Central venous occlusion in hemodialysis access: Comparison between percutaneous transluminal angioplasty alone and nitinol or stainless-steel stent placement

A Systematic Review and Meta-analysis of 24 Month Patency After Endovenous Stenting of Superior Vena Cava, Subclavian, and Brachiocephalic Vein Stenosis

OBJECTIVE

This systematic review and meta-analysis aimed to appraise recent evidence assessing patency outcomes at various time points in patients with superior vena cava, subclavian, and brachiocephalic vein stenosis who had undergone stenting.

DATA SOURCES

PubMed, Scopus, and Cochrane Library databases were searched for studies up to December 2022.

REVIEW METHODS

Measured outcomes included technical success rate, primary, primary assisted, and secondary patency at various time points. A subgroup analysis was also conducted to compare malignant and benign obstruction. GRADE was used to assess the certainty of evidence.

RESULTS

Thirty nine studies reporting outcomes in 1 539 patients were included in the meta-analysis. Primary patency up to one year after the procedure was 81.5% (95% CI 74.5 - 86.9%). Primary patency declined after one year to 63.2% (95% CI 51.9 - 73.1%) at 12 - 24 months. Primary assisted patency and secondary patency at ≥ 24 months were 72.7% (95% CI 49.1 - 88.0%) and 76.6% (95% CI 51.1 - 91.1%). In the subgroup analysis, primary patency was significantly higher in patients with a malignant stenosis compared with a benign stenosis at 1 - 3 and 12 - 24 months. No significant difference was seen for pooled secondary patency rates when comparing the malignant and benign subgroups. GRADE analysis determined the certainty of evidence for all outcomes to be very low.

CONCLUSION

Stenting is an effective intervention for benign and malignant stenosis of the superior vena cava, subclavian, and brachiocephalic veins. Primary patency rates were good up to one year after the procedure, with 81.5% of stents retaining patency at 6 - 12 months. Patency rates declined after one year, to 63.2% primary and 89.3% secondary patency at 12 - 24 months, showing improved outcomes following re-intervention. High quality evidence is lacking. More research is needed to investigate patency outcomes and the need for surveillance or re-intervention programs.

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.

Hybrid venous recanalization and cardiac implantable electronic device lead revision procedures: A single-center retrospective analysis of 38 patients

PURPOSE

The purpose of this study was to describe the safety and efficacy of hybrid recanalization procedures in a series of patients with obstructed central veins requiring cardiac implantable electronic device (CIED) revision.

METHODS

Between 2008 and 2016, 38 consecutive patients (24 M; age 60.5 ± 16.2 years; range 25-87 years) with central venous obstruction underwent 42 recanalization interventions performed in conjunction with CIED revision or extraction. Fifty percent of patients (19/38) presented with veno-occlusive symptoms, and 13% (5/38) of patients had CIED leads with an ipsilateral upper extremity dialysis conduit.

RESULTS

Ninety-one percent (38/42) of all procedures resulted in successful recanalization and CIED revision. Twenty-four percent (9/38) of all patients required secondary procedures due to recurrent stenosis, and 78% (7/9) of those requiring secondary procedures had indwelling dialysis conduits and/or clinical symptoms related to venous occlusion before the initial procedure. There were complications in 2 patients related to recanalization, and in 3 related to CIED revision.

CONCLUSIONS

Recanalization of central venous stenosis/occlusion in patients with CIED can be technically challenging but is successful in most patients. Symptomatic patients and those with dialysis conduits often require more aggressive revascularization interventions and may be at increased risk of complication or need for secondary interventions.