Proximal venous outflow obstruction in patients with upper extremity arteriovenous dialysis access

A case of thoracic central venous obstruction treated by the innominate-to-right-atrial bypass grafting technique under extracorporeal circulation

A 46-year-old woman with stage 5 chronic kidney disease was unable to undergo hemodialysis treatment due to thoracic central venous obstruction (TCVO) and blockage of the tunneled cuffed catheter. This patient also presented with symptoms of TCVO. When percutaneous procedure was not possible, we resolved the obstruction with the innominate-to-right-atrial bypass grafting technique under extracorporeal circulation. There are few reports on this surgical approach. In terms of patient prognosis, this may be an effective solution to this problem.

Radiofrequency guidewire-facilitated recanalization of chronic thoracic central venous occlusions in hemodialysis patients

PURPOSE

To assess the outcome and safety of radiofrequency (RF) wire recanalization in patients with end-stage renal disease (ESRD) and chronic central venous occlusions (CVO).

MATERIALS AND METHODS

A retrospective review of ESRD patients who underwent RF-wire recanalization of symptomatic chronic thoracic CVO from January 2017 to August 2022 yielded 20 patients who underwent 21 procedures. All patients had undergone at least one prior unsuccessful attempt at central venous recanalization using conventional catheter-based techniques. Technical success was defined by the ability to cross the CVO using RF-wire recanalization enabling endovascular treatment. Access circuit patency was evaluated based on follow-up imaging and symptomatic improvement.

RESULTS

Radiofrequency wire recanalization was successful in 17/21 procedures (81%) with all patients (100%) reporting resolution of arm ± facial swelling. Three major complications occurred (14%): two hemothoraces and one hemopericardium. Medial stent diameter was 13 mm (range, 9-14 mm). Mean duration of hospital stay was 2 days ± 3 days. Mean procedure time was 158 ± 46 min with a mean fluoroscopy time of 31.7 ± 16.3 min. Primary unassisted patency at 6 and 12 months was 94 ± 6% and 85 ± 10%, respectively. Additional interventions resulted in significantly increased stent graft patency (P = 0.006).

CONCLUSION

Radiofrequency wire-enabled recanalization of CVO in symptomatic dialysis patients has a high rate of technical success with resolution of arm and facial swelling and resumed use of the ipsilateral dialysis access. Although a superior safety profile was seen than with needle-based techniques such as sharp recanalization, major complications were not infrequent indicating that this RF-wire procedure should be performed in centers equipped to manage central venous perforations.

Feasibility and safety of guidewire-balloon entrapment technique for recanalization of thoracic central vein occlusion in hemodialysis patients

OBJECTIVE

To explore the feasibility and safety of Guidewire-Balloon Entrapment Technique (GBET) for the recanalization of thoracic central vein occlusions (TCVOs) in hemodialysis patients.

METHODS

A retrospective observational study was conducted using data from 28 patients who required the establishment or maintenance of hemodialysis access and were treated with GBET for the recanalization of right-sided TCVOs from January 2017 to April 2021. Of the patients, 27 required tunneled cuffed catheter (TCC) placement or exchange, and 1 had an outflow tract occlusion of the Brescia-Cimino radio cephalic arteriovenous fistula (AVF).

RESULTS

A total of 26 patients successfully underwent TCC exchange and placement using GBET; 1 patient underwent successful recanalization of an occlusion of the outflow tract of the right Brescia-Cimino AVF; and 1 patient underwent successful TCC placement in the left internal jugular vein (LIJV) after the failure of TCC placement in the right internal jugular vein (RIJV). The success rate for GBET was 27/28 (96.43%), and there were no major complications.

CONCLUSION

GBET is a safe and effective method for the recanalization of right-sided TCVOs, especially for TCC exchange and placement, and can be used as a safe and easy approach for TCVO recanalization.

Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery

Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.

A systematic review of venoplasty versus stenting for the treatment of central vein obstruction in ipsilateral hemodialysis access

OBJECTIVE

This review examines the evidence regarding treatment of central vein obstruction (CVO) in the setting of ipsilateral hemodialysis access. The aim of this work is to identify whether long-term venous patency after central vein stenting is superior compared with balloon venoplasty. To date, there are no evidence-based guidelines to direct the management of CVO in the setting of ipsilateral hemodialysis access.

METHODS

An extensive systematic database search was performed using Medline, Embase, and the Cochrane Databases to identify all articles published from January 2000 to November 2019 comparing the management of CVO with venoplasty and/or stenting in the setting of ipsilateral hemodialysis access fistulae/grafts.

RESULTS

There were 655 patients with 456 stenoses and 208 occlusions who were treated; 288 underwent venoplasty and 345 underwent stenting. Twenty-two patients failed intervention owing to an inability to traverse the occlusion. The most affected vein was the brachiocephalic vein. A superior primary patency (PP) is noted in those treated with stenting compared with venoplasty in the first 2 years. Overall, both treatments are suboptimal demonstrating a 12-month PP rate of less than 60%. Assisted PP and secondary patency rates were similar for both venoplasty and stenting with a 12-month secondary patency rate of 77.8% to 91.6% for venoplasty and 89.6% to 98.4% for stenting. Periprocedural and long-term complications were rare for both interventions, occurring in 2% of patients.

CONCLUSIONS

Although both treatments demonstrated poor patency rates, greater PP is noted for stenting in the first 2 years. Coupled with low complication rates, this finding highlights a potential benefit of stenting as a first-line treatment for CVO. Allowing for the overall poor quality of current studies, even this short-term improvement in PP may benefit patients undergoing hemodialysis. Further research with randomised control trials as well as assessment of adjuvant techniques such as drug-coated stents and balloons, anticoagulant therapy, and the role of intravascular ultrasound use is required.

Evaluating a Novel Telescoping Catheter Set for Treatment of Central Venous Occlusions

BACKGROUND

Central venous occlusive disease (CVOD) is a prevalent problem in patients with end-stage renal disease (ESRD) and can lead to access malfunction or ligation for symptomatic relief. The purpose of this study is to evaluate the efficacy of the TriForce® Peripheral Crossing Set (Cook Medical), a novel reinforced telescoping catheter set designed to provide additional support for crossing difficult central venous occlusions.

METHODS

This is a single-center retrospective study from a quaternary referral center. We identified 37 patients over a 17-month period who underwent 56 attempts at endovascular recanalization for the treatment of central venous occlusion. Technical success rates, procedural data, and outcomes were compared between those undergoing recanalization using traditional wire/catheter sets versus the TriForce catheter set.

RESULTS

Average age was 48 ± 2 years. Comorbidities were similar between the two cohorts and included ESRD (61%), deep venous thrombosis (30%), and May-Thurner syndrome (7%). Forty attempts were made with traditional wire/catheter sets and 16 attempts with the TriForce catheter set to treat 2.1 ± 0.2 and 1.9 ± 0.3 occluded venous segments, respectively (P = 0.74). Technical success rates were significantly higher for the group undergoing recanalization using the TriForce catheter (69% versus 38%, P = 0.04) and 4 patients were successfully recanalized using the TriForce catheter set after a failed attempt with traditional wire/catheter sets. Mean fluoroscopy time and radiation dose were 13 ± 3 min and 14,623 ± 2,775 μGy∗m² for traditional techniques versus 30 ± 6 min and 30,408 ± 10,433 μGy∗m² for the novel telescoping catheter set (P = 0.01 and 0.09, respectively). Freedom from reintervention at 1 year was 60% for the TriForce cohort versus 44% for the traditional wire/catheter cohort (P = 0.25).

CONCLUSIONS

The novel TriForce reinforced telescoping catheter set is a useful adjunct that may improve recanalization rates of CVOD compared with traditional wire/catheter sets.

Endovascular iliac vein reconstruction through an obstructive pelvic nodal recurrence of urothelial carcinoma

Background

Chronic venous occlusion is common particularly in cancer patient due to hypercoagulate state associated with venous compression. Treatment options include endovascular management with venoplasty and stenting. Recanalization can be challenging in patients with complete venous occlusion secondary to significant external compression by a mass.

Case presentation

We report a case of a 73-year-old man with a history of bladder and prostate cancer who presented with worsening right leg edema and pain due to deep venous thrombosis secondary to a retroperitoneal mass. Management was sharp recanalization, venoplasty and stenting.

Conclusion

Endovascular intervention of chronic venous occlusion is technically challenging and time consuming. Sharp venous recanalization is feasible and safe in patients who failed standard recanalization procedures. We present a case of cancer-related obstruction of the right iliac veins and acute thrombosis of the femoral vein with symptomatic lower limb swelling relieved by sharp recanalization through the tumor mass.

Long Thoracic Vein Embolization for the Treatment of Breast Edema Associated with Central Venous Occlusion and Venous Hypertension

Purpose

Breast edema is a rare complication in hemodialysis patients with central venous occlusions. The present study sought to determine whether coil embolization of the long thoracic vein is an effective long-term treatment for this pathology.

Methods

The study patients were 6 female hemodialysis patients whose primary clinical manifestation of central vein occlusion was breast edema. When conservative treatment (allowing collaterals to dilate over time), as well as recanalization of occlusions through angioplasty with or without stent placement, failed to alleviate symptoms, patients underwent coil embolization of the long (lateral) thoracic vein.

Results

In 4 of the 6 cases, the breast edema was completely resolved without recurrence, while the other 2 patients experienced durable symptomatic improvement with only mild residual swelling. Average follow-up was 22 months. There were no adverse sequelae and none of the patients experienced increased swelling elsewhere following the coil embolization procedure.

Conclusions

Coil embolization of the long thoracic vein effectively alleviates breast edema in hemodialysis patients with elevated venous hydrostatic pressure due to central venous occlusions.

Complications of the Arteriovenous Fistula: A Systematic Review

The implementation of patient-centered care requires an individualized approach to hemodialysis vascular access, on the basis of each patient's unique balance of risks and benefits. This systematic review aimed to summarize current literature on fistula risks, including rates of complications, to assist with patient-centered decision making. We searched Medline from 2000 to 2014 for English-language studies with prospectively captured data on ≥100 fistulas. We assessed study quality and extracted data on study design, patient characteristics, and outcomes. After screening 2292 citations, 43 articles met our inclusion criteria (61 unique cohorts; n>11,374 fistulas). Median complication rates per 1000 patient days were as follows: 0.04 aneurysms (14 unique cohorts; n=1827 fistulas), 0.11 infections (16 cohorts; n>6439 fistulas), 0.05 steal events (15 cohorts; n>2543 fistulas), 0.24 thrombotic events (26 cohorts; n=4232 fistulas), and 0.03 venous hypertensive events (1 cohort; n=350 fistulas). Risk of bias was high in many studies and event rates were variable, thus we could not present pooled results. Studies generally did not report variables associated with fistula complications, patient comorbidities, vessel characteristics, surgeon experience, or nursing cannulation skill. Overall, we found marked variability in complication rates, partly due to poor quality studies, significant heterogeneity of study populations, and inconsistent definitions. There is an urgent need to standardize reporting of methods and definitions of vascular access complications in future clinical studies to better inform patient and provider decision making.

Magnetic resonance venography and three-dimensional image fusion guidance provide a novel paradigm for endovascular recanalization of chronic central venous occlusion

OBJECTIVE

Endovascular recanalization is considered first-line therapy for chronic central venous occlusion (CVO). Unlike arteries, in which landmarks such as wall calcifications provide indirect guidance for endovascular navigation, sclerotic veins without known vascular branching patterns impose significant challenges. Therefore, safe wire access through such chronic lesions mostly relies on intuition and experience. Studies have shown that magnetic resonance venography (MRV) can be performed safely in these patients, and the boundaries of occluded veins may be visualized on specific MRV sequences. Intraoperative image fusion techniques have become more common to guide complex arterial endovascular procedures. The aim of this study was to assess the feasibility and utility of MRV and intraoperative cone-beam computed tomography (CBCT) image fusion technique during endovascular CVO recanalization.

METHODS

During the study period, patients with symptomatic CVO and failed standard endovascular recanalization underwent further recanalization attempts with use of intraoperative MRV image fusion guidance. After preoperative MRV and intraoperative CBCT image coregistration, a virtual centerline path of the occluded segment was electronically marked in MRV and overlaid on real-time two-dimensional fluoroscopy images. Technical success, fluoroscopy times, radiation doses, number of venograms before recanalization, and accuracy of the virtual centerline overlay were evaluated.

RESULTS

Four patients underwent endovascular CVO recanalization with use of intraoperative MRV image fusion guidance. Mean (± standard deviation) time for image fusion was 6:36 ± 00:51 mm:ss. The lesion was successfully crossed in all patients without complications. Mean fluoroscopy time for lesion crossing was 12.5 ± 3.4 minutes. Mean total fluoroscopy time was 28.8 ± 6.5 minutes. Mean total radiation dose was 15,185 ± 7747 μGy/m², and mean radiation dose from CBCT acquisition was 2788 ± 458 μGy/m² (18% of mean total radiation dose). Mean number of venograms before recanalization was 1.6 ± 0.9, whereas two lesions were crossed without any prior venography. On qualitative analysis, virtual centerlines from MRV were aligned with actual guidewire trajectory on fluoroscopy in all four cases.

CONCLUSIONS

MRV image fusion is feasible and may improve success, safety, and the surgeon's confidence during CVO recanalization. Similar to arterial interventions, three-dimensional MRV imaging and image fusion techniques could foster innovative solutions for such complex venous interventions and have the potential to affect a great number of patients.

First rib removal and decompression of the thoracic outlet as an indication to facilitate hemodialysis

We present two cases of thoracic outlet decompression performed to facilitate hemodialysis through upper limb arteriovenous fistulas. In patients undergoing arteriovenous fistula formation for dialysis access, venous hypertension is a well-known complication. We used a supraclavicular approach in our two reported cases to remove the first rib to facilitate hemodialysis. Dialysis patients presenting with central venous stenosis should be assessed for evidence of extrinsic compression by the first rib as management options differ from those with central venous stenosis due to an intravenous catheter.

Iatrogenic percutaneous vascular injuries: clinical presentation, imaging, and management

Vascular interventional radiology procedures are relatively safe compared with analogous surgical procedures, with overall major complication rates of less than 1%. However, major vascular injuries resulting from these procedures may lead to significant morbidity and mortality. This review will discuss the etiology, clinical presentation, diagnosis, and management of vascular complications related to percutaneous vascular interventions. Early recognition of these complications and familiarity with treatment options are essential skills for the interventional radiologist.

A case of mediastinal fibrosis due to radiotherapy and 'downhill' esophageal varices: a rare cause of upper gastrointestinal bleeding

'Downhill' varices are located in the proximal part of the esophagus. Their etiology differs from the distal types, with most of them usually being related to superior vena cava obstruction. Although bleeding due to 'downhill' varices is very rare, it can be life-threatening. Here, we present a case of upper gastrointestinal bleeding due to mediastinal fibrosis associated with chest radiotherapy for seminoma metastasis sixteen years previously, which was successfully treated conservatively.

Transposition of cephalic vein to rescue hemodialysis access arteriovenous fistula and treat symptomatic central venous obstruction

It is known that stenosis or central venous obstruction affects 20 to 50% of patients who undergo placement of catheters in central veins. For patients who are given hemodialysis via upper limbs, this problem causes debilitating symptoms and increases the risk of loss of hemodialysis access. We report an atypical case of treatment of a dialysis patient with multiple comorbidities, severe swelling and pain in the right upper limb (RUL), few alternative sites for hemodialysis vascular access, a functioning brachiobasilic fistula in the RUL and severe venous hypertension in the same limb, secondary to central vein occlusion of the internal jugular vein and right brachiocephalic trunk. The alternative surgical treatment chosen was to transpose the RUL cephalic vein, forming a venous necklace at the anterior cervical region, bypassing the site of venous occlusion. In order to achieve this, we dissected the cephalic vein in the right arm to its junction with the axillary vein, devalved the cephalic vein and anastomosed it to the contralateral external jugular vein, providing venous drainage to the RUL, alleviating symptoms of venous hypertension and preserving function of the brachiobasilic fistula.

Stent grafts for central venous occlusive disease in patients with ipsilateral hemodialysis access

PURPOSE

To assess long-term outcomes of stent grafts in patients with symptomatic central venous stenoses and occlusions ipsilateral to hemodialysis grafts or fistulas.

MATERIALS AND METHODS

The study included 52 of 55 consecutive patients with symptomatic stenoses of the central veins draining upper limb dialysis access grafts or fistulas treated with stent grafts. Indications for stent grafts were poor angioplasty results, rapid recurrence, or total occlusion. Endpoints were lesion patency and access patency following intervention. Mean follow-up was 25 months with a median of 24 months and 1.25 additional procedures per patient year. Patency rates were calculated using Kaplan-Meier analysis.

RESULTS

All stent grafts were successfully deployed. The lesion patency rates at 6, 12, 24, and 36 months after intervention were 60%, 40%, 28%, and 28%. The access patency rates at 6, 12, 24, and 36 months after intervention were 96%, 94%, 85%, and 72%. There was one major complication and no minor complications. In 40 patients (77%), the internal jugular vein confluence was covered by the stent graft. In five patients, the dialysis circuits became occluded, with no clinical sequelae in four; one patient was lost to follow-up. The contralateral brachiocephalic vein was covered in three patients (6%), preventing contralateral access construction in one patient.

CONCLUSIONS

Central vein stent graft placement in patients with hemodialysis access is associated with prolonged access patency. Coverage of major vein confluences, which occurred in 83% of the patients in this series, can compromise future access and should be avoided whenever possible by careful technique.

Prophylactic distal revascularization and interval ligation procedure during femoral vein transposition fistula creation in patients at high risk for ischemic complications

Femoral vein transposition arteriovenous fistula (FVt AVF) is a viable autologous option when upper extremity dialysis access sites have become compromised. High volume flow through the AVF can lead to ischemic complications, including steal syndrome (SS), and may threaten access and limb viability. Risk factors for SS include: age >60 years, female sex, diabetes, atherosclerosis, hypertension, and previous limb procedures. Two dialysis patients, who were at high risk for SS in their lower extremities as assessed during the preoperative evaluation for an elective FVt AVF, had a distal revascularization and interval ligation (DRIL) procedure concurrently performed. At 42 and 24 months from their respective surgeries, both patients are reliably using their lower extremity autologous access sites and have not developed any signs or symptoms of ischemia. DRIL may represent an effective surgical strategy that can prophylactically be used to minimize the incidence of ischemic complications during FVt AVF in carefully selected, high-risk patients.

Recanalization of Chronic Refractory Central Venous Occlusions Utilizing a Radiofrequency Guidewire Perforation Technique

Purpose

To assess the technical success rate and safety of radiofrequency perforation guidewire (RF) technology for the recanalization of refractory chronic central venous occlusions in symptomatic hemodialysis patients with failed conventional endovascular methods.

Methods

This single center retrospective cohort of hemodialysis patients comprised of six men (mean age 67 years, range 55 to 80) with autogenous fistulae, who had already undergone failed conventional endovascular methods. These patients underwent the RF perforation technique from December 2006 to January 2010.

Results

Three patients were successfully treated using the RF perforation technique, after which they had PTFE stent grafts placed at the site of occlusion. There was no recurrence of clinical symptoms. In the remaining three patients, the procedure was terminated after multiple unsuccessful attempts. There were no complications.

Conclusions

The RF perforation technique is a potential alternative technology for recanalization of refractory chronic central venous occlusions in hemodialysis patients in the setting of failed conventional endovascular recanalization techniques.

An unusual cause of venous hypertension after dialysis access creation

Venous hypertension after creation of arteriovenous fistula or arteriovenous shunt occurs in approximately 10-15% of patients (Kojecky et al., Biomed Papers, 2002;146:77-79; Criado et al., Ann Vasc Surg 1994;8:530-535). Its etiology is commonly stenosis and/or thrombosis of the central venous system secondary to previous catheterization with subsequent development of venous hypertension after the arteriovenous connection is made. Treatment strategies often involve venography to determine the site of venous stenosis and/or occlusion centrally and subsequent endovascular recanalization of the stenotic or occluded veins. In this article, we report a case of venous hypertension in a 76-year-old man who presented with a swollen arm after placement of an arteriovenous fistula. In this circumstance, venography revealed extrinsic compression of the subclavian vein at the level of the first rib, the anatomic abnormality seen in venous thoracic outlet syndrome. In this report, we describe surgical and endovascular management of this patient, and review the literature on the causes of central vein stenosis discovered after creation of dialysis access.

Sharp Needle Recanalization for Salvaging Hemodialysis Accesses with Chronically Occluded Peripheral Outflow

Purpose

To assess the effectiveness of sharp needle recanalization (SNR) for treatment of chronically occluded venous outflow in hemodialysis access.

Methods

A retrospective analysis of patient records from January 2006 to March 2010 was conducted. Forty-four hemodialysis patients (31 fistulas, 13 grafts) were referred for arm swelling (18%), excessive bleeding after dialysis (29%), and thrombosis (53%). All patients had chronic occlusion of the outflow vein which failed conventional recanalization techniques. A new outflow pathway was established by advancing a 21g needle and dilating the subcutaneous tract to bridge the fistula body to a juxtaposed patent vein. If necessary, uncovered or covered stents were utilized to maintain patency of the newly formed subcutaneous tract.

Results

Forty-four patients underwent 45 SNR procedures, with restoration of normal function and complete relief of symptoms in 40 (91%) patients. The average tract length was 15 mm (range, 1 to 32) and the average dilatation diameter was 8 mm. During the initial SNR procedure, bare metal (n=21) or covered (n=5) stents were inserted in 26 patients. The average follow-up was 18.4 months (range, 0.2 to 48 months). No major complications were observed with the procedure. At 12 months, the primary access, primary tract, and secondary access patencies were 10%, 51%, and 92%, respectively. Percutaneous thrombectomy procedures were performed at a rate of 1.16 per access-year and the number of interventions within the tract was 0.94 per access-year.

Conclusions

Sharp needle recanalization is an effective percutaneous treatment for restoring function to hemodialysis accesses with chronically occluded venous outflow pathways.

Use of a rosch-uchida needle for recanalization of refractory dialysis-related central vein occlusion

OBJECTIVE

The purpose of this study was to evaluate our experience with the use of a Rösch-Uchida needle technique to recanalize central vein occlusion that cannot be traversed with a guidewire.

MATERIALS AND METHODS

We retrospectively evaluated 33 recanalization procedures performed with a Rösch-Uchida needle on 20 men and 13 women with central vein occlusion during the period January 1999-December 2008. The occlusions were in the subclavian vein (n = 29) and the brachiocephalic vein (n = 4). A 9- or 10-French Rösch-Uchida introducer sheath was advanced centrally to abut the occlusion. The Rösch-Uchida needle was directed and advanced toward a transfemoral angiographic catheter placed on the central side of the occlusion. After passage of a guidewire through the occlusion, balloon angioplasty and stent insertion were performed. The outcome measures evaluated were technical success rate, primary and secondary patency, and complication rate.

RESULTS

The mean occlusion length was 1.73 +/- 0.8 cm. The rate of technical success of recanalization was 93.9% (31 of 33 procedures). The 3-, 6-, and 12-month primary patency rates were 43.6%, 24%, and 8%, and the 3-, 6-, and 12-month secondary patency rates were 77.4%, 68.8% and 55.9%. One patient reported shoulder pain lasting 2 weeks, which resolved with conservative treatment.

CONCLUSION

Use of a Rösch-Uchida needle to recanalize central vein occlusion refractory to a traditional procedure is feasible and safe and can preserve the involved extremity for long-term hemodialysis.

Formation of downhill esophageal varices as a rare but serious complication of hemodialysis access: a case report and comprehensive literature review

BACKGROUND

Proximal or "downhill" esophageal varices are a rare complication of superior vena caval (SVC) obstruction. Few reports describe downhill varices in dialysis patients with catheter-related SVC occlusion.

METHODS

We studied a case of downhill esophageal varices in a dialysis patient from our center and reviewed the published literature on presentation, evaluation and treatment in other dialysis patients (MEDLINE database search).

RESULTS

Including our current case, we identified eight reports of dialysis patients with downhill varices. All cases were recognized after presentation with gastrointestinal bleeding, in contrast to low reported bleeding rates of downhill varices in non-dialysis patients. Localized edema and superficial venous engorgement (signs of SVC occlusion) were each observed in four of eight patients. The duration of hemodialysis dependence ranged from 2.5 to 23 years, and dialysis access history included multiple central venous catheters when described (seven cases). Central venous imaging by direct, magnetic resonance or computerized tomographic venography documented SVC stenosis in all cases. Management included percutaneous transluminal angioplasty of the SVC with or without stenting in five of eight patients, three of whom developed restenosis during observation. Successful surgical venous bypass was performed in one patient after failed percutaneous venoplasty. Varices were treated with band ligation in four of eight cases without reported complications.

CONCLUSIONS

Although rare, downhill esophageal varices should be considered in the differential diagnosis of upper gastrointestinal hemorrhage in dialysis patients exposed to central venous catheters. Diagnosis should prompt radiographic evaluation of SVC patency. Treatment requires timely and coordinated care by specialists in endovascular interventions and gastrointestinal endoscopy.

Use of nitinol stents following recanalization of central venous occlusions in hemodialysis patients

PURPOSE

To retrospectively review the patency of endovascular interventions with nitinol stent placement for symptomatic central venous occlusions in hemodialysis patients.

METHODS

A retrospective review of all patients who underwent endovascular interventions for dysfunctional hemodialysis grafts and fistulas was performed from April 2004 to August 2006. A total of 6 patients presented with arm and/or neck and facial swelling and left brachiocephalic vein occlusion. The study group consisted of 3 men and 3 women with a mean age of 79.5 years (SD 11.2 years). Of these 6 patients, 1 had a graft and 5 had fistulas in the left arm. The primary indication for nitinol stent placement was technical failure of angioplasty following successful traversal of occluded central venous segments. Patency was assessed from repeat fistulograms and central venograms performed when patients redeveloped symptoms or were referred for access dysfunction determined by the ultrasound dilution technique. No patients were lost to follow-up.

RESULTS

Nitinol stent placement to obtain technically successful recanalization of occluded venous segments was initially successful in 5 of 6 patients (83%). In 1 patient, incorrect stent positioning resulted in partial migration to the superior vena cava requiring restenting to prevent further migration. Clinical success was observed in all patients (100%). Over the follow-up period, 2 patients underwent repeat intervention with angioplasty alone. Primary patency was 83.3% (95% CI 0.5-1.2) at 3 months, and 66.7% at 6 and 12 months (0.2-1.1, 0.1-1.2). Secondary patency was 100% at 12 months with 3 patients censored over that time period. Mean primary patency was 10.4 months with a mean follow-up of 12.4 months. No complications related to recanalization of the occluded central venous segments were observed.

CONCLUSION

Our initial experience has demonstrated that use of nitinol stents for central venous occlusion in hemodialysis patients is associated with good mid-term patency and may exceed historical observations with prior use of Wallstents.

Balancing Fistula First With Catheters Last

The success of Fistula First nationwide has been accompanied by an unplanned increase in hemodialysis catheters. Complications related to prolonged hemodialysis catheter use include increased morbidity, mortality, and cost. We hypothesize that the national focus on increasing fistulas may have inadvertently diverted attention away from initiatives to decrease dependence on hemodialysis catheters. Based on a synthesis of guidelines, reviews, published evidence, and the authors' opinions, we propose that the national vascular access initiative be revised to have a dual goal of Fistula First and "Catheters Last." These goals are not mutually exclusive, but rather complementary. We recommend a systematic refocus on interventions that not only increase fistulas, but help avoid extended catheter use. Clearly, the ideal practice for hemodialysis vascular access remains early placement of fistulas with enough maturation time such that they can be used for initiating long-term hemodialysis therapy when the need arises. To effect this change, a reimbursement policy covering the costs associated with permanent access placement before the need for dialysis is essential. Individualized patient management strategies may consider such innovative approaches as initiating patients on peritoneal dialysis therapy or using nonautogenous grafts as bridge accesses in lieu of catheters. For patients who are dialyzing using catheters, immediate active planning for permanent access placement and removal of the catheter is necessary. In the same vein as Fistula First, the renal community should once again be galvanized in working together toward controlling the catheter epidemic in our dialysis population.

Central vein stenosis: a nephrologist's perspective

Central vein stenosis is commonly associated with placement of central venous catheters and devices. Central vein stenosis can jeopardize the future of arteriovenous fistula and arteriovenous graft in the ipsilateral extremity. Occurrence of central vein stenosis in association with indwelling intravascular devices including short-term, small-diameter catheters such as peripherally inserted central catheters, long-term hemodialysis catheters, as well as pacemaker wires, has been recognized for over two decades. Placement of multiple catheters, longer duration, location in subclavian vein, and placement on the left-hand side of neck seem to predispose to the development of central vein stenosis. Endothelial injury with subsequent changes in the vessel wall results in development of microthrombi, smooth muscle proliferation, and central vein stenosis. Central vein stenosis is often asymptomatic in nondialysis patients, but can result in edema of ipsilateral extremity and breast when challenged by increased flow from an arteriovenous fistula or arteriovenous graft. Bilateral central vein stenosis or superior vena cava stenosis can produce a clinical picture of superior vena cava syndrome, associated with engorgement of face and neck. Endovascular interventions are the mainstay of management of central vein stenosis. Percutaneous angioplasty and stent placement for elastic and recurring lesions can restore the functionality of the vascular access, at least temporarily. Frequent or multiple interventions are usually required. In recalcitrant cases, surgical bypass of the obstruction is an option. In resistant cases with severe symptoms, occlusion of the functioning vascular access will usually provide relief of symptoms. Further study of mechanisms of development of central vein stenosis and search for a targeted therapy is likely to lead to better ways of managing central vein stenosis. Prevention of central vein stenosis is the key to avoid access failure and other complications from central vein stenosis and relies upon avoidance of central vein stenosis placement and timely placement of arteriovenous fistula in prospective dialysis patient.

Patency of Endovascular Treatment for Central Venous Stenosis: Is There a Difference Between Dialysis Fistulas and Grafts?

PURPOSE

To determine if there is a difference in intervention patency for central venous stenosis (CVS) and occlusion between patients with autogenous hemodialysis fistulas and those with grafts.

MATERIAL AND METHODS

A retrospective study was performed from March 1998 to September 2005 identifying all patients with autogenous fistulas and synthetic grafts who underwent percutaneous angioplasty and/or stent placement for CVS. This study cohort consisted of 38 patients (22 with fistulas and 16 with grafts). Age, sex, type of access, location and side of the access, location and side of the CVS, presence of diabetes, previous hemodialysis catheter placement, date and type of interventions, and outcomes were recorded. The patency of each intervention was estimated by using the Kaplan-Meier survival curves. Univariate and multivariate analysis of the variables were performed.

RESULTS

Eighty-nine interventions were performed; 83 were angioplasties and six were stent placements. Previous catheter placement on the side of the CVS occurred in 29 of the 38 patients (76%). Technical and clinical success of the interventions were 93.3% and 94.4% respectively. The intervention or primary patency rates +/- standard errors at 3, 6, and 9 months in the fistula group were 88.5% +/- 4.8, 59.4% +/- 7.6, and 46% +/- 7.9, respectively. In the graft group, the rates were 78.1% +/- 7.3, 40.7% +/- 9, and 16% +/- 7.3, respectively. With multivariate analysis, intervention patency remained significantly longer for fistulas (P .014) and in patients who did not have a previous catheter (P .001).

CONCLUSION

Longer intervention-free survival for CVS was observed in patients with autogenous fistulas compared with grafts and in patients who did not previously undergo hemodialysis catheter insertion.

Sharp Central Venous Recanalization by Means of a TIPS Needle

The purpose of this study was to perform an alternative technique for recanalization of a chronic occlusion of the left brachiocephalic vein that could not be traversed with a guidewire. Restoration of a completely thrombosed left brachiocephalic vein was attempted in a 76-year-old male hemodialysis patient with massive upper inflow obstruction, massive edema of the face, neck, shoulder, and arm, and occlusion of the stented right brachiocephalic vein/superior vena cava. Vessel negotiation with several guidewires and multipurpose catheters proved unsuccessful. The procedure was also non-viable using a long, 21 G puncture needle. Puncture of the superior vena cava (SVC) at the distal circumference of the stent in the right brachiocephalic vein/superior vena cava, however, was feasible with a transjugular intrahepatic portosystemic shunt (TIPS) set under biplanar fluoroscopy using the distal end of the right brachiocephalic vein as a target, followed by balloon dilatation and partial extraction of thrombotic material of the left brachiocephalic vein with a wire basket. Finally, two overlapping stents were deployed to avoid early re-occlusion. Venography demonstrated complete vessel patency with free contrast media flow via the stents into the SVC, which was reconfirmed in follow-up examinations. Immediate clinical improvement was observed. Venous vascular recanalization of chronic venous occlusion by means of a TIPS needle is feasible as a last resort under certain precautions.

Immediate postimplant hemodialysis through a new “self-sealing” heparin-bonded polycarbonate/urethane graft

BACKGROUND

Immediate accessibility of a newly implanted dialysis graft is desirable to avoid temporary catheters. The most commonly used dialysis graft, expanded polytetrafluorethylene (ePTFE), does not allow early access. This report presents the first clinical data regarding the immediate puncturability of a newly introduced "self-sealing" polycarbonate urethane graft (PUG).

METHODS

Patients implanted with a PUG due to the need for immediate vascular access through their new grafts were followed prospectively for early and late complications.

RESULTS

Five patients who were implanted with a PUG were dialyzed through their grafts within hours after surgery. Dialysis was continued three times per week in each patient, without a puncture-related problem.

CONCLUSION

The availability of a self-sealing graft allowing immediate vascular access on the same day of the implant was achieved with the PUG system. Decreasing the need for temporary catheters may initiate some of the complications associated with hemodialysis.

Percutaneous treatment of symptomatic central venous stenosis angioplasty

OBJECTIVES

The increased use of central venous access primarily for hemodialysis has led to a significant increase in clinically relevant central venous occlusive disease (CVOD). The magnitude of and the optimal therapy for CVOD are not clearly established. The purpose of this study is to define the problem of CVOD and determine the success of percutaneous therapy for relieving symptoms and maintaining central venous patency.

METHODS

Patients presenting with disabling upper-extremity edema suggestive of central venous stenosis or occlusion during a 3-year period were evaluated by venography of the upper extremity and central veins. Percutaneous venous angioplasty (PTA) and/or stent placement was performed as clinically indicated. The success of therapy was assessed, and the patients were observed to determine the incidence of recurrence and additional procedures. Recurrent lesions underwent similar evaluation and treatment.

RESULTS

A total of 32 sides were treated in 29 patients with a mean of 1.9 interventions per side treated. Hemodialysis-related lesions were the underlying cause in 87% with the remaining 13% related to previous central venous catheterization. The lesions involved the axillary, subclavian, and innominate veins with complete venous occlusion in six (19%) cases. Percutaneous angioplasty was followed by stent placement in six (19%) cases. The procedure was a technical success and was performed without complications in all cases (100%). Mean follow-up was 16.5 months (range, 4-36 months). On average, patient symptoms were controlled for 6.5 months after the initial intervention. Recurrent edema led to additional PTA in 20 (63%) cases. Fifty percent (n = 14) of patients with an arteriovenous fistula (AVF) experienced recurrent symptoms after initial and/or repeat PTA and required AVF ligation. Complete resolution after the initial PTA was predictive of long-term success.

CONCLUSIONS

Central venous occlusive disease has emerged as a significant clinical problem. Percutaneous venous angioplasty can provide temporary symptomatic relief; however, multiple procedures are often required and long-term relief is rarely achieved.

Central vein obstruction in hemodialysis patients: Results of radiological and surgical intervention

BACKGROUND/AIMS

Symptomatic central venosus obstruction (CVO) in dialysis patients with arteriovenous fistulas (AVFs) leads to significant morbidity and patient inconvenience. We evaluated the results of surgical and radiological interventional treatment of symptomatic central venous obstruction.

METHODS

Clinical data, site and length of vein obstruction, type and outcome of intervention were obtained from patient records. Patency rates of radiological and surgical treatment were calculated using Life Table survival analysis.

RESULTS

In 28 patients with VH, 45 interventions (percutaneous intervention 30; surgical reconstruction 10; AVF closure five) were performed. Mean vessel obstruction length was 4.9 cm, mainly localized in the subclavian vein (55%). Initial clinical success rate of PTA and surgery was 92%, with complications after percutaneous transluminal angioplasty (PTA) on six occasions. Restenosis after PTA was observed in 39%. One-year primary and secondary patency after PTA was 50 and 63%, respectively. One-year primary patency after surgical reconstruction was 75%.

CONCLUSION

Symptomatic CVO in dialysis patients with AVFs can be treated with a high success rate through radiological intervention. Surgical reconstruction is an appropriate alternative method in case of failed PTA.

Surgical treatment of hemodialysis-related central venous stenosis or occlusion: another option to maintain vascular access

BACKGROUND

The most common cause of graft failure in patients undergoing hemodialysis is outflow venous stenosis. Long-term compromise of venous central trunks must be resolved.

PURPOSE

This study was undertaken to evaluate an unusual surgical option, bypass to decompress a long-term vascular graft to the femoral vein, improving venous outflow, alleviating symptoms of venous hypertension, and restoring vascular integrity for dialysis.

PATIENTS AND METHODS

The study included 3 patients with end-stage renal disease with signs and symptoms of dysfunctioning grafts. Angiographic studies showed occlusion or stricture of the central venous tract and venous outflow compromise. All patients had multiple temporary and long-term vascular access sites for hemodialysis, which were revised several times. Venous decompression was performed with a bridge to the ipsilateral femoral vein. A 6 mm reinforced polytetrafluoroethylene graft was tunneled subcutaneously along the thoracoabdominal wall. Patients were released 48 hours after the procedure, and periodic follow-up was carried out to detect changes in graft patency and function.

RESULTS

There were no preoperative or intraoperative complications. Clear improvement in signs and symptoms of venous hypertension were observed. Venous pressures decreased. Average follow-up was 16.3 months. In 1 patient the new graft malfunctioned, and it was revised and repaired at 25 months. The presence of deep venous thrombosis and pulmonary embolism required peritoneal dialysis. Two other patients, with no change in graft patency, died of concomitant disease.

CONCLUSION

Decompression of the femoral vein enables preservation of vascular graft patency and improves symptoms of venous hypertension.

Surgical bypass for subclavian vein occlusion in hemodialysis patients

BACKGROUND

The majority of patients with end-stage renal disease are dependent on hemodialysis. Significant stenosis or occlusion of the subclavian vein is known to occur in 20% to 50% of patients who have had central venous catheters inserted into the subclavian vein or the internal jugular vein. Surgical bypass of the obstructed venous segment proximal to a functioning dialysis access site is an established treatment to relieve symptoms and salvage the functional dialysis access.

STUDY DESIGN

A retrospective review of all subclavian venous bypass procedures performed at St Louis University Hospital from May 1987 to May 2000 was undertaken. Twelve procedures were performed during this time. The mean age of the patient was 55.5 years (range 17 to 72 years). There were 11 men and 1 woman. Before surgical bypass, all patients underwent bilateral venograms to evaluate their central venous systems.

RESULTS

An extraanatomic surgical bypass was performed in all patients. Patients were followed for a mean of 16 months (range 1 to 79 months). At 1 month, 100% of hemodialysis access sites remained functional. At 1 year, 80%; 2 years, 60%; and 3 years, 25% of the salvaged arteriovenous hemodialysis access sites provided for functional dialysis. One patient required thrombectomy of the bypass graft at 14 months.

CONCLUSIONS

Surgical bypass of an occluded or stenotic subclavian vein segment is successful in providing both symptomatic relief and salvage of a functioning dialysis access in the hemodialysis patient population. Study of the central venous system is essential in selecting an appropriate bypass procedure in individual patients.

3D gadolinium-enhanced MRI venography: evaluation of central chest veins and impact on patient management

AIM

To assess the value of a simplified 3D gadolinium-enhanced magnetic resonance imaging (MRI) venography for central chest veins.

MATERIALS AND METHODS

In this retrospective study of 24 patients, the MRI findings and medical records were reviewed to determine whether MRI results correlated with subsequent findings, and to determine the effect on clinical management. 3D steady state gradient-echo sequence, fast imaging with steady state precession (FISP), was used. We employed a simplified protocol not requiring bolus timing or subtraction to achieve rapid data acquisition and hence good compliance in this group of frail patients. Following intravenous administration of a bolus of gadolinium, two acquisitions were obtained in order to ensure adequate opacification of all veins. Individual partitions and maximum intensity projections were then analysed to determine whether the veins were patent, stenosed or occluded.

RESULTS

The indications for MRI were to assess the patency of central veins for the purpose of cannulation or arteriovenous fistula formation in 17 patients. Out of the 12 patients who proceeded to an intervention, MRI venography successfully predicted an appropriate site in 10 patients. In the remaining seven patients, MRI venography was valuable in confirming or excluding the clinical suspicion of central venous thrombosis and directly influenced the management in five patients.

CONCLUSION

3D gadolinium-enhanced MRI venography is a valuable means of providing a global representation of the central venous system and guiding subsequent central venous cannulation.

Critical hand ischemia after angioaccess surgery: diagnosis and treatment

Severe hand ischemia is an uncommon complication of angioaccess surgery. Prompt recognition is necessary to prevent finger necrosis and permanent nerve damage. Treatment should relieve symptoms without compromising dialysis access. From January 1989 to September 1999, we treated critical hand ischemia in 23 patients (16 men, 7 women), including 8 diabetic patients with a total of 19 arteriovenous fistulas (AVF) and 4 arteriovenous grafts (AVG). In 21 patients, the symptom was critical ischemia, with finger necrosis occurring in 7 patients. In the remaining two patients, the manifestation was acute ischemia due to venous thrombosis. Four patients required finger amputation. Fifteen patients (65%) had previous AVF on the lateral extremity. The mean number of previous AVF in this group was 2.5 (range, 2 to 6). Various treatments were used for arterial insufficiency (n = 20), including ligation of the fistula (n = 8), distal revascularization-interval ligation (DRIL) (n = 4), bypass (n = 4), sympathectomy (n = 1), ligation of the radial artery (n = 1), medical therapy (n = 1), and banding technique (n = 1). Medical therapy and banding relieved symptoms after thrombosis of the AVF. Through the use of DRIL, healing of finger necrosis (n = 3) and improvement of symptoms (n = 1) were achieved. The findings of this study indicate that severe hand ischemia occurs mainly in diabetic patients with multiple previous AVF and finger arteriopathy. DRIL is the conservative treatment of choice, since it can be used to achieve both symptomatic relief and maintenance of dialysis access.

Complicated emergent endovascular repair of a life-threatening bilateral internal jugular vein occlusion

A 62-year-old woman had painful facial swelling that progressed to extensive periorbital and perioral edema with loss of vision, hearing, and consciousness. Her past surgical history was significant for right radical neck dissection including internal jugular vein (IJV) resection, laryngectomy, partial esophagectomy, tracheoesophageal fistula repair, and tracheostomy for squamous cell carcinoma of the oropharynx. In addition, the patient had received radiation therapy to the neck. A venogram revealed occlusion of the left IJV. A guidewire from the femoral vein was passed through the occluded segment; however, attempts to introduce an angioplasty balloon failed. A percutaneous basilic vein approach allowed passage of a dilator sheath over a guidewire, thereby enabling Wallstent deployment across the IJV occlusion. A second Wallstent was inserted across a stenosis in the brachiocephalic vein; however, this second stent reoccluded the IJV. Surgical removal of the second Wallstent was required through a segmental claviculectomy and venotomy. Patency was restored in the IJV and the brachiocephalic vein with the return of baseline neurologic function. This case demonstrates a complicated emergent endovascular repair of a life-threatening IJV occlusion that required surgical salvage.

Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment option

PURPOSE

Central venous obstruction is a common problem in patients with chronic renal failure who undergo maintenance hemodialysis. We studied the use of right atrial bypass grafting in nine cases of central venous obstruction associated with upper extremity venous hypertension. To better understand the options for managing this condition, we discuss the roles of surgery and percutaneous transluminal angioplasty with stent placement.

METHODS

All patients had previously undergone placement of bilateral temporary subclavian vein dialysis catheters. Severe arm swelling, graft thrombosis, or graft malfunction developed because of central venous stenosis or obstruction in the absence of alternative access sites. A large-diameter (10 to 16 mm) externally reinforced polytetrafluoroethylene (GoreTex) graft was used to bypass the obstructed vein and was anastomosed to the right atrial appendage. This technique was used to bypass six lesions in the subclavian vein, two lesions at the innominate vein/superior vena caval junction, and one lesion in the distal axillary vein.

RESULTS

All patients except one had significant resolution of symptoms without operative mortality. Bypass grafts remained patent, allowing the arteriovenous grafts to provide functional access for 1.5 to 52 months (mean, 15.4 months) after surgery.

CONCLUSION

Because no mortality directly resulted from the procedure and the morbidity rate was acceptable, this bypass grafting technique was adequate in maintaining the dialysis access needed by these patients. Because of the magnitude of the procedure, we recommend it only for the occasional patient in whom all other access sites are exhausted and in whom percutaneous dilation and/or stenting has failed.

Efficacy of color flow duplex imaging for proximal upper extremity venous outflow obstruction in hemodialysis patients

PURPOSE

The efficacy of color flow duplex imaging (CFDI) in detecting proximal upper extremity venous outflow obstruction in hemodialysis patients was compared with that of traditional contrast venography.

METHODS

From 1993 through 1997, all hemodialysis patients who were evaluated for upper extremity venous outflow obstruction of the axillary, subclavian, or brachiocephalic veins with both CFDI and venography were identified. Medical history, hemodialysis access procedures, and indications for imaging were reviewed. The diagnostic accuracy of CFDI was compared with that of venography for proximal venous outflow obstruction, including focal stricture, partial obstruction, or complete occlusion.

RESULTS

Sixty upper extremities in 42 hemodialysis patients were imaged with both CFDI and venography. Previous ipsilateral intravenous dialysis catheters had been present in 33 (55%) of the extremities imaged; current catheters were present in 16 (27%) of the extremities imaged; and 28 (67%) of the extremities imaged had a current ipsilateral arteriovenous (AV) shunt. Five (8%) of the 60 duplex scans were nondiagnostic because of artifact from intravenous dialysis catheters (3) or incomplete visualization of the subclavian or brachiocephalic veins (2) and were excluded from further analysis. In the remaining 55 duplex scans, proximal venous outflow obstruction was found in 18 (33%), compared with 21 (38%) identified by means of venography (P = not significant [NS]). Overall sensitivity, specificity, positive predictive value, and negative predictive value for CFDI were 81%, 97%, 94%, and 89%, respectively.

CONCLUSION

CFDI is a reliable means of detecting proximal upper extremity venous outflow obstruction and should replace contrast venography as the initial imaging study in hemodialysis patients.

Use of a puncture needle for recanalization of an occluded right subclavian vein

We report a patient in whom we used a puncture needle to initiate percutaneous recanalization of a chronic occlusion of the junction between the right subclavian vein and the right brachiocephalic vein. Under fluoroscopic guidance, an 18-gauge needle was used to puncture the right subclavian vein. When contrast material injected through the needle confirmed intravascular location, the needle was advanced until it deflected and perforated an occlusion balloon target positioned within the right brachiocephalic vein. This technique may be useful in patients with central venous occlusions that are refractory to traversal using traditional catheter and guidewire techniques.