of the thrombosed or dysfunctional dialysis access","volume":"14","author":"Aruny JE","year":"2003","unstructured":"Aruny JE, Lewis CA, Cardella JF, et al. Quality improvement guidelines for percutaneous management of the thrombosed or dysfunctional dialysis access. J Vasc Interv Radiol 2003; 14(9 Pt 2): S247\u2013S253.","journal-title":"J Vasc Interv Radiol"},{"key":"e_1_3_3_12_2","doi-asserted-by":"crossref","unstructured":"Ye G Cao R Lu J et al. Association between thrombus density and reperfusion outcomes using different thrombectomy strategies: a single-center study and meta-analysis. 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Pharmacomechanical thrombectomy with Angiojet in acute arterial occlusions: a prospective study among the results and outcomes. Vascular 2025; 33(1): 42\u201349. https:\/\/doi.org\/10.1177\/17085381241237559","DOI":"10.1177\/17085381241237559"},{"key":"e_1_3_3_16_2","doi-asserted-by":"crossref","unstructured":"Dilek I Baytok A Erol S et al. Comparative outcomes of pharmacomechanical thrombectomy and thrombolysis with balloon maceration for thrombosed native arteriovenous fistulas: a single-center study. J Vasc Access 2026: 11297298261434519. Epub ahead of print. https:\/\/doi.org\/10.1177\/11297298261434519","DOI":"10.1177\/11297298261434519"}],"container-title":["The Journal of Vascular Access"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/11297298261477928","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/11297298261477928","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/11297298261477928","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,25]],"date-time":"2026-10-25T10:19:15Z","timestamp":1792923555000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/11297298261477928"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,26]]},"references-count":15,"alternative-id":["10.1177\/11297298261477928"],"URL":"https:\/\/doi.org\/10.1177\/11297298261477928","relation":{},"ISSN":["1129-7298","1724-6032"],"issn-type":[{"value":"1129-7298","type":"print"},{"value":"1724-6032","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,26]]},"article-number":"11297298261477928"}}