Success Rate and Complications of Sharp Recanalization for Treatment of Central Venous Occlusions. Cardiovasc Intervent Radiol. 2018;41:73-79. [PMID: 28879566 DOI: 10.1007/s00270-017-1787-x]

Sharp recanalization with transseptal needle for unsuccessful standard recanalization of chronic thoracic central vein occlusion in hemodialysis patients

BACKGROUND

Many cases of chronic thoracic central vein occlusion (CVO) fail to recanalize using the standard conventional guidewire technique. This study aims to present the outcomes of sharp recanalization with a transseptal needle in chronic thoracic CVO.

METHODS

This retrospective study involved 22 hemodialysis patients who developed clinical signs and symptoms of CVO, had unsuccessful conventional endovascular treatment using guidewire, and underwent sharp recanalization with a transseptal needle from January 2018 to December 2021. Demographic information of patients, technical success rate, and complications were kept. Post-intervention primary patency rate was examined using survival regression.

RESULTS

Thirteen men and nine women were enrolled with a median age of 50 years (range: 30-83 years). The most common site of thoracic CVO was the right brachiocephalic vein (21 patients). The average length of occlusion was 2.5 cm (range: 1-4.4 cm). Technical success rate was 90.9% (20 patients). Major complications occurred in three instances, including severe hemothorax and pulmonary edema. The median post-intervention primary patency between balloon angioplasty alone and primary stenting was 2.1 and 8.0 months (p = 0.015). Post-intervention primary patency rates at 6 and 12 months in the group receiving balloon angioplasty alone versus primary stenting were 33.3% and 0% versus 70.6% and 29.4% (p = 0.013).

CONCLUSION

Sharp recanalization with a transseptal needle is successful in chronic thoracic CVO cases that fail with conventional recanalization. Primary stenting in this CVO lesion shows a greater primary patency compared to balloon angioplasty alone.

Interventional treatment for post-thrombotic chronic venous obstruction: Progress and challenges

Chronic venous obstruction, including nonthrombotic iliac vein lesions and post-thrombotic syndrome, presents a significant burden on patients' quality of life and health care systems. Venous recanalization and stenting have emerged as promising minimally invasive approaches, yet challenges in patient selection, procedural techniques, and long-term outcomes persist. This review synthesizes current knowledge on the interventional treatment of post-thrombotic syndrome, focusing on the evolution of endovascular techniques and stenting. Patient selection criteria, procedural details, and the characteristics of dedicated venous stents are discussed. Particular emphasis is given to the role of inflow and other anatomical considerations, along with postoperative management protocols for an optimal long-term outcome.

CT guided sharp recanalization to restore dialysis access in patients with central venous obstruction: A single centre experience and review of alternative techniques

Central venous obstructions that impedes catheter placement or results in catheter dysfunction is a significant problem for haemodialysis patients. Recanalization can be performed with an intent to restore central venous access, improve outflow from arteriovenous fistula or to relieve symptomatic venous obstructions. Sharp recanalization encompasses various interventional techniques using a sharp instrument to puncture through or bypass around a venous obstruction. In this paper we outline our experience performing CT guided sharp recanalization and review alternative sharp recanalization techniques that are specifically used to restore haemodialysis access in patients with thoracic central venous obstruction.

Vascular Interventions in Oncology

Vascular interventions are an important and established tool in the management of the oncology patient. The goal of these procedures may be curative, palliative or adjunctive in nature. Some of the common vascular interventions used in oncology include transarterial embolisation or chemoembolisation, selective internal radiation therapy, chemosaturation, venous access lines, superior vena cava stenting and portal vein embolisation. We provide an overview of the principles, technology and approach of vascular techniques for tumour therapy in both the arterial and venous systems. Arterial interventions are currently mainly used in the management of hepatocellular carcinoma. Transarterial embolisation, chemoembolisation and selective internal radiation therapy deliver targeted catheter-delivered treatments with the aim of reducing tumour burden, controlling tumour growth or increasing survival in patients not eligible for transplantation. Chemosaturation is a regional chemotherapy technique that delivers high doses of chemotherapy directly to the liver via the hepatic artery, while reducing the risks of systemic effects. Venous interventions are more adjunctive in nature. Venous access lines are used to provide a means of delivering chemotherapy and other medications directly into the bloodstream. Superior vena cava stenting is a palliative procedure that is used to relieve symptoms of superior vena cava obstruction. Portal vein embolisation is a procedure that allows hypertrophy of a healthy portion of the liver in preparation for liver resection. Interventional radiology-led vascular interventions play an essential part of cancer management. These procedures are minimally invasive and provide a safe and effective adjunct to traditional cancer treatment methods. Appropriate work-up and discussion of each patient-specific problem in a multidisciplinary setting with interventional radiology is essential to provide optimum patient-centred care.

XperCT facilitates sharp recanalization for the treatment of chronic thoracic venous occlusive disease in hemodialysis patients

OBJECTIVE

Our objective was to evaluate the feasibility of XperCT combined fluoroscopy to guide sharp recanalization for the treatment of chronic thoracic venous occlusive disease in hemodialysis patients.

METHODS

The records of hemodialysis patients with chronic thoracic venous occlusive disease who received endovascular sharp recanalization after conventional techniques failed were retrospectively reviewed. The sharp devices used for recanalization included the stiff end of a guidewire, Chiba biopsy needle, RUPS-100 set, and transseptal needle. The needle was advanced toward a target placed at the opposite end of the occlusion and was guided by fluoroscopy and/or XperCT. While the guidewire crossed the occlusion, endovascular procedures such as percutaneous angioplasty were performed for the treatment of the occlusion.

RESULTS

The analysis included 32 sharp thoracic vein recanalization procedures in 29 patients. Two attempts in one patient failed, and in one patient the first attempt failed but the second attempt was successful. In one patient, two separate successful procedures were performed, and the other 26 procedures in 26 patients were successful. The overall technical success rate of sharp recanalization was 90%. The mean number of puncture attempts in the combined group was less than that of the fluoroscopy-guided alone group (2 vs 5, p < 0.05). The success rate of sharp recanalization in the combined group was higher (100% vs 86%), and the recanalization time (28.5 min vs 36 min, p > 0.05) was no different. There was no statistical difference in procedure-related complications between the groups.

CONCLUSION

XperCT can facilitate sharp recanalization for the treatment of chronic thoracic venous occlusive disease in hemodialysis patients.

Recanalization of a long segment occluded superior vena cava by puncturing the remnant calcified fibrin sheath of the internal jugular vein: A case report

A fibrin sheath with central venous occlusion is a common complication after central venous catheterization, and these patients often experience catheter dysfunction. A calcified fibrin sheath can cause a catheter to be stuck, and typically necessitates catheter removal or replacement. From another point of view, a calcified fibrin sheath can be seen in ultrasound and computed tomography, and the original fibrin sheath channel between the internal jugular vein and the atrium is unusually strong. When central vein occlusion occurs, the remnant calcified fibrin sheath of the internal jugular vein can be punctured under ultrasound guidance, allowing the guidewire to enter the atrium directly through the fibrin sheath. Here, we report a case in which we achieved easy recanalization of a long segment occluded superior vena cava by puncturing the remnant calcified fibrin sheath of the internal jugular vein.

Efficacy and Safety of Sharp Recanalization with the Stiff End of a Microguidewire for Treatment of Refractory Central Venous Occlusions in Hemodialysis Patients

BACKGROUND

Sharp recanalization is a viable procedure for some refractory central venous occlusions that cannot be recanalized with the conventional technique. The sharp recanalization procedures reported in previous studies are often rely on costly devices and with a certain proportion of complications. This study aimed to present an inexpensive and risk-controllable coaxial centrifugally sharp recanalization technique that was independent of any additional costly devices.

METHODS

This retrospective study enrolled 8 patients who had received sharp recanalization of central venous occlusions, between August 2017 and May 2021. The sharp recanalization technique was performed centrifugally with the stiff end of a microguidewire after the lesions failed to be passed through with the conventional technique. Clinical data of patients on their lesions, technical success rate, procedure-related complications, and patency rates were collected and analyzed to assess the efficacy and safety of the technique.

RESULTS

Technical success was achieved in all patients, with no complications were observed. All symptoms were ameliorated within 48h postsurgery. The median follow-up period was 22 months. All patients maintained patency or assisted patency at 12 month follow-up.

CONCLUSIONS

Sharp recanalization performed centrifugally with the stiff end of the microguidewire could be a cost-effective and safe alternative procedure for the treatment of refractory central venous occlusion that cannot be recanalized with conventional technique.

The outcome of sharp recanalization of chronic central venous occlusions in patients undergoing hemodialysis

BACKGROUND

Patients on hemodialysis are particularly vulnerable to central venous occlusion (CVO). Endovascular treatment has gained wide acceptance for the treatment of CVO. However, difficulties in crossing the occluded segment can be encountered during conventional endovascular management. Sharp recanalization has been adopted when conventional endovascular methods could not recanalize the obstructed region. This study aimed to assess the outcome of the sharp venous recanalization technique with angioplasty and stenting in the treatment of CVO in Egyptian patients undergoing hemodialysis.

METHODS

This retrospective study is based on data from a prospectively maintained department database of patients under regular hemodialysis who underwent the sharp venous recanalization technique for CVO. Routinely, the patients were followed up at 3, 6, and 12 months with a clinical examination. The primary outcomes were technical success and primary patency. Secondary outcomes included complication rates and clinical success.

RESULTS

This study included 40 patients. Thirty-six patients (90%) achieved technical and clinical success. Seven patients (17.5%) had immediate postoperative complications. Four cases had minor complications (10%) and three patients had major complications (7.5%): hemothorax in two patients (5.1%) and pneumothorax in one patient (2.6%). At the 1-year follow-up, reintervention was required in nine patients (22.5%), with primary patency rate of 77.5% and a secondary patency rate of 100%.

CONCLUSIONS

Sharp recanalization offers a solution for patients undergoing hemodialysis who developed CVO and failed to be recanalized using the conventional endovascular method. It offered promising technical success, clinical improvement, and good primary patency rates.

Balloon-Targeted Extra-Anatomic Sharp Recanalization Technique to Re-establish Supraclavicular Vascular Access

A balloon-targeted extra-anatomic sharp recanalization (BEST) technique was investigated to re-establish supraclavicular vascular access in patients with central venous occlusion. Query of the authors' institution's database yielded 130 patients who underwent central venous recanalization. Of these, a retrospective review of 5 patients with concurrent thoracic central venous and bilateral internal jugular vein occlusions who underwent sharp recanalization using the BEST technique from May 2018 to August 2022 was performed. Technical success was achieved in all cases without major adverse events. Four (80%) of the 5 patients underwent hemodialysis reliable outflow (HeRO) graft placement using the newly established supraclavicular vascular access.

Management of Central Venous Stenoses and Occlusions

Symptomatic central venous stenosis and occlusion remains the gordian knot of vascular access. Advances in techniques, like sharp recanalization, allowed for improved success rates in crossing these difficult lesions. There is also increasing evidence of new devices in treating central venous stenosis and, at the same time, improving the time needed between interventions. High-pressure balloons, paclitaxel-coated balloons, bare metal stents and covered stents have been tested with an aim to offer additional treatment options, although obstacles still exist. In the current review, authors describe relevant techniques and options, provide the evidence and evaluate the actual implementation of these devices in this demanding field.

Factors associated with difficulty in stenting the chronic iliofemoral venous obstruction

BACKGROUND

The main aim of this article is to investigate the causes of technical failure during endovascular recanalization in patients with post-thrombotic syndrome with occluded iliofemoral veins and to suggest alternative techniques to improve outcomes in such challenging cases.

METHODS

Between November 2015 and August 2020, 230 patients (274 limbs) treated in our institution with symptomatic chronic iliofemoral venous obstruction underwent endovascular recanalization with angioplasty and stent placement. Overall, the initial attempt was unsuccessful in 15 limbs. We retrospectively analyzed the basic demographic and health characteristics of the involved patients and evaluated the endovascular procedures and techniques that resulted in a successful second intervention.

RESULTS

The first attempts at endovascular intervention were unsuccessful in 15 of the 274 limbs (5.4%). Failures were attributed to hostile groin areas in intravenous drug abusers caused by multiple punctures in six cases. In addition, five interventions failed due to prior surgery at the site of venous occlusion and in retroperitoneal space, three patients due to severe stent deformity, and one patient due to congenital venous aplasia. Of the 15 patients, 11 underwent a subsequent attempt that included six successful recanalizations. The mean follow-up time of the six patients with successful recanalization was 27 months (5-62 months). The primary, assisted primary and secondary patency rates were 83.3%, 100%, and 100%, respectively. The remaining five patients, in whom the second recanalization attempt failed, received conservative treatment.

CONCLUSIONS

Recanalization failure is rare in chronic venous obstruction patients. Severe stent deformities have the lowest chance of successful second intervention. Patients with a hostile groin or prior open surgeries at the occlusion site may be considered for reintervention with a success rate of nearly 50%.

Advanced intraoperative imaging guidance for inside-out central venous recanalization using a novel catheter access system

BACKGROUND

The novel Surfacer Inside-Out recanalization technique facilitates right-sided central venous access in occluded vessels but carries a risk of arterial and pleural injuries. This article demonstrates how an advanced intraoperative imaging protocol can help to avoid these potential complications.

METHODS

This retrospective review included patients undergoing the Surfacer Inside-Out central venous recanalization procedure between December 2017 and October 2021. The study sample comprised patients included in the SAVE-US trial at our site as well as patients treated after US Food and Drug Administration approval of the device. All procedures were performed using intraoperative cone-beam computed tomography (CBCT) angiography to map out the trajectory of the device through the mediastinum and supraclavicular space with fusion imaging for guidance. Procedures were aborted if CBCT findings predicted injury to arterial or respiratory structures. The intraoperative coronal and sagittal orientation of the device was compared to preoperatively predicted trajectory.

RESULTS

A total of 17 procedures were performed in 16 patients with end-stage renal disease and a mean age of 61 ± 11 years. Most patients presented a type 3 central venous occlusion (9/15). Successful recanalization was achieved in 14 of the 17 cases (82.4%) with no intraoperative complications. The procedure had to be aborted in 3 of the 17 cases based on intraoperative CBCT findings, which projected the device to perforate the right pleural space in one patient, the trachea and right subclavian artery in another, and the innominate artery in the third patient. The total radiation dose per procedure was 753 ± 346 mGy and the mean procedural time was 101.6 ± 29.7 minutes. A median of 2 (range, 1-5) intraoperative CBCT scans were performed per patient and accounted for 70% of the total radiation dose. Statistical analysis showed intraoperative CBCT findings to differ significantly from preoperative predicted values.

CONCLUSIONS

The nonsteerable and penetrating nature of the Surfacer device may lead to serious complications when performed under fluoroscopic guidance alone. Intraoperative CBCT with fusion overlay enhances the safety and effective use of this device and inside out crossing technique.

Difficult Vascular Access in Children with Short Bowel Syndrome: What to Do Next?

Short Bowel Syndrome and intestinal failure are chronic and severe conditions that may require life-long parenteral nutrition in children. Survival of these children rely on the correct functioning of central venous catheters; therefore, careful management, prevention, and treatment of complications is of paramount importance. Despite a growing awareness of preserving the vascular real estate, a certain number of patients still experience a progressive and life-threatening exhaustion of vascular access. We searched the literature to highlight the current management of children with vascular exhaustion, specifically focusing on vascular access salvage strategies and last-resource alternative routes to central veins. Given the paucity of data, results are reported in the form of a narrative review.

Antithrombotic Therapy After Venous Interventions: AJR Expert Panel Narrative Review

Interventions for thrombotic and nonthrombotic venous disorders have increased with technical advances and more trained venous specialists. Antithrombotic therapy is essential to clinical and procedural success; however, post-procedural therapeutic regimens exhibit significant heterogeneity due to limited prospective randomized data as well as incomplete mechanistic understanding of the critical factors driving long-term patency. Post-interventional antithrombotic therapy for thrombotic venous disorders should adhere to existing venous thromboembolism management guidelines, which include 3-6 months of therapeutic anticoagulation at minimum and consideration of extended therapy in patients with higher risk of thrombosis due to procedural or patient factors. The additive benefit of antiplatelet agents in the acute and intermediate period is unknown, having shown improved long-term stent patency in some retrospective studies. Dual and/or triple agent therapy should be limited based on individual risks of thrombosis and bleeding. The treatment of non-thrombotic disorders is more heterogeneous, though patients with limited flow, extensive stent material, or underlying prothrombotic states such as malignancy or chronic inflammation may benefit from single- or multi-agent antithrombotic therapy. However, the agent, dose, and duration of therapy remain indeterminate. Future prospective studies are warranted to improve patient risk stratification and standardize post-procedural antithrombotic therapy in patients receiving venous interventions.

Management of Central Venous Stenosis and Occlusion in Dialysis Patients

Central venous occlusions (CVOs) of the major intrathoracic veins (jugular, subclavian, brachiocephalic, superior vena cava) can cause debilitating symptoms, negatively impact arteriovenous fistula/graft function, or limit potential access creation options in end-stage kidney disease (ESKD) utilizing hemodialysis (HD). This review summarizes the incidence, pathophysiology, indications/contraindications, and management options of CVOs in the ESKD on HD population and concludes with considerations and examples when planning endovascular central recanalization procedures, which have risen as the first-line management when appropriate.

Sharp recanalization for treatment of central venous occlusive disease in hemodialysis patients

BACKGROUND

The purpose of the present study was to evaluate the technical feasibility and safety of sharp recanalization for central venous occlusive disease (CVOD) in patients requiring hemodialysis.

METHODS

Patients with CVOD requiring hemodialysis who had undergone endovascular recanalization using sharp devices, including the stiff end of a guidewire, Chiba needle, or RUS-100 to cross occluded segments after conventional techniques had failed were included. The needle was guided toward a target placed at the opposite end of the occlusion. Although the guidewire was passed though the occlusion, subsequent procedures such as percutaneous transluminal angioplasty could be performed.

RESULTS

A total of 27 sharp recanalization procedures in 25 patients were performed. Two attempts failed, 1 patient had undergone two separate successful procedures, and 23 procedures in 23 patients were successful. The overall technique success was 92.6%. The stiff end of a guidewire was the first choice for all the procedures, and recanalization was achieved in 18 patients (66.7%). A Chiba biopsy needle was used in six procedures (22.2%), with 100% technical success. A RUPS-100 set was used in two procedures (7.4%), with one aborted because of concern for complications. The occlusion was subsequently crossed using a Chiba needle. Four minor adverse events (two of mediastinal hematoma and two of chest pain) had occurred, and two major adverse events (pericardial tamponade and acute pleural effusion in one patient [4%], treated with the guidewire stiff-end technique, who recovered after drainage) had occurred.

CONCLUSIONS

Sharp recanalization is safe and feasible with high technical success for CVOD in patients requiring hemodialysis who cannot be recanalized using conventional techniques.

Sharp recanalization and rendezvous technique for biliary occlusions due to spacious bile leak after hepatectomy

Highlight Hirata and colleagues report on a difficult case of biliary strictures and extensive bile leak near the hepatic hilum after hepatectomy for metastatic cancer. Treatment with sharp recanalization and the rendezvous technique was effective to establish bridging between the common bile duct and intrahepatic bile duct in this case.

Effectiveness of sharp recanalization of superior vena cava-right atrium junction occlusion

BACKGROUND

Conventional recanalization techniques may fail in patients with completely occluded superior vena cava (SVC).

AIM

To analyze the effectiveness and complications of sharp recanalization for completely occluded SVC.

METHODS

This was a retrospective study of patients that underwent puncture and recanalization of the SVC between January 2016 and December 2017 at our hospital. Sharp recanalization was performed using the RUPS-100 system. The patients were followed for 12 mo. The main outcomes were the patency rate of SVC and arteriovenous fistula flow during dialysis.

RESULTS

The procedure was successful in all 14 patients (100%). Blood pressure in the distal SVC decreased in all 14 cases (100%) from 26.4 ± 2.7 cmH₂O to 14.7 ± 1.3 cmH₂O (P < 0.05). The first patency rates of the SVC at 24 h and at 3, 6, 9 and 12 mo after sharp recanalization were 100%, 92.9%, 85.7%, 78.6% and 71.4%, respectively. There were two (14.3%) severe, one (7.1%) moderate and one (7.1%) minor complication. The severe complications included one case of pericardial tamponade and one case of hemothorax.

CONCLUSION

The results suggest that sharp recanalization can be an additional tool to extend or renew the use of an occluded upper extremity access for hemodialysis. This could be of use in patients with long-term maintenance hemodialysis in whom the maintenance of central venous access is often a challenge.

Long Term Results of Bypass Graft to the Right Atrium in the Management of Superior Vena Cava Syndrome in Dialysis Patients

BACKGROUND

Superior vena cava (SVC) occlusion in dialysis patients is a serious complication that can cause SVC syndrome and vascular access dysfunction. While endovascular therapy has advanced to become the first line of treatment, open surgical treatment may still be needed occasionally. However, no long term outcome data has been previously reported.

METHODS

We performed a retrospective review of 5 dialysis patients treated with bypass graft to the right atrium from 2012 to 2014. Four patients had severe dysfunction of their upper arm dialysis access as well as superior vena cava syndrome, and one patient with a femoral tunneled dialysis catheter (TDC) had SVC occlusion. None of the patients were candidates for lower extremity access creation or peritoneal dialysis (PD). Three patients underwent a left brachiocephalic-right atrial bypass and 2 underwent a bypass from the cephalic fistula to the right atrium.

RESULTS

All procedures were technically successful and maintained function of the arteriovenous fistulas or allowed creation of a new upper extremity dialysis graft. One-year secondary patency rate of the bypass was 100%. Longer follow up revealed that one patient died of leg sepsis and another one of a stroke within 14 months after the procedure. Another patient did well for 16 months when recurrent graft thrombosis occurred; and ultimately the graft failed after 31 months despite multiple interventions. Two patients maintained bypass graft patency during a follow up of 78 months; however, they underwent multiple endovascular interventions (23) and open vascular access procedures (4) to maintain hemodialysis function.

CONCLUSION

Bypass grafts to the right atrium in dialysis patients with SVC occlusion are successful in maintaining function of already existing vascular access or new ones. Long term secondary patency can be achieved but requires strict follow up and a proactive endovascular strategy to treat lesions in the access and or the bypass graft.

Management of Superior Vena Cava Occlusion Causing Bleeding "Downhill" Esophageal Varices

The health care system in Peru treats 15,000 dialysis patients annually. Approximately 45% of patients receive therapy using catheters. The incidence of catheter-induced superior vena cava (SVC) occlusion is increasing along with its associated significant morbidity and vascular access dysfunction. One of the unusual manifestations of this complication is bleeding "downhill" esophageal varices caused by reversal of blood flow through esophageal veins around the obstruction to the right atrium. Herein is presented the case of an 18-year-old woman on hemodialysis complicated by SVC occlusion and bleeding esophageal varices who underwent successful endovascular recanalization of the SVC. Bleeding from "downhill" esophageal varices should be considered in the differential diagnosis of dialysis patients exposed to central venous catheters. Aggressive endovascular treatment of SVC occlusion is recommended to preserve upper extremity access function and prevent bleeding from this complication.

Blunt Transmediastinal Dissection with Radiofrequency Wire Reentry for Extravascular Bypass of Thoracic Central Venous Occlusions Refractory to Recanalization

Extravascular perforation is a risk of recanalizing chronic central venous occlusions. The authors describe an endovascular technique to bypass venous occlusions using a combination of a hydrophilic guide wire and radiofrequency wire in 7 patients to achieve central venous access to the right atrium without major complications.

Sharp Recanalization of Chronic Central Venous Occlusions of the Thorax Using a Steerable Coaxial Needle Technique from a Supraclavicular Approach

PURPOSE

To evaluate the technical success and safety of a steerable coaxial sharp recanalization technique that utilizes routine needles in patients with refractory thoracic central venous occlusions.

MATERIALS AND METHODS

This retrospective study was performed on 36-attempted sharp recanalizations in 35 patients (mean age 50 years, 23 male) performed via a supraclavicular approach. In all cases, an 18-gauge trocar needle was custom curved to provide directional control during fluoroscopic triangulation. A 22-gauge Chiba needle was then advanced coaxially across the occlusion. A tractogram was performed to assess for traversal of unintended structures. Procedures were completed by catheter placement, angioplasty, or stenting follow successful recanalizations.

RESULTS

Sharp recanalization using this steerable coaxial needle technique demonstrated a technical success rate of 94% (34/36). The mean occlusion length was 30 mm (range 3-53 mm). In 11 patients, success was achieved using this technique after failure of other advanced techniques. In five procedures, stent interstices were traversed. Sharp recanalization was the direct cause of one major complication consisting of pleural transgression causing mild hemothorax treated successfully with a stent graft.

CONCLUSION

The proposed technique is effective and safe for patients who have failed traditional blunt recanalization techniques.

LEVEL OF EVIDENCE

Level 4, Case Series.

Use of the Surfacer® Inside-Out® Catheter Access System to Obtain Central Venous Access in Dialysis Patients With Thoracic Venous Obstructions: Single-Center Series

BACKGROUND

Thoracic central venous obstruction (TCVO) is a common condition which can impact the ability to achieve central venous access (CVA) in patients on hemodialysis. The Surfacer^® Inside-Out^® Catheter Access System is designed to enable repeated right-side central venous access in patients with TCVO.

METHODS

We retrospectively analyzed medical records of 10 dialysis patients who presented with TCVO and underwent the Inside-Out procedure with the Surfacer System to obtain CVA between 2017 and 2020. Patient demographics, hemodialysis vascular access history, and procedural data were identified and analyzed. The mean patient age was 62.4 ± 19.6 years (25.9-89.1 years) with 7 of the 10 patients being male. Eight patients (80.0%) were diagnosed with chronic kidney disease with time on hemodialysis ranging from 3 to 13 years. The remaining 2 required CVA to treat acute-on-chronic kidney injury due to septic shock. Patients in our series had a mean of 2.8 ± 1.6 previous catheters placed prior to the Surfacer procedure.

RESULTS

CVA was achieved in all 10 patients with 1 patient requiring a second attempt to achieve access due to the inability to initially traverse the iliac vein with the device, possibly due to a history of kidney transplantation. One multimorbid patient died shortly after the successful procedure, possibly due to cardiac decompensation. Mean total procedure time for the 7 patients having only dialysis catheter placement using the Surfacer device was 67.2 ± 19.1 minutes (49-103 minutes). The remaining 3 patients received a Hemodialysis Reliable Outflow (HeRO) graft in conjunction with the Inside-Out procedure. All vascular accesses functioned properly during the immediate time period following placement. No adverse events associated with the use of Surfacer device were encountered.

CONCLUSIONS

Data presented from our patient series confirms the effectiveness of the Surfacer System to safely achieve CVA in dialysis patients with TCVOs with a history of multiple catheter placements.

Efficacy and safety of recanalization with transseptal needle for chronic total occlusion of the brachiocephalic vein in hemodialysis patients

Background

Whilst there are effective techniques for the recanalization of central venous occlusions, recanalization of chronic total occlusions remains particularly challenging. This study aims to evaluate the safety and efficacy of recanalization using a transseptal needle in chronic total occlusions of the right brachiocephalic vein (RBV) in long-term hemodialysis patients.

Methods

In this single-center, retrospective study, maintenance hemodialysis patients with chronic total occlusion of the RBV were enrolled between February 2017 to March 2019 from West China Hospital of Sichuan University. Refractory lesions were defined as complete vascular occlusions with failed recanalization using conventional techniques. Occlusions were approached using a transseptal needle to penetrate which offers an alternative strategy with firm support force. Patient data, treatment outcomes and patency rates were collected and analyzed to assess the safety and efficacy of the technique.

Results

A total of 16 eligible patients were analyzed. The operation was successful in 13 of the 16 patients and the success rate was 81.25% (13/16). Twelve patients underwent percutaneous balloon dilatation and stent implantation after sharp recanalization, whilst one patient underwent balloon dilatation only. We achieved procedural success in 13 patients without surgical complications, and all of the patients were discharged in a stable condition. The primary patency rates at 3, 6 and 12 months after surgery were 100%, 84.6% and 69.2%, respectively. The primary assisted patency rates were 100%, 84.6% and 76.9%, respectively, and the secondary patency rates were 100%, 84.6% and 76.9%, respectively.

Conclusions

This study demonstrates that recanalization of chronic total occlusions to the RBV using a transseptal needle is a safe and effective method after traditional guide wire and catheter techniques fail. It was also found that additional techniques are needed for recanalization in patients with RBV occlusion combined with proximal stenosis or occlusion of the right subclavian vein.

Superior vena cava syndrome

The superior vena cava syndrome (SVCS) is caused by compression, invasion, and/or thrombosis of the superior vena cava and/or the brachiocephalic veins. Benign SVCS is separated from malignant SVCS. SVCS comprises a broad clinical spectrum reaching from asymptomatic cases to rare life-threatening emergencies with upper airway obstruction and increased intracranial pressure. Symptoms are correlated to the acuity and extent of the venous obstruction and inversely correlated to the development of the venous collateral circuits. Imaging is necessary to determine the exact underlying cause and to guide further interventions. Interventional therapy has widely changed the therapeutic approach in symptomatic patients. This article provides an overview over this complex syndrome and focuses on interventional therapeutic methods and results.

Multicenter Experience with the Surfacer Inside-Out Access Catheter System in Patients with Thoracic Venous Obstruction: Results from the SAVE Registry

PURPOSE

To report the device performance and safety for the Surfacer Inside-Out access catheter system in patients with thoracic central venous obstruction (TCVO) requiring central venous access (CVA).

MATERIALS AND METHODS

Five sites prospectively enrolled 30 patients requiring a tunneled dialysis catheter between February 2017 and September 2018 in the SAVE (Surfacer System to Facilitate Access in Venous Obstructions) registry. Patient demographics, medical history, and type of TCVO were documented at enrollment. Device performance and adverse events were collected during the procedure and upon hospital discharge. Twenty-nine of the 30 patients enrolled required CVA for hemodialysis. Retrospective classification of TCVOs according to SIR reporting standards showed 9 patients (30%) had Type 4 obstructions, 8 (26.7%) had Type 3, 5 (16.7%) had Type 2, and 8 (26.7%) had Type 1 obstruction.

RESULTS

Central venous catheters (CVCs) were successfully placed in 29 of 30 patients (96.7%). The procedure was discontinued in 1 patient due to vascular anatomical tortuosity. All 29 patients with successful CVC placement achieved adequate catheter patency and tip positioning. There were no device-related adverse events, catheter malposition, or intra- or postprocedural complications. Mean time from device insertion to removal for the 29 patients who successfully completed the procedure was 24 ± 14.9 (range, 6-70) minutes. Mean fluoroscopy time was 6.8 ± 4.5 (range, 2.2-25.5) minutes.

CONCLUSIONS

The Surfacer Inside-Out procedure provided an alternative option to restore right-sided CVA in patients with TCVO.

Overview of the safety and efficacy of the Surfacer® Inside-Out® Access Catheter System for obtaining central venous access in patients with thoracic central venous obstructions

INTRODUCTION

The development of thoracic central venous obstruction (TCVO) leads to narrowing of the vessel lumen which impacts blood flow and the placement of central venous access. The most common cause of TCVO is central venous catheters (CVCs) which can induce intravascular scarring or endoluminal obstruction via thrombus formation.

AREAS COVERED

The Surfacer® System is used to obtain central venous access (CVA) in patients with TCVO by facilitating catheter insertion via the novel Inside-Out® approach. This review summarizes the results of clinical studies to date with the Surfacer System, focusing on how the procedure is performed, clinical efficacy and safety of the device and patient populations where the device offers substantial clinical benefit.

EXPERT OPINION

The Surfacer System offers a safe and effective approach to reliably preserve and restore critical upper body vascular access sites. For dialysis patients, the device offers an alternative which avoids placement of dialysis catheters in veins which may impact the ability to achieve maturation of hemodialysis vascular access or in locations which have an increased risk of insertion-related complications or are associated with higher morbidity.

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.

Delayed pericardial tamponade following central venous recanalization

A patient with central venous occlusion at the junction of the superior vena cava and right atrium underwent endovascular revascularization. The leakage of contrast agents was detected during sharp recanalization that was then managed with covered stent deployment. The initial symptom of facial swelling disappeared and the vital signs were stable after treatment. Regrettably, the patient suffered from the clinical features of cardiac tamponade on the third day post-treatment, which was confirmed by computed tomography. Finally, a pericardial effusion was drained, leading to dramatic improvement in the cardiovascular status of the patient.

Efficacy and safety associated with the use of the Surfacer® Inside-Out® Access Catheter System: Results from a prospective, multicenter Food and Drug Administration-approved Investigational Device Exemption study

Purpose:

Thoracic central venous obstruction is commonly associated with the use of central venous catheters. The Surfacer System to Facilitate Access in Venous Occlusions Study was an Food and Drug Administration–approved US Investigational Device Exemption study designed to evaluate the performance and safety of the Surfacer System when used to facilitate central venous access in patients with thoracic central venous obstruction.

Methods:

Thirty patients were enrolled in this prospective, multicenter, single-arm study between December 2017 and May 2019. Device performance and adverse events were collected peri-procedurally and at discharge. Enrollment included 15 female and 15 male subjects with a mean age of 55.5 ± 12.9 (range: 30–79) years. Twenty-eight patients (93.3%) required central venous access for hemodialysis access. Locations of thoracic central venous obstruction were graded from 1 to 4 based on severity and extension of venous occlusions. Seven patients (23.3%) had type 1, 6 (20.0%) type 2, 16 (53.3%) type 3, and 1 (3.3%) type 4 obstruction.

Results:

Successful central venous catheter placement was achieved in 27 of 30 patients (90.0%). The procedure was discontinued in three (10.0%) due to tortuous anatomy discovered intraprocedurally. All 27 patients with successful CVC placement achieved adequate catheter patency and tip positioning with a mean overall procedural time and time to achieve central venous access with the Surfacer System being 44.1 ± 30.6 and 19.1 ± 25.1 min, respectively. There were no device-related adverse events or catheter malposition.

Conclusion:

The results of the SAVEUS Study confirm the safety and efficacy of the Surfacer System and the Inside-Out procedure when used for the placement of right-sided central venous access in patients with thoracic central venous obstruction.

Sharp recanalization of the brachiocephalic vein occlusion through the external jugular vein in hemodialysis patients

Background

Although the internal jugular vein (IJV) is the most widely used puncture site in hemodialysis catheter insertion and central vein angioplasty, the external jugular vein (EJV) offers an alternative vascular access point in cases when the IJV is inaccessible. The present study aims to observe the efficacy and safety of sharp recanalization of the brachiocephalic vein occlusion through the EJV in hemodialysis patients.

Methods

This retrospective study enrolled a cohort of hemodialysis patients who received sharp recanalization of occlusive brachiocephalic vein through the EJV at a university-affiliated hospital between January 2017 and January 2019. The demographic information and clinical outcome data of the patients were collected and analyzed.

Results

A total of 16 hemodialysis patients who received right brachiocephalic vein sharp recanalization through the EJV were analyzed. The technical success rate was 100%. Twelve patients (12/16, 75%), whose EJV-subclavian vein angle (E-S angle) was 60–80 degrees, were successfully recanalized on the first attempt. With the other 4 patients (4/16, 25%), whose E-S angle approached 90 degrees, the brachiocephalic vein was recanalized on the second attempt by elevating the ipsilateral shoulder, therefore decreasing the E-S angle to align the course of the EJV with the brachiocephalic vein. Three minor complications were recorded, including 1 patient with blood continuously oozing from the EJV at the puncture site and 2 patients with mild chest pain. After an average of 10 months of follow-up, the clinical patent rate was 81.25% with no procedure-related complications reported.

Conclusions

Sharp recanalization through the EJV could be an effective and safe alternative treatment for right brachiocephalic vein occlusion in hemodialysis patients if performed by an experienced practitioner. Measuring the angle formed by the EJV and the subclavian vein might provide helpful information for selecting patients.

Intraprocedural guidance for recanalization of post-thrombotic venous lesions using live overlay of center lines from pre-operative cross-sectional imaging: a preliminary experience

Purpose

Pre-procedural contrast-enhanced CT and MRI imaging is typically acquired prior to deep venous recanalization procedures for post-thrombotic syndrome. This technical note reports the utility of live-overlay of augmented centerlines extracted from pre-procedural CT and MRI imaging in facilitating fluoroscopic-guided recanalization of post-thrombotic venous lesions.

Methods and materials

Six patients with pre-procedural CT or MR venography data were incorporated into a commercially available 3D overlay software (Vessel Assist, GE Healthcare, Buc, France) during venous disease interventions for post-thrombotic venous lesions. Procedures were performed on the GE Discovery IGS 740 fluoroscopy system. After manual determination of the vasculature from preprocedural CT or MR, centerlines were created representing the location and trajectory of the vessels. Steps showcasing the creation of centerlines and their representation during overlay with real-time fluoroscopic guidance in these cases are outlined. Time required to cross the post-thrombotic and occlusive venous segments were reviewed.

Results

All iliocaval recanalization procedures were successfully performed utilizing vessel centerline 3D overlay. In one case where occlusion extended to the femoral vein, mis-registration was identified over the femoral anatomy due to a complex leg rotation compared to pre-procedural imaging. No procedural complications related to utilization of software were noted. Average crossing time for occlusions was 3.4 min (range 1.6–5.2).

Conclusion

3D overlay with vessel tracking from pre-procedural CT and MRI imaging is technically feasible and assists in catheter navigation for post-thrombotic venous segments. While results from these preliminary experiences support the continued use of this technology, further prospective and comparative evaluation of this technique is warranted to assess for added value in technical success, reductions in procedure time or reductions in radiation exposure.

Thoracic Central Vein Occlusion in the Dialysis Patient: An Interventional Perspective

Thoracic central venous occlusion in hemodialysis patients can cause significant disability from arm and facial swelling and can lead to worsening function of dialysis access. Current techniques for managing thoracic central venous occlusion and some of the newer techniques for achieving dialysis access when all central veins are occluded. Techniques for dealing with acute superior vena cava thrombosis will also be covered as will the complications of central venous recanalization techniques.

A novel technique to restore access in patients with central venous occlusion using the Surfacer® Inside-Out® Access Catheter System

Exhausted central venous access is a potentially life-threatening situation for patients dependent on haemodialysis. If standard guidewire recanalisation fails, unconventional venous access or central venous needle recanalisation can be considered but are often associated with higher rates of complications and/or dysfunction. Here, we report about two patients treated successfully with the Surfacer^® Inside-Out^® Access Catheter System (Bluegrass Vascular Technologies, San Antonio, TX, USA) to achieve transmediastinal central venous access.

The Surfacer® Inside-Out® Access System for right-sided catheter placement in dialysis patients with thoracic venous obstruction

Purpose:

Thoracic central venous obstruction is a common clinical complication in dialysis patients utilizing hemodialysis catheters. Thoracic central venous obstruction can lead to inability to utilize affected veins for catheter placement and sequential use of less preferred alternative venous access sites. The latter can affect the ability to create and/or mature permanent arteriovenous access and contribute to the future loss of thoracic veins for venous access. While alternative procedures exist for gaining venous access in patients who have exhausted routine venous access options, these procedures are complex, time-consuming, and associated with high patient risk. The Surfacer System provides a new approach in patients with right-sided thoracic central venous obstruction, enabling the ability to establish repeated access from the right side of the neck to the right atrium.

Methods:

We describe the use of the Surfacer System to facilitate placement of hemodialysis catheters in a series of nine patients with thoracic central venous obstruction involving one or more central veins. Patient characteristics and procedure-related outcomes were recorded for all patients.

Results:

Central venous access was successfully achieved in eight of nine patients using the Surfacer System. Significant venous tortuosity resulted in the inability to achieve venous access in one patient and prolonged procedural time to achieve access in another patient. The mean time required for Surfacer-related procedural steps and associated fluoroscopy time in the remaining seven patients was 13.3 and 3.7 min, respectively.

Conclusion:

The Surfacer System provides an efficient low-complexity alternative for gaining repeated right-sided central venous access in hemodialysis patients with obstructed thoracic veins.

Evidence-Based Strategies and Recommendations for Preservation of Central Venous Access in Children

Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.

A Fine Needle Recanalization Technique for Iliac Artery Occlusions in Endovascular Surgery

BACKGROUND

Endovascular intervention for chronic total occlusions (CTOs) in aortoiliac occlusive disease (AIOD) poses technical challenges. In this manuscript, our experience of fine needle recanalization for the treatment of iliac artery CTO is described.

METHOD

A prospective database recorded treatment of 11 limbs in 11 patients since 2011 using this technique. The majority of these CTO were of the common iliac artery (n = 9).

RESULTS

Technical success rate was 91% (n = 10). One failed case was due to tortuous iliac anatomy. There was no restenosis of the treated segments at 8 weeks and no major complications, perforations, major limb loss, or periprocedural mortality.

CONCLUSIONS

This technique is a safe and viable adjunct for difficult CTO in AIOD with suitable anatomy. It benefits from being a simple, low-profile, low-cost coaxial system and should be part of the armamentarium with other advanced endovascular techniques.