An occult cause of arteriovenous access failure: central vein stenosis from permanent pacemaker wire. Report of three cases and review of the literature

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.

A surgical method to be reminded for the treatment of symptomatic ipsilateral central venous occlusions in patients with hemodialysis access: Axillo-axillary venous bypass case report and review of the literature

BACKGROUND

In this case report, we present two chronic hemodialysis patients with upper extremity swelling due to central venous occlusions together with their clinical presentation, surgical management and brief review of the literature.

METHODS

The first patient who was a 63-year-old female patient with a history of multiple bilateral arteriovenous fistulas (AVFs) was referred to our clinic. Physical examination demonstrated a functioning right brachio-cephalic AVF, with severe edema of the right arm, dilated venous collaterals, facial edema, and unilateral breast enlargement. In her history, multiple ipsilateral subclavian venous catheterizations were present for sustaining temporary hemodialysis access. The second patient was a 47-year-old male with a history of failed renal transplant, CABG surgery, multiple AV fistula procedures from both extremities, leg amputation caused by peripheral arterial disease, and decreased myocardial functions. He was receiving 3/7 hemodialysis and admitted to our clinic with right arm edema, accompanied by pain, stiffness, and skin hyperpigmentation symptoms ipsilateral to a functioning brachio-basilic AVF. He was not able to flex his arms, elbow, or wrist due to severe edema.

RESULTS

Venography revealed right subclavian vein stenosis with patent contralateral central veins in the first patient. She underwent percutaneous transluminal angioplasty (PTA) twice with subsequent re-occlusions. After failed attempts of PTA, the patient was scheduled for axillo-axillary venous bypass in order to preserve the AV access function. In second patient, venography revealed right subclavian vein occlusion caused secondary to the subclavian venous catheters. Previous attempts for percutaneously crossing the chronic subclavian lesion failed multiple times by different centers. Hence, the patient was scheduled for axillo-axillary venous bypass surgery.

CONCLUSION

In case of chronic venous occlusions, endovascular procedures may be ineffective. Since preserving the vascular access function is crucial in this particular patient population, venous bypass procedures should be kept in mind as an alternative for central venous reconstruction, before deciding on ligation and relocation of the AVF.

Pulsatile tinnitus as a presenting symptom of central venous stenosis secondary to an ipsilateral upper arm arteriovenous PTFE graft

A 51-year-old man presented with a swollen left arm and unilateral pulsatile tinnitus 2 weeks after a left upper arm polytetrafluoroethylene graft was created for haemodialysis access. A fistulogram of the left upper arm showed a central venous stenosis and significant retrograde flow up the left internal jugular vein. Percutaneous transluminal angioplasty was attempted unsuccessfully and fistula ligation was subsequently performed. This led to immediate resolution of the tinnitus. The venous stenosis was likely secondary to a cardiac resynchronisation therapy defibrillator, which had been removed 1 year previously. Central venous stenosis is a common but often asymptomatic complication of a cardiac device, with the exception of patients with upper extremity arteriovenous fistulas, who frequently develop symptomatic venous hypertension. This generally presents with ipsilateral arm swelling and/or high venous pressures during dialysis. To our knowledge, this is the first report of pulsatile tinnitus arising in this context.

Central Venous Stenosis after Hemodialysis: Case Reports and Relationships to Catheters and Cardiac Implantable Devices

The appropriate vascular access for hemodialysis in patients with cardiac implantable electronic devices (CIED) is undefined. We describe two cases of end-stage renal disease patients with CIED and tunneled central venous catheter (CVC) who developed venous cava stenosis: (1) a 70-year-old man with sinus node disease and pacemaker in 2013, CVC, and a Brescia-Cimino forearm fistula in 2015; (2) a 75-year-old woman with previous ventricular arrhythmia with implanted defibrillator in 2014 and CVC in 2016. In either case, after about 1 year from CVC insertion, patients developed superior vena cava (SVC) syndrome due to stenosis diagnosed by axial computerized tomography. In case 1, the patient was not treated by angioplasty of SVC and removed CVC with partial resolving of symptoms. In case 2, a percutaneous transluminal angioplasty with placement of a new CVC was required. To analyze these reports in the context of available literature, we systematically reviewed studies that have analyzed the presence of central venous stenosis associated with the simultaneous presence of CIED and CVC. Five studies were found; two indicated an increased incidence of central venous stenosis, while three did not find any association. While more studies are definitely needed, we suggest that these patients may benefit from epicardial cardiac devices and the insertion of devices directly into the ventriculus. If the new devices are unavailable or contraindicated, peritoneal dialysis or intensive conservative treatment in older patients may be proposed as alternative options.

Venous Obstruction in Cardiac Rhythm Device Therapy

PURPOSE OF REVIEW

A variety of complex vascular pathologies arise following the implantation of electronic cardiac devices. Pacemaker and defibrillator lead insertion may cause proximal venous obstruction, resulting in symptomatic venous congestion and the compromise of potential future access sites for cardiac rhythm lead management.

RECENT FINDINGS

Various innovative techniques to recanalize the vein and establish alternate venous access have been pioneered over the past few years. A collaborative team of electrophysiologists and vascular specialists strategically integrate the patient's vascular disease into the planning of electrophysiology procedures. When vascular complications occur after device implantation, the same team effectively manages both the resulting vascular sequelae and related cardiac rhythm device challenges. This review will outline the various vascular challenges related to device therapy and offer an effective strategy for their management.

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.

Cardiovascular implantable electronic devices in hemodialysis patients: prevalence and implications for arteriovenous hemodialysis access interventions

Cardiovascular implantable electronic devices (CIEDs) are frequently utilized in hemodialysis patients. CIED leads are typically implanted via the subclavian vein resulting in stenosis and venous hypertension. We studied 1235 chronic hemodialysis patients under the care of our nephrology practice. For each, we determined the presence of a CIED, indication for implantable cardioverter-defibrillator (ICD), and type of hemodialysis access. Records were reviewed to identify all interventions performed on the access circuit and the central veins specifically. A CIED was present in 129 patients (10.5%), including ICDs in 75 (6.1%) and pacemakers in 54 (4.4%). The access circuit intervention rate was 1.48/access year (AY) and was similar when a CIED was ipsilateral (1.53/AY) or contralateral (1.44/AY) to arteriovenous access (p = 0.477). The rate of central venous interventions was greater in the ipsilateral (0.59/AY) versus contralateral group (0.28/AY), (p < 0.001). Fifty-four of 59 patients with ipsilateral access and CIED required <2 interventions per AY, but six failed angioplasty and required access ligation. None had superior vena cava stenosis requiring intervention. We conclude that there is a high prevalence of CIEDs in our HD patients. Ipsilateral CIED and arteriovenous access results in higher central venous intervention rates compared with contralateral cases; overall access circuit intervention rates are similar.

Extending the longevity of a complicated arteriovenous fistula using endovascular intervention

A brachiocephalic arteriovenous fistula was complicated by a central venous stenosis, which could not be relieved. A cephalojugular bypass was performed using an interpositoned graft, which later developed tight stenoses at both ends of the graft. This was successfully treated with endovascular intervention, extending the longevity of the vascular access.

Central vein stenosis

Central vein stenosis (CVS) is commonly seen in patients receiving hemodialysis through an arteriovenous access, threatening the usability of arteriovenous access for dialysis. Subclavian and internal jugular catheters are prime reasons for the development of CVS, especially in the setting of long-term use of multiple catheters. CVS related to cardiac rhythm devices also is seen frequently. Idiopathic CVS can be encountered, although it is less common. Clinical features ultimately become sufficiently prominent to prompt angiographic evaluation. CVS should be evaluated carefully because management must be individualized. The primary method for treatment of CVS is endovascular intervention, including angioplasty and stent placement, whereas surgical options should be pursued in only refractory cases due to the invasiveness of the intervention. Early referral of patients for chronic kidney disease care; timely discussion of kidney replacement modality choices, including nonhemodialysis options such as peritoneal dialysis and kidney transplantation; placement of arteriovenous access prior to the onset of dialysis; and avoidance of catheters and other central vein instrumentation will prevent the development of CVS in most patients with kidney disease.

Central venous disease in hemodialysis patients: an update

Central venous occlusive disease (CVD) is a common concern among the hemodialysis patient population, with the potential to cause significant morbidity. Endovascular management of CVD, comprising percutaneous balloon angioplasty and bare-metal stenting, has been established as a safe alternative to open surgical treatment. However, these available treatments have poor long-term patency, requiring close surveillance and multiple repeat interventions. Recently, covered stents have been proposed and their efficacy assessed for the treatment of recalcitrant central venous stenosis and obstruction. Moreover, newly proposed algorithms for the surgical management of CVD warrant consideration. Here, we seek to provide an updated review of the current literature on the various treatment modalities for CVD.

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.

Central venous disease in hemodialysis patients: prevalence, etiology and treatment

A common problem in the management of hemodialysis patients is central venous occlusive disease. There has been extensive literature on the treatment of this important and prevalent problem. Treatment options to date include percutaneous balloon angioplasty, bare metal stents and surgical bypass. Unfortunately, all the available treatment options have poor long-term patency, requiring repetitive intervention. More recently, covered stents have been mentioned in the literature for the treatment of central venous stenosis and obstruction. There is very little data to date on this technology, and further randomized controlled trials will be needed to compare the efficacy of percutaneous balloon angioplasty, bare metal stents and covered stents. It appears prevention of this difficult problem is paramount, by limiting venous access or intervention of the central venous system.

Review of central venous disease in hemodialysis patients

A common problem in the management of patients who are undergoing hemodialysis is central venous occlusive disease. There has been extensive literature on the treatment of this important and prevalent problem. Treatment options to date include percutaneous balloon angioplasty, bare metal stents, and surgical bypass. Unfortunately, all the available treatment options have poor long-term patency, requiring repeated interventions. More recently, covered stents have been mentioned in the literature for the treatment of central venous stenosis and obstruction. There are very few data to date on this technology, and further randomized controlled trials will be needed to compare the efficacy of percutaneous balloon angioplasty, bare metal stents, and covered stents. It appears that it is of paramount importance to prevent this difficult problem by limiting access to, or intervention in, the central venous system.

Limited venous access and pacemaker insertion in a haemodialysis patient: case report

The population of haemodialysis patients is increasing as is their age. There is a higher risk of cardiac comorbidities in these patients. Pacing is increasingly common in this group. We present a case highlighting the difficult issues and exemplifies the need for careful planning preprocedure. Haemodialysis patients often have difficult and limited vascular access. Insertion of pacing leads is associated with subclavian vein stenosis. If this is on the side of an AV fistula there is significant risk of losing the fistula with obvious consequences to the patient. Careful consideration of site and route of access needs to be made prior to pacing. The need for involvement of renal and vascular teams before starting the procedure is essential as it is paramount that the best route of access for pacing wires is selected.

Patency rates for angioplasty in the treatment of pacemaker-induced central venous stenosis in hemodialysis patients: results of a multi-center study

While hemodialysis access ligation has been used to manage pacemaker (PM) and implantable cardioverter-defibrillator (ICD) lead-induced central venous stenosis (CVS), percutaneous transluminal balloon angioplasty (PTA) has also been employed to manage this complication. The advantages of PTA include minimal invasiveness and preservation of arteriovenous access for hemodialysis therapy. In this multi-center study we report the patency rates for PTA to manage lead-induced CVS. Consecutive PM/ICD chronic hemodialysis patients with an arteriovenous access referred for signs and symptoms of CVS due to lead-induced CVS were included in this analysis. PTA was performed using the standard technique. Technical and clinical success was examined. Technical success was defined as the ability to successfully perform the procedure. Clinical success was defined as the ability to achieve amelioration of the signs and symptoms of CVS. Both primary and secondary patency rates were also analyzed. Twenty-eight consecutive patients underwent PTA procedure. Technical success was 95%. Postprocedure clinical success was achieved in 100% of the cases where the procedure was successful. The primary patency rates were 18% and 9% at 6 and 12 months, respectively. The secondary patency rates were 95%, 86%, and 73% at 6, 12, and 24 months, respectively. On average, 2.1 procedures/year were required to maintain secondary patency. There were no procedure-related complications. This study finds PTA to be a viable option in the management of PM/ICD lead-induced CVS. Additional studies with appropriate design and sample size are required to conclusively establish the role of PTA in the management of this problem.

Central vein stenosis: current concepts

Central vein stenosis (CVS) is a common complication of the central venous catheter (CVC) placement. The prevalence of CVS has mostly been studied in those who present with symptoms such as swelling of the extremity, neck and breast. CVS compromises arteriovenous access and can be resistant to treatment. A previous history of CVC placement is the most important risk factor for the development of CVS later. Pacemaker and defibrillator wires are associated with a high incidence of CVS. Increasingly liberal use of peripherally inserted central catheters (PICC) is likely to increase the incidence of CVS. The trauma and inflammation related to the catheter placement is thought to result in microthrombi formation, intimal hyperplasia and fibrotic response, with development of CVS. Treatment of CVS by endovascular procedures involves angioplasty of the stenosis. An elastic or recurrent stenosis may require a stent placement. The long-term benefits of the endovascular procedures, although improved with newer technology, remain modest. Surgical options are usually limited. Future studies to explore the pathogenesis and the use of novel therapies to prevent and treat CVS are needed. The key to reducing the prevalence of CVS is in reducing CVC placement and placement of arteriovenous accesses prior to initiating dialysis. Early referral of the patients to the nephrologists by the primary care physicians is important. Timely vein mapping and referral to the surgeon for fistula creation can obviate the need for a CVC and decrease incidence of CVS.

Central venous obstruction management

A major challenge in the management of hemodialysis patients is central venous stenosis and obstruction. Placement of central venous catheters has been shown to result in a high incidence of central venous stenosis or obstruction. There has been extensive literature on the treatment of this important and prevalent problem. Treatment options include percutaneous balloon angioplasty and bare metal stents. Unfortunately, all the available treatment options have variable rates of patency, requiring repeated intervention. More recently, covered stents have been mentioned in the literature for the treatment of central venous stenosis and obstruction. There is very little data to date, and further randomized controlled trials will be needed to compare the efficacy of percutaneous balloon angioplasty, bare metal stents, and covered stents. It appears prevention of this difficult problem is paramount, by limiting use of central venous catheters.

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.

Central vein obstruction in vascular access

Central venous obstruction has become a major problem because of the frequent need for central venous catheters in haemodialysis patients. This article discusses the epidemiology and clinical features of central venous obstruction and the different surgical and interventional alternatives for its treatment.

Tunneled double-lumen silicone hemodialysis catheter placement in three patients with permanent pacemaker wires: a case study

Permanent pacemaker wires have been described as a cause of central vein stenosis. Furthermore, in hemodialysis (HD) patients with transvenous pacemakers, permanent vascular access (VA) created at the ipsilateral arm is not always successful. We report the use of tunneled double-lumen silicone HD catheters, as permanent VA in three HD patients wearing permanent transvenous pacemakers. In one patient, the catheter was inserted ipsilateral to the pacemaker site. Catheter-related infections were the most significant complications.

Symptomatic subclavian vein stenosis and occlusion in hemodialysis patients with transvenous pacemakers

The objective of this study was to determine the incidence and timing of complications associated with ipsilateral transvenous pacemakers and hemodialysis access, including subclavian vein stenosis and occlusion, and assess their impact on dialysis access patency. All patients who had pacemakers placed at St. Francis Medical Center were reviewed during the 10-year period from 1988 to 1998. Patients requiring chronic hemodialysis were identified and their demographic data, the presence of arm swelling, and fistula patency were noted. Development of subclavian vein stenosis and occlusion was documented by venography in symptomatic patients. The ultimate outcome of dialysis access was recorded. During the 10-year period 495 patients had transvenous pacemakers placed. Twenty patients were identified with renal failure requiring hemodialysis and 14 had hemodialysis access in the extremity ipsilateral to the pacemaker. Ten (10/14, 71%) patients developed symptoms of subclavian stenosis, including venous hypertension, high recirculation rate, arm swelling, pain, and neurologic symptoms. Eighty percent (8/10) of symptomatic patients had subclavian vein occlusion. All 10 symptomatic patients required ligation of the hemodialysis access to control symptoms. The four asymptomatic patients expired within 6 months of placement of the pacemaker or hemodialysis access from unrelated causes. There is a high incidence of complications in patients who have ipsilateral pacemakers and hemodialysis access. The presence of pacemaker electrodes in the subclavian vein and the flow associated with hemodialysis may accelerate the occurrence of subclavian venous stenosis and occlusion. Patients who did not develop symptoms may have expired before venous outflow obstruction could develop. Vascular surgeons and cardiac surgeons/cardiologists need to coordinate their procedures to avoid ipsilateral transvenous pacemakers and hemodialysis access.

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.