Central vein obstruction in vascular access

Numerical modelling of the interaction between dialysis catheter, vascular vessel and blood considering elastic structural deformation

The dialysis catheter indwelling in human bodies has a high risk of inducing thrombus and stenosis. Biomechanical research showed that such physiological complications are triggered by the wall shear stress of the vascular vessel. This study aimed to assess the impact of CVC implantation on central venous haemodynamics and the potential alterations in the haemodynamic environment related to thrombus development. The SVC structure was built from the images from computed tomography. The blood flow was calculated using the Carreau model, and the fluid domain was determined by CFD. The vascular wall and the CVC were computed using FEA. The elastic interaction between the vessel wall and the flow field was considered using FSI simulation. With consideration of the effect of coupling, it was shown that the catheter vibrated in the vascular systems due to the periodic variation of blood pressure, with an amplitude of up to 10% of the vessel width. Spiral flow was observed along the catheter after CVC indwelling, and recirculation flow appeared near the catheter tip. High OSI and WSS regions occurred at the catheter tip and the vascular junction. The arterial lumen tip had a larger effect on the WSS and OSI values on the vascular wall. Considering FSI simulation, the movement of the catheter inside the blood flow was simulated in the deformable vessel. After CVC indwelling, spiral flow and recirculation flow were observed near the regions with high WSS and OSI values.

Management of thoracic outlet syndrome in patients with hemodialysis access

Patients with threatened arteriovenous access are often found to have central venous stenoses at the ipsilateral costoclavicular junction, which may be resistant to endovascular intervention. Stenoses in this location may not resolve unless surgical decompression of thoracic outlet is performed to relieve the extrinsic compression on the subclavian vein. The authors reviewed the management of dialysis patients with central venous lesions at the thoracic outlet, as well as the role of surgical decompression with first-rib resection or claviculectomy for salvage of threatened, ipsilateral dialysis access.

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.

Comparison of supraclavicular brachiocephalic and femoral vein approaches for tunneled dialysis catheter placement in patients with thrombosed internal jugular veins

INTRODUCTION

There is still debate on the best access route in case of bilateral internal jugular vein thrombosis. We aimed to compare the safety, effectiveness, and outcomes of tunneled dialysis catheter placement via supraclavicular brachiocephalic and femoral vein approaches in patients with bilateral internal jugular vein thrombosis.

METHODS

Between January 2018 and December 2021, data of the patients in whom tunneled dialysis catheters were placed via the supraclavicular brachiocephalic vein (n = 42) and femoral vein (n = 57) approaches were extracted. Patient demographics, technical and clinical success rates, complications, and outcomes were noted. The Likert scale was used to assess patient satisfaction.

FINDINGS

Forty two (42.4%) patients were men, and the mean age was 61.9 (range, 12-93) years. The technical and clinical success rate was 100% for both groups. No major complication was encountered. The mean follow-up period was 497.5 (range, 32-1698) catheter days. Thirty-day patency was similar for the brachiocephalic vein and femoral vein group (40 [95.2%] vs. 55 [96.5%], p = 0.754). Also, primary and cumulative patency rates were comparable (p = 0.158; p = 0.660). The infection rate was 2.6 and 4.1 per 1000 catheter days for the brachiocephalic vein and femoral vein group. The infection-free survival was significantly higher in the brachiocephalic vein group (71.9% vs. 35.3% at 12 months, p < 0.001). Patient satisfaction was higher in the brachiocephalic vein group (median satisfaction, 5 vs. 4, p < 0.001).

DISCUSSION

Both supraclavicular brachiocephalic vein and femoral vein approaches have high technical and clinical success with comparable patency rates. However, low infection rate and high patient satisfaction make the supraclavicular brachiocephalic vein approach a reasonable alternative before proceeding to the femoral vein access.

Contemporary review of management techniques for cephalic arch stenosis in hemodialysis

The type of hemodialysis access and its preservation impact the quality of life and survival of patients undergoing hemodialysis. Vascular access complications are among the top causes of morbidity, hospitalization, and catheter use, with significant economic burden. Poor maturation and stenosis continue to be key impediments to upper arm arteriovenous fistula feasibility. Cephalic arch is a common location for vascular access dysfunction due to its distinctive anatomy, complex valves, and biochemical alterations attributable to renal failure. Understanding cephalic arch stenosis is critical due to its high prevalence and treatment failure. The appropriate management option is highly debatable and mostly dependent on patient characteristics and interventionist's preference. Current options include, percutaneous transluminal balloon angioplasty, stent grafts, bare metal stents, cutting balloon angioplasty, endovascular banding, and surgical procedures. This article discusses the etiologies of cephalic arch stenosis as well as currents trends in management including endovascular and surgical options.

Central vein stenosis in hemodialysis vascular access: clinical manifestations and contemporary management strategies

Central venous stenosis is a significant and frequently encountered problem in managing hemodialysis (HD) patients. Venous hypertension, often accompanied by severe symptoms, undermines the integrity of the hemodialysis access circuit. In central venous stenosis, dialysis through an arteriovenous fistula is usually inefficient, with high recirculation rates and prolonged bleeding after dialysis. Central vein stenosis is a known complication of indwelling intravascular and cardiac devices, such as peripherally inserted central catheters, long-term cuffed hemodialysis catheters, and pacemaker wires. Hence, preventing this challenging condition requires minimization of central venous catheter use. Endovascular interventions are the primary approach for treating central vein stenosis. Percutaneous angioplasty and stent placement may reestablish vascular function in cases of elastic and recurrent lesions. Currently, there is no consensus on the optimal treatment, as existing management approaches have a wide range of patency rates.

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.

Superficialization of dilated radial artery for vascular access: A case report

Successful hemodialysis treatment need a well functioning vascular access (VA) allowing two cannulation sites with enough blood flow have minimum adverse events. The expectations, age of the HD population are rising as well as the lack of conventional methods due to central venous exhaustion, we have to choose some complex access, including complex or tertiary vascular access mentioned in 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) and the option to abandon the venous circuit in instead of arterial system, including arterial-arterial graft and arterial superficialization. This article report a complicated case of AVF dysfunction, central venous stenosis due to central venous catheter and aortic dissection stent as well as lower extremity arteriosclerosis occlusion, using the simple method of superficialization of enlarged radial artery to maintain hemodialysis.

Venous thoracic outlet syndrome and hemodialysis

Central venous stenotic disease is reported in 7%-40% of patients needing a central venous catheter for dialysis and in 19%-41% of hemodialysis patients who have had a prior central venous catheter. Half of these patients will be asymptomatic. Venous Thoracic Outlet syndrome in hemodialysis (hdTOS) is part of this spectrum of disease. The extrinsic mechanical compression of the subclavian vein at the costoclavicular triangle between the clavicle and 1st rib results in an area of external compression with a predisposition to intrinsic mural disease in the vein. The enhanced flow induced by the presence of a distal arteriovenous access in all patients exacerbates the subclavian vein's response to ongoing extrinsic and intrinsic injury. Repeated endovascular interventions during the maintenance of vascular access accelerates chronic untreatable occlusion of the subclavian vein in the long term. Similar to patients with central venous stenosis, patients with hdTOS can present immediately after access formation with ipsilateral edema or longitudinally with episodes of access dysfunction. hdTOS can be treated in an escalating manner with arteriovenous access flow reduction to <1,500 ml/min, endovascular management, surgical decompression by first rib resection in healthy patients and medial clavicle resection in less healthy patients followed by secondary venous interventions, or finally, a venous bypass. hdTOS represents a complex and evolving therapeutic conundrum for the dialysis community, and additional clinical investigations to establish robust algorithms are required.

Post-acute sequelae of COVID-19 (PASC): a meta-narrative review of pathophysiology, prevalence, and management

Coronavirus Disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Over 220 countries and territories have been affected by this virus, and the infection rate has continued to rise. As patients recover from the virus, many are experiencing lingering symptoms. Understanding the impact of demographics and comorbidities on symptom prevalence, manifestations, and severity is not only relevant during acute infection, it is critical to the clinical management of patients with post-acute sequelae of COVID-19, also known as PASC. Herein, we provide a comprehensive review on the most recent research related to PASC. Specifically, we focus on the description of the disorder itself, compared to acute COVID-19, and which types of patients are most affected by long-term sequelae. Further, we share recommendations for management of the most common complications of PASC.

Internal jugular to internal jugular vein bypass of symptomatic central vein obstruction

INTRODUCTION

Central venous obstruction (CVO) often arises among hemodialysis patients with upper extremity access due to a varying number of risk factors. While the true incidence of CVO in hemodialysis patients is unknown, it been reported in the range of 20%-40% in dialysis patients undergoing venograms. In the non-hemodialysis population, chronic central vein obstruction has a compensatory mechanism comprised of numerous collaterals along the chest wall, neck, and mediastinum. However, the presence of an AVF or AVG ipsilateral to a central venous stenosis or occlusion can overwhelm the collateral network due to the significantly elevated blood flow. This may result in severe and debilitating upper extremity and fascial swelling. While ligation results in almost instantaneous symptomatic relief, it does not address the patient's underlying pathologic process and necessitates an additional access. As these patients continue to live longer, our strategies to manage these failing accesses are becoming increasingly complex. The goal of preserving existing access while correcting any symptoms is paramount. Previous case reports have documented various surgical options for preserving an existing access.

CASE PRESENTATION

Our patient is a 49-year-old female with hypertension and end-stage renal disease, on hemodialysis through a right arm arteriovenous (AV) fistula. She had a history of multiple AV fistulae creations in the past, all of which previously thrombosed. Several years after the creation of her most recent fistula, she developed severe throbbing headaches, right arm and facial swelling, right eye lacrimation, and blurry vision. AV fistula angiogram demonstrated right brachiocephalic vein chronic occlusion and endovascular revascularization through both trans-AVF and transfemoral approaches were attempted, but unsuccessful.

DISCUSSION

This case illustrates the success of the creation of an internal jugular-jugular vein bypass to maintain a right arm arteriovenous fistula, while at the same time, correcting the symptoms of a right brachiocephalic vein occlusion.

Brachio-azygos transthoracic arteriovenous grafts for hemodialysis patients with bilateral central venous obstruction: A small case series

BACKGROUND

It is difficult to find a reliable outflow vein for vascular access in hemodialysis patients with bilateral central venous obstruction. The lower extremity veins are currently used as the most common alternative veins to make a new vascular access. However, in patients not amenable to make lower extremity access, intrathoracic vein should be considered as an outflow vein, but there are limitations in its use due to postoperative complications.

METHODS

We introduce a series of cases that underwent arteriovenous graft operation using an intrathoracic vein, the azygos arch, as an outflow vein. Brachio-azygos transthoracic arteriovenous graft is a surgical procedure that anastomoses the azygos arch and the brachial artery with 7 mm ringed polytetrafluoroethylene graft via lateral thoracotomy without median sternotomy.

RESULTS

The chest tubes of the patients were removed on the third postoperative day and they discharged within a week. About 1 month later, hemodialysis was initiated through the BATAVG, and it has been used without access dysfunction.

CONCLUSION

Brachio-azygos transthoracic arteriovenous grafts were performed using the azygos arches without major complications. The azygos arch can be a good alternative outflow vein to make a new vascular access for hemodialysis patients with bilateral central venous obstruction.

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.

The arteriovenous access stage (AVAS) classification

Background

Key anatomical factors mean that individuals needing arteriovenous access are unique and have different possibilities for fistula creation. The aim of this article is to describe a new classification system for all patients needing haemodialysis vascular access in the upper extremity with the purpose to simplify sharing the information about suitability for surgical access creation depending on vascular anatomy.

Methods

According to the patient's vascular anatomy in right and left superior extremities, patients were separated into three arteriovenous access stages (AVAS). The AVAS was validated by three blinded observers using a sample of 70 upper limb arteriovenous maps that were performed using ultrasound on patients referred for vascular access assessment. A sample size calculation was performed and calculated that for three observers, a minimum of 67 maps were required to confirm significant agreement at a Kappa value of 0.9 (95% confidence interval 0.75-0.99).

Results

The Kappa value for inter-rater reliability using Fleiss' Kappa coefficient was 0.94 and all patients fitted into the AVAS classification system.

Conclusion

The AVAS classification system is a simplified way to share information about vascular access options based on a patient's vascular anatomy with high inter-rater reliability.

Lesion Type Analysis of Hemodialysis Patients Who Underwent Endovascular Management for Symptomatic Central Venous Disease

Purpose

Central venous lesions (CVLs) can adversely affect hemodialysis access maturation and maintenance, which in turn worsen patient morbidity and access circuit patency. In this study, we assessed several clinical variables, patient characteristics, and clinical consequences of symptomatic central vein stenosis and obstruction in patients who underwent renal replacement therapy in the form of hemodialysis.

Patients and Methods

The medical records of all hemodialysis patients with clinically symptomatic CVLs who underwent digital subtraction angiography treatment at King Abdullah University Hospital between January 2017 and December 2019 were retrieved. Patient characteristics and the clinical and anatomical features of CVLs were analyzed retrospectively. Pearson’s chi-square tests of association were used to identify and assess relationships between patient characteristics and CVLs.

Results

The study cohort comprised 66 patients with end-stage renal disease who developed symptomatic central vein stenosis. Of the 66 patients, 56.1% were men, and their mean age was approximately 52 years. Most (62.1%) of the patients were determined to have a history of central catheter insertion into the jugular vein. Hypertension was the most common comorbidity (78.8%, p<0.001), followed by type 2 diabetes mellitus (47.0 %, p<0.01). The incidence of stenosis was found to be significantly higher in the brachiocephalic vein than in other central veins (43.9%, p<0.001). A repeated central catheter insertion in a patient was predictive of central venous occlusion (p<0.05). Stenotic lesions were found to be associated with a significantly higher success rate than occlusive lesions (91.2%, p<0.01).

Conclusion

Multiple central venous catheters (CVCs) are found to be associated with occlusive CVLs and unfavorable recanalization outcomes. Multiple CVC should be avoided by creating a permanent vascular access in a timely fashion for patients with chronic kidney disease and by avoiding the ipsilateral insertion of CVC and AVF.

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.

Angiectasia of the parietal pleura in a hemodialysis patient with central venous stenosis and bloody pleural effusion: a case report

Pleural effusion in hospitalized patients with long-term hemodialysis (HD) has been frequently reported. The most common causes of unilateral pleural effusions include hypervolemia, parapneumonic, uremic effusion, and malignancy. In contrast, central venous stenosis (CVS) has rarely been shown to result in pleural effusion. CVS is often diagnosed by percutaneous angiography, yet there are no reports of cases where percutaneous angiography missed CVS and instead intrathoracic endoscopy was performed. Herein, we report a case of CVS with angiectasia of the parietal pleura detected on intrathoracic endoscopy. A 62-year-old man with HD presented with massive unilateral pleural effusion. Although the cause of pleural effusion was suspected to be CVS, percutaneous angiography did not show apparent stenosis, and as a result, other potential causes of bloody effusion were investigated. The intrapleural cavity was assessed using intrathoracic endoscopy, which revealed angiectasia and no malignancy. As these findings might be suggestive of congestive and dilated vessels with venous stenosis or occlusion, 3D-computed tomography (CT) scans were performed instead of percutaneous angiography to determine whether a stenosis or occlusion was present. Brachiocephalic vein stenosis was found near the aortic arch. CVS was treated through ligation of the arteriovenous fistula (AVF), resulting in a dramatic decrease in the left pleural effusion. This case would suggest that CVS should be suspected when angiectasia of the parietal pleura is observed in HD patients. In addition, the benefit of utilizing 3D-CT should be considered when HD patients present with a unilateral hemothorax on the same side as that of the AVF, particularly when on the left side.

An unusual cause of subacute airway obstruction in a hemodialysis patient with brachio-cephalic arteriovenous fistula: A rare presentation of central venous occlusion

A young lady with an arteriovenous (AV) fistula on hemodialysis was referred for surgical management following a failed endovascular approach to relieve central venous occlusion. She had an obstructed left brachiocephalic vein with a history of numerous central vein catheter placements. Alternative routes for new arteriovenous fistula creation had been exhausted due to previous contralateral upper limb fistula rupture and ligation. To the best of our knowledge, no similar cases of airway obstruction in central venous occlusion occurring in hemodialysis patients with AV fistula have been reported. The importance of identifying the possible emergency red flags in hemodialysis patients with central venous occlusion is important to prevent unwanted consequences.

Percutaneous Venous Interventions in The Pulmonary Vascular, Central and Peripheral Venous Systems: How to Recognize, Avoid and Treat Complications

Endovascular treatment of venous disease encompasses a broad range of interventions. Both central and peripheral venous interventions can range from the simple to the complex which increases the need for proper patient selection, procedural planning and technical proficiency. The following article will discuss the importance of avoiding, recognizing and addressing complications associated with venous interventions. Our goal is to raise awareness and educate to help the reader improve performance.

Transjugular percutaneous endovascular treatment of dysfunctional hemodialysis access

PURPOSE

To evaluate the feasibility and the outcomes of transjugular percutaneous endovascular treatment of dysfunctional hemodialysis access in patients with chronic kidney disease.

METHODS

A total of 50 transjugular treatments in 38 patients with arteriovenous fistulas or arteriovenous grafts from September 2011 to May 2015 were included in this study. Medical records and angiographies were retrospectively reviewed. Success rate, patency rate, procedure time, and complications including internal jugular vein stenosis were evaluated.

RESULTS

A total of 50 sessions of transjugular treatments were performed in 38 patients. There were 31 native arteriovenous fistulas including 10 immature cases and 19 arteriovenous grafts. Among the 50 cases, technical success was achieved in 45 and clinical success was achieved in 44; 37 cases (74%) with multiple stenotic sites were treated by the transjugular approach without placement of cross-sheaths. The mean time from puncture of the internal jugular vein to first fistulography was 10 min, and the mean total procedure time was 64 min. The primary patency rate at 6 months was 77%, while the secondary patency rate at 6 months was 97%. Perforation occurred in two cases during conventional percutaneous transluminal angioplasty after failure of the transjugular approach. One dissection occurred during the transjugular approach. There was no newly developed internal jugular vein stenosis during a mean follow-up period of 19.3 months.

CONCLUSION

For the treatment of dysfunctional or immature hemodialysis access, the transjugular approach is a feasible and effective option that avoids injury to the graft or draining vein, especially in immature fistulas.

Reduction mammoplasty as a treatment for symptomatic central venous stenosis

Central venous stenosis is a rare cause of unilateral breast edema occurring in hemodialysis patients that needs to be differentiated from other differential diagnoses, including, but not limited to, inflammatory breast carcinoma, mastitis, lymphedema, and congestive heart failure. All reports of similar cases in the available literature have described improvement or resolution of the edema after treatment. Herein, we report and discuss the pathophysiology of breast edema formation in a patient who presented with massive left-sided breast edema 7 years after being diagnosed with central venous stenosis. Medical and minimally invasive therapy had not been successful, so she underwent reduction mammoplasty to relieve the symptoms.

Radiological Central Vein Treatment in Vascular Access

In the last decades, the percutaneous interventional approach for the treatment of central venous obstructions (CVO) has become increasingly popular as the treatment of first choice because of its minimal invasiveness and reported success rates. CVOs are caused by a diverse spectrum of diseases which can be broadly categorized into two principal eliciting genera, either benign or malignant obstructions. The large group of benign venous obstructions includes the increasing number of end-stage renal disease patients with vascular access related complications. Due to the invasiveness and complexity of thoracic surgery for benign CVOs, the less invasive percutaneous interventional therapy can generally be considered the preferred treatment option. Initially, the radiological intervention consisted of balloon angioplasty alone, subsequently additional stent placement was applied. This was advocated as either primary placement or secondary in cases of elastic recoil or residual stenosis after percutaneous transluminal angioplasty (PTA). The efficacy of angioplasty of CVO in patients with vascular accesses, either with or without stenting, has been addressed by various studies. Overall, reports indicate an initial technical and clinical success rate above 95% and satisfactory patency rates. However, systematic follow-up and frequent re-interventions are necessary to maintain vascular patency to achieve long-term success.

Percutaneous intervention for symptomatic central vein stenosis in patients with upper limb arteriovenous dialysis access

Central venous stenosis is an important hindrance to long-term maintenance of arteriovenous access in the upper extremities in dialysis patients.

Aim

The present study was done to determine feasibility and clinical success of endovascular approach for the treatment of symptomatic central venous stenosis associated with significant ipsilateral limb edema in dialysis patients with vascular access in the upper limb.

Methods

A database of hemodialysis patients who underwent endovascular treatment for central venous stenosis from January 2014 to January 2017 at our institute was retrospectively reviewed. Follow-up was variable.

Results

The study included ten patients (6 men and 4 women) with a mean age of 45.2 years, who underwent thirteen interventions during a period of 3 years. The technical success rate for endovascular treatment was 100%. One patient underwent primary PTA (percutaneous transluminal angioplasty). Seven patients underwent primary PTA and stenting. Three patients underwent secondary PTA. One among these patients underwent secondary PTA twice along with fistuloplasty. One patient underwent secondary PTA with stenting. No immediate complications were encountered during the procedure. Our study shows a primary patency rate of 67% and 33% at 6 months and 12 months for PTA with stenting. Our study also shows secondary or assisted primary patency of 75% at 6 months of follow-up.

Conclusions

Endovascular therapy (PTA) with or without stenting for central venous stenosis is safe, with low rates of technical failure. Multiple additional interventions are the rule and long-term patency rate is not very good.

Symptomatic superior vena cava syndrome in hemodialysis patients: mid-term results of primary stenting

This clinical report details the results of endovascular treatment of symptomatic superior vena cava syndrome due to central vein stenosis or obstruction (CVSO) by stent angioplasty in patients with dialysis-dependent end-stage renal disease. A 3-year retrospective review of two institutional registries identified 25 chronic hemodialysis patients (17 men, 8 women) affected by CVSO who received endovascular treatment. The majority of the patients (n = 19) presented with symptomatic arm, breast, and facial swelling; and 6 patients presented with dialysis-access dysfunction and venous-line hypertension. The etiology of CVSO was before central venous catheter in all but 2 patients. Venography showed 19 cases of stenosis (4 stenoses of superior vena cava, 3 brachiocephalic, 10 subclavian, and 2 axillary veins) and 6 occlusions of the superior vena cava. After percutaneous transluminal angioplasty and primary stent angioplasty, there was an immediate regression of symptoms and arteriovenous fistula preservation in 21 cases; 4 patients received a new arteriovenous fistula after interventional treatment. No procedural major complications or patient deaths occurred. During the follow-up period, we recorded a primary patency rate of 95%, 80%, and 70%, respectively, at 6, 12, and 18 months; and a secondary patency rate of 100%, 95%, and 90%, respectively, at 6, 12, and 18 months. In conclusion, endovascular treatment with primary stenting has proven to be a durable treatment option for hemodialysis patients with CVSO, and this treatment should be considered before dialysis access placement in patients with catheter-induced central vein obstruction.

Sternocostoclavicular Hyperostosis: An Insufficiently Recognized Clinical Entity

A 79-year-old male chronic hemodialysis patient with no history of central venous catheterization was referred to our hospital with progressive swelling of the left upper limb ipsilateral to a forearm arteriovenous fistula. Radiological assessments revealed marked hyperostosis in the ribs, sternum, and clavicles with well-developed ossification of the sternocostoclavicular ligaments. Such characteristic structural abnormalities and our failure to identify the left subclavian vein with contrast material despite the abundant dilated collaterals in the left shoulder area encouraged us to diagnose our patient with sternocostoclavicular hyperostosis (SCCH) complicated by central vein obstruction. The structural impact of the sternocostoclavicular region as a potential risk for inducing central vein obstruction and the diagnostic concerns of SCCH in this patient are also discussed.

Endovascular treatment of central venous obstruction as a complication of prolonged hemodialysis - Preliminary experience in a tertiary care center

Background:

Central venous disease is a serious complication in patients undergoing hemodialysis, often presenting with symptoms of venous hypertension. Treatment is aimed to provide symptomatic relief and to maintain hemodialysis access site patency.

Aim:

To describe our initial experience in the endovascular treatment of central venous stenosis or obstruction in patients undergoing hemodialysis.

Settings and Design:

This was a retrospective study carried out in a tertiary care center. Study duration was 24 months. Follow-up was variable.

Materials and Methods:

Eleven patients of chronic renal failure undergoing hemodialysis presented with central vein stenosis or obstruction having ipsilateral vascular access, between July 2012 and July 2014. All the patients underwent endovascular treatment and were analyzed retrospectively.

Results and Conclusion:

A total of 11 patients (4 male and 7 female) underwent 18 interventions for 13 stenotic segments during a time period of 2 years. Eight stenotic segments were in brachiocephalic vein, three in subclavian vein, and two in axillary veins. The technical success rate for endovascular treatment was 81.8%. Two patients underwent percutaneous transluminal angioplasty (PTA) alone and presented with restenosis later. Balloon angioplasty followed by stenting was done in seven patients, two of which required reintervention during follow-up. We found endovascular treatment safe and effective in treating central venous disease.

Innominate Vein Stenosis in Breast Cancer Patients after Totally Implantable Venous Access Port Placement

Purpose

To evaluate the risk factors for central vein stenosis after placement of the totally implantable venous access ports (TIVPs) and the clinical relevance of this condition in breast cancer patients.

Materials and methods

TIVPs were placed in 191 women with breast cancer via the internal jugular vein (IJV) from January 2009 to December 2012 (mean age, 51.42 years) by left-side ( n = 102) and right-side ( n = 89) approaches. Medical records were retrospectively reviewed. The presence of significant central vein stenosis, tip location of the catheter and retrosternal space were evaluated on chest computed tomography images. Statistical analysis was performed.

Results

Central vein stenosis developed in 1 and 14 patients after placement via the right and left IJV, respectively. Differences in the cumulative incidence of central vein stenosis were statistically significant between left- and right-side approach groups (log rank test p-value: 0.009). In Cox regression analysis, the hazard ratio for central vein stenosis was 9.441 (p = 0.031) in the left-side approach. The distance between the sternum and the left innominate vein was found to be significantly and independently related to the development of central vein stenosis (p = 0.026). The hazard ratio of distances between the sternum and left innominate vein <16 mm was 10.133 (1.319-77.841).

Conclusions

The incidence of central vein stenosis in breast cancer patients was higher after placement of TIVPs via the left IJV. When left-side TIVP placement is required in a patient with right-side breast cancer, the possibilities of left innominate vein stenosis should be considered.

Extra- and intrathoracic access

The most complex patients requiring vascular access are those with bilateral central vein occlusions. Endovascular repair of the central lesions when feasible allow upper extremity use for access. When endovascular repair is not feasible, femoral vein transposition should be the next choice. When lower limb access sites have been exhausted or are contraindicated as in obese patients and in patients with peripheral arterial obstructive disease, a range of extrathoracic "exotic" extra-anatomic access procedures as the necklace cross-chest arteriovenous (AV) grafts, the ipsilateral axillo-axillary loops, the brachial-jugular AV grafts, the axillo-femoral AV grafts or even intra-thoracic ones as the right atrial AV bypasses represent the vascular surgeon's last resort. The selection among those extra-anatomical chest-wall procedures should be based upon each patient's anatomy or patient-specific factors.

Treatment of hemodialysis vascular access arteriovenous graft failure by percutaneous intervention

A patent vascular access is the lifeline of end-stage renal disease patients depending on hemodialysis treatment. Once a functioning vascular access has been established, maintaining its patency is of utmost importance. During the last decades percutaneous techniques became increasingly important for the treatment of hemodialysis vascular access graft failure. In this review, the role of percutaneous balloon angioplasty and stent implantation is evaluated for different clinical scenarios, based on the available evidence.

Predicting Outcomes in Native AV Forearm Radio-cephalic Fistulae; the CAVeA2T2 Scoring System

Purpose

The aim of this study was to identify significant factors relating to fistula survival and create an easy-to-use scoring system for predicting fistula patency rates.

Methods

A total of 276 consecutive radio-cephalic forearm fistulae created in a single tertiary vascular unit were identified retrospectively. Numerous patient- and fistula-related demographics were noted. Cox regression analysis was used to identify significant factors predictive of reduced fistula patency rates, and significant variables weighted according to their hazard ratio.

Results

Five significant factors were identified: ipsilateral Central venous access, Age >73 years, anastomosed Vein <2.2 mm, previous lower limb Angioplasty and absent intraoperative Thrill (1 point for first three variables, 2 points for the latter two). The CAVeA2T2 score (maximum 7 points) significantly predicted for reduced fistula patency (p = 0.001) and a reduced rate of successful dialysis (p = 0.001). Fistulae with CAVeA2T2 scores ≥2 had 6 week and 1 year patency rates significantly below pooled published rates. Without scoring for thrill, that is in the pre-operative setting, the scoring system remained significant at all stages.

Conclusion

The CAVeA2T2, scoring system is a potential scoring system for predicting fistula patency rates and the likelihood of dialysing through a fistula. Further studies and/or external validation is required in the context of methodological limitations. How to manage patients with a high CAVeA2T2 score is unknown.

Using Tunneled Femoral Vein Catheters for “Urgent Start” Dialysis Patients: A Preliminary Report

Background

Multiple benefits of arteriovenous fistulas (AVF) and arteriovenous grafts (AVGs) exist over catheters. As part of a strategy to preserve thoracic venous sites and reduce internal jugular (IJ) vein catheter use, we inserted tunneled femoral vein catheters in incident “urgent start” dialysis patients while facilitating a more appropriate definitive dialysis access.

Methods

“Urgent start” dialysis patients between January 15, 2013 and January 15, 2014 who required chronic dialysis, and did not have prior modality and vascular access plans, had tunneled femoral vein catheters inserted. We determined the femoral vein catheter associated infections rates, thrombosis, and subsequent dialysis access. Eligible patients were surveyed on their femoral vein catheter experience.

Results

Twenty-two femoral vein catheters were inserted without complications. Subsequently, one catheter required intraluminal thrombolytic locking, while all other catheters maintained blood flow greater than 300 ml/min. There were no catheter-related infections (exit site infection or bacteremia). Six patients continued to use their tunneled catheter at report end, one transitioned to peritoneal dialysis, thirteen to an arteriovenous graft, and two to a fistula. One patient received a tunneled IJ vein catheter. Of the patients who completed the vascular access survey, all indicated satisfaction with their access and that they had minimal complaints of bruising, bleeding, or swelling at their access sites. Pain/discomfort at the exit site was the primary complaint, but they did not find it interfered with activities of daily living.

Conclusions

Femoral vein tunneled catheters appear to be a safe, well tolerated, and effective temporary access in urgent start dialysis patients while they await more appropriate long-term access.

Central vein stenosis in an Asian hemodialysis population

Objective and background: Central vein stenosis occurs commonly after instrumentation of the major thoracic veins. We aimed to investigate factors that contributed to this condition in an Asian hemodialysis population, and the results of intervention.

Patients and methods: Hemodialysis patients diagnosed with central vein stenosis between January 2003 and December 2008, were identified from the records of the National University Hospital, Singapore. Eligible controls had a minimum of 2 years of hemodialysis via an arteriovenous fistula and/or central venous catheter, without clinical or radiological evidence of central vein stenosis.

Results: Central vein stenosis was diagnosed in 108 patients. The most common presenting features were arm swelling (32%) and failed hemodialysis catheter insertion (28%). The median frequency of permanent hemodialysis catheter insertion in those who subsequently developed venous stenosis (1.44 per patient per year) was 4 times that of controls (0.36 per patient per year; p < 0.001). Ischemic heart disease ( p = 0.03) and in certain patients, arteriovenous fistula surgery were associated with the development of central vein stenosis; whereas line sepsis, diabetes, and hypertension were not. Central vein angioplasty was attempted in 53 patients; the primary patency was 52% at 1 year.

Conclusion: Central vein stenosis is associated with a higher frequency of hemodialysis catheter insertion and access surgery. Efforts to decrease permanent hemodialysis catheter use should reduce the incidence of central vein stenosis.

A comparison of standard dual-tip hemodialysis catheter split lumen hemodialysis catheter

PURPOSE

To compare a split lumen (SLC) with the standard dual-tip hemodialysis catheter (DTC).

MATERIALS AND METHODS

The patients who underwent DTC insertion or SLC insertion were enrolled. Initial catheter dwell times (ICDT) and catheter-related complications were compared.

RESULTS

SLC (n=80) and DTC (n=133) were enrolled. ICDT was 71.94 days (SLC) and 68.55 days (DTC) (P=.76). Catheter migration was detected in 10.5% and 12.4% (SLC) and in 1.7% and 2.0% (DTC) (P=.0026).

CONCLUSIONS

SLC did not extend the ICDT compared to DTC. Furthermore, SLC was more prone to catheter-related complications, particularly catheter migration, than DTC.

Is unilateral breast enlargement always a sign of cancer?

Breast swelling is caused by many etiological factors, but should alert central vein occlusion in hemodialysis patients when the permanent vascular access is in the same arm. The swelling of the breast is caused by venous hypertension in the venous plexus draining the breast. Endovascular treatment relieves venous hypertension and related clinical signs. Additional diagnostic workup or invasive interventions such as a biopsy should be avoided in such patients, as diagnosis is straightforward with the presence of a functioning arteriovenous fistula in the same arm.

Reversal of Deep Vein Reflux After Successful Stenting in a Patient With Venous Hypertension After Thigh Access Graft Creation

Presented here is a case of reversal of deep vein reflux after successful stenting in a patient with venous hypertension and valve incompetence after thigh angioaccess creation. The patient with exhausted upper-extremity access sites underwent a loop graft in the upper thigh. Six months later, the patient developed leg edema and significant femoral vein reflux on duplex ultrasound. Fistulography revealed an iliac vein stenosis, which was treated successfully with stenting. The edema and reflux on duplex promptly resolved. In similar cases, reflux may be a consequence of functional valve incompetence and can be reverted by timely treating the underlying stenosis.

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.

Factors affecting long-term survival of tunnelled haemodialysis catheters--a prospective audit of 812 tunnelled catheters

BACKGROUND

In 2001, in the US, 23% of haemodialysis patients were dialysing through tunnelled venous catheters (TVCs), and in the UK (2006) there were 28% of prevalent patients using catheters. It is unlikely that numbers will significantly decrease. We present the results of a prospective audit of the survival of 812 TVCs placed in 492 patients at our institution over a 6-year period (comprising 212 048 patient catheter days or 7068 patient catheter months of follow-up). Four different designs of catheter were studied: Split-Cath III (Medcomp), HemoSplit (Bard), Tesio twin catheter (Medcomp) and Permcath (Quinton).

METHODS

We used Kaplan-Meier survival analysis with log-rank test, to compare the effect of different parameters on catheter survival. The relative importance of significant parameters was determined by Cox regression analysis.

RESULTS

We have shown a significant catheter survival advantage of first catheters over second and subsequent insertions, of right internal jugular site over left internal jugular and thereafter over femoral site, and of non-diabetic over diabetic patients. Patient age, sex and operator (physician in ward-based procedure room under ultrasound control or surgeon in operating theatre under fluoroscopic assistance) did not significantly affect survival. The Permcath design demonstrated inferior survival in all but first catheter insertions in catheter-naïve patients. The HemoSplit and Tesio twin catheter designs demonstrated best survival overall. By Cox proportional hazard modelling the design and the position of the TVC seemed to be the most significant independent survival factors.

CONCLUSIONS

Clinicians need accurate data regarding catheter survival, mode of insertion and design, to inform practice.