Radiofrequency Wire for the Recanalization of Central Vein Occlusions that Have Failed Conventional Endovascular Techniques

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Novel therapy for recanalization of chronic iliocaval venous occlusion using radiofrequency

OBJECTIVE

Chronic venous disease of the lower extremities is one of the most common diseases in the United States. The sequelae of this disease process are the source of a significant amount of morbidity, and its prevalence is expected to increase in the coming decades. Interventional therapy is warranted for relief of patients with CEAP C3-C6 disease. With advances in endovascular therapy, chronic iliocaval venous occlusion (CICVO) pathology can be corrected through minimally invasive approaches with limited morbidity and mortality. However, failure to recanalize the venous system leads to high failure rates. The purpose of this study was to assess the procedural success for recanalization of CICVO in the community setting using the novel technique of the Baylis radiofrequency (RF) wire in patients who had failed previous endovascular intervention.

METHODS

A retrospective review of patients who underwent RF recanalization for CICVO at our institution from 2019 to 2020 was conducted. All patients had failed previous endovascular attempts at recanalization. The primary outcome was recanalization (defined as restoration of >70% of luminal patency as determined on multiplanar venography [MPV] and intravascular ultrasound [IVUS]) confirmed on both IVUS and MPV. Secondary outcomes included adjunctive interventions and complications (hematoma, pulmonary embolism, new onset renal insufficiency).

RESULTS

A total of 10 patients, 50% male with a mean (standard deviation) age of 58.4 (10.4), were evaluated in the study. Successful recanalization was achieved in 60% of cases, with a resolution of >70% of luminal obstruction observed using MPV and IVUS. Adjunctive interventions were performed in 70% of cases. There were no clinically significant complications or blood transfusion requirements.

CONCLUSIONS

New techniques and technologies continue to be developed for advanced endovascular management of CICVO, especially with the expanding market for Food and Drug Administration approved venous stents. The Baylis RF wire can assist in recanalization and treatment of patients who had failed previous endovascular therapy.

Imaging to intervention: Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a clinical disorder resulting from compression of the neurovascular bundle of the lower neck and upper chest. TOS can be categorized into neurogenic, venous, and arterial subtypes which result from anatomical compression of the brachial plexus, subclavian vein, and subclavian artery, respectively. This can lead to neurogenic pain as well as vascular injury with thrombosis and thromboembolism. Interventional and diagnostic radiologists play a critical role in the imaging diagnosis and treatment of vascular TOS. Prompt imaging and endovascular management with surgical collaboration has been shown to provide the most successful and long-lasting clinical outcomes, from vessel patency to symptom relief. In this article, we review the anatomy and clinical presentations of TOS as well as the initial imaging modalities used for diagnosis. Furthermore, we detail the role of the diagnostic and interventional radiologist in the management of TOS, including pre-procedure and endovascular interventions, along with medical and surgical treatments. PRECIS: Diagnostic and Interventional Radiologists play a key role in diagnosis and management of vascular thoracic outlet syndromes and are critical for timely and successful outcomes.

Superior Vena Cava Syndrome: Etiologies, Manifestations, and Treatments

Superior vena cava (SVC) obstruction, whether from benign or malignant causes, results in a variety of symptoms. It is a potential medical emergency when cerebral or laryngeal edema occurs. Endovascular therapy is the treatment of choice for patients in need of emergent relief of symptoms. This article will provide a review of SVC syndrome with a focus on endovascular treatment techniques.

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 Needle Recanalization Technique for Peripheral Hemodialysis Arteriovenous Fistula Occlusion

PURPOSE

To determine the efficacy of a percutaneous sharp needle recanalization technique for the treatment of peripheral hemodialysis arteriovenous fistula (AVF) occlusion.

MATERIALS AND METHODS

This study included 13 patients (14 procedures) between May 2010 and February 2020 with non-thrombotic AVF occlusion wherein guidewire passage through the occluded segment had failed. We successfully passed the guidewire through the occluded segment using a sharp needle recanalization technique with Chiba or Colapinto needles, under ultrasound or fluoroscopic guidance. The type of AVF, site and length of occlusion, technical success, complications, and long-term patency were analyzed.

RESULTS

Technical success was achieved in 12 (85.7%) out of 14 procedures. The procedure failed in two patients due to the poor angle of approach in the axillary area and diffuse severe stenosis in the draining cephalic vein. In eight procedures, sharp needle recanalization was performed under ultrasound guidance, while the other six procedures were performed under fluoroscopic guidance. Chiba and Colapinto needles were used in five and nine procedures, respectively. The mean length of occlusion was 2.7 cm (range 1.8-4.2 cm). There was one case of mild complication, that is, mild contrast extravasation, which was treated by stent deployment. The post-intervention primary patency rates at 6 months, 1 year, and 2 years were 81.8%, 36.4%, and 18.2%, respectively.

CONCLUSION

The results of this limited series suggest that the sharp needle recanalization technique is a simple and effective method for the treatment of peripheral non-thrombotic AVF occlusion.

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.

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.

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.

Creation of a neoinfundibulum and serial balloon dilations for the treatment of the excluded calyx: Two cases describing a novel technique

An excluded calyx is a rare, acquired urologic condition where there is discontinuity between a portion of the renal collecting system with the remainder of the collecting system. Re-establishment of reliable long-term communication between the excluded calyx and the remaining collecting system is crucial for preservation of renal function and possible relief of symptoms. In this manuscript, we discuss two such cases where a previously undescribed novel procedure is used for treatment of this uncommon condition, where percutaneous antegrade transcatheter techniques were used to establish long-term urinary drainage. The first case discusses an excluded calyx in a 17-year-old male who suffered left renal injury after a high speed motor vehicle accident, where the kidney was divided by the injury and subsequently required creation of a neoinfundibulum in order to maintain continuity of the collecting system. The second case involves a 39-year-old female who underwent resection of a renal cell carcinoma, later developing an excluded calyx where radiofrequency wire recanalization was performed and the neoinfundibular track underwent serial retrograde balloon dilation, resulting in a continuous collecting system. Both patients have done well for more than 2 years after neoinfundibulum creation, showing that this novel technique should be considered a viable and safe procedure in the treatment of this rare condition.

Outcome of Central Vein Occlusion Recanalization in Hemodialysis Patients and Predictors for Success: A Retrospective Study

Background:

Catheter-directed treatment is the standard approach for the management of chronic central venous occlusion.

Purpose:

The objective of this study is to report the outcome of conventional recanalization of chronic central vein occlusion in hemodialysis patients and to determine the predictors for success.

Material and Methods:

All hemodialysis patients who underwent endovascular recanalization of central vein occlusion from January 2012 to December 2016 were retrospectively evaluated. The procedure was percutaneous transluminal angioplasty. Stenting was performed in case of a significant recoil stenosis. Kaplan-Meier analysis was used to evaluate central vein patency. Univariate analysis and multivariate logistic regression were used to calculate the predictive factors.

Results:

Ninety-seven patients (mean age, 61.2 years; range, 25‒89 years old) with 97 central vein occlusions were enrolled. Technical success was achieved in 49 patients (50.5%). The primary patency rates of central veins at 6 and 12 months were achieved in 17 patients (34.4%) and 8 patients (15.8%), respectively. The assisted primary patency rates at 6 and 12 months were achieved in 38 patients (77.3%) and 30 patients (61%), respectively. Patient age ≥60 years and a tapered-type of lesion were significant predictive factors for successful recanalization.

Conclusion:

Endovascular treatment of the central vein occlusion using a conventional technique is moderately effective and safe. Angioplasty alone and stenting were not significantly different in terms of patency rate. The age of the patients and type of occlusion were significant predictors for successful recanalization.

Endovascular septal fenestration using a radiofrequency wire to salvage inadvertent false lumen deployment of a frozen elephant trunk stent graft

We report a case of a frozen elephant trunk arch repair, where the stent graft was unintentionally placed into the false lumen. Postoperative imaging demonstrated an enlarged false lumen with no thoracic aorta fenestrations that could be traversed to place another thoracic endovascular aortic repair endograft into the true lumen. An atraumatic radiofrequency wire (PowerWire, Baylis Medical, Montreal, Quebec, Canada) was used to create a new septal fenestration, enabling thoracic endovascular aortic repair endograft extension into the thoracic true lumen. This novel use of a radiofrequency wire can enable safe and controlled endovascular septal fenestration even in chronic dissections to redirect flow into the true lumen.

How to do it: value-driven sharp recanalization of central vein occlusion

Patients on haemodialysis are susceptible for central vein occlusions, which can result in debilitating clinical consequences. These may be resistant to conventional revascularization with guidewire and catheter technique. Value-driven sharp recanalization of central vein occlusion is depicted as a safe and affordable option.

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.

Radiofrequency wire technique and image fusion in the creation of an endovascular bypass to treat chronic central venous occlusion

The goal of this case report was to demonstrate the feasibility, safety, and efficacy of image fusion software to treat symptomatic central venous occlusion with radiofrequency wire after failure of conventional endovascular techniques. The complex and chronic central venous occlusion was successfully treated without complications. The combination of these techniques provided an endovascular solution and could be considered in select cases.

Radiofrequency wire 'power wire' recanalization of calcified chronically occluded inferior vena cava

Background

Radiofrequency (RF) wire recanalization of short segments of central venous obstruction has been considered safe; however its use for recanalization of long segments of inferior vena cava (IVC) has not been reported.

Case presentation

A 55-year-old female with recurrent massive hematemesis was found to have systemic venous upper esophageal varices on endoscopy and an extensive chronic IVC occlusion on CT. Using both a percutaneous transhepatic and transfemoral approach IVC recanalization was performed. A snare was advanced to the cavo-atrial junction via transhepatic venous access. From the groin utilizing RF wire steerable guide sheaths, endovascular reconstruction of the IVC was performed. Post recanalization venography demonstrated patent stented IVC and marked decrease in the intraabdominal-pelvic collaterals. No recurrence of hematemesis was noted. After 6 months, patient remained asymptomatic and had functioning right femoral arteriovenous hemodialysis graft.

Conclusions

Using appropriate techniques, Power wire recanalization of long occlusive segments of IVC can be safe and effective.

Creation of a Ureterocystostomy in a Transplanted Cadaveric Kidney with the Use of a Radiofrequency Guide Wire

A duplicated collecting system (DCS) is a common anatomical variant of the kidney. As surgeons now perform more donor cadaveric transplants than in the past, the discovery of an occluded DCS may occur in the post-transplant setting. Over a dozen articles have reported on the use of DCS in the renal transplant setting. However, to our knowledge, this case report is the first to describe the creation of a ureterocystostomy with the use of a radiofrequency (RF) guide wire, involving a previously unidentified DCS in a transplanted kidney.

Success Rate and Complications of Sharp Recanalization for Treatment of Central Venous Occlusions

PURPOSE

To evaluate success and safety of needle (sharp) recanalization as a method to re-establish access in patients with chronic central venous occlusions.

MATERIALS AND METHODS

Thirty-nine consecutive patients who underwent this procedure were retrospectively reviewed to establish success rate and associated complications. In all cases, a 21- or 22-gauge needle was used to restore connection between two chronically occluded segments after conventional wire and catheter techniques had failed. The needle was guided toward a target placed through a separate access by fluoroscopic guidance. When successful, the procedure was completed by placing a catheter, ballooning the segment, and/or stenting.

RESULTS

The procedure was successful in 37 of the 39 patients (95%). The vast majority of the treated lesions were in the SVC and/or right innominate vein. Occlusions ranged in length between 10 and 110 mm, and the average length of occluded venous segment was 40 mm in the treated group. There were four minor (SIR classification B) complications involving pain management after the procedure. There were two major (SIR classification D) complications both of which involved hemorrhage into the pericardium treated with covered stents (5.1%).

CONCLUSIONS

Sharp recanalization is a viable procedure for patients who have exhausted standard wire and catheter techniques. The operator performing this procedure should be familiar with potential complications so that they can be addressed urgently if needed.

Percutaneous sharp recanalization of a membranous IVC occlusion with an occlusion balloon as a needle target

A 50-year-old male with right upper quadrant symptoms and hepatic dysfunction was found to have multiple dilated hepatic veins (HVs) with intrahepatic collateralization and membranous occlusion of the intrahepatic inferior vena cava (IVC) consistent with primary Budd–Chiari syndrome. Venacavograms depicted drainage of the intrahepatic collaterals through a left-sided HV entering the IVC above the level of the occlusion. Sharp recanalization of the membranous IVC occlusion was performed with an occlusion balloon as a needle target under echocardiographic monitoring followed by balloon angioplasty with restoration of IVC patency. Clinical, laboratory, and venographic procedural success has been demonstrated to 9 months with minimal residual stenosis.

Modified Inside-Out Technique for Continued Use of Chronically Occluded Upper Central Veins

This report describes a 2-step, inside-out procedure for upper body central venous access in patients with chronic central venous occlusions. Blunt cephalad dissection through the mediastinum was achieved with a curved metal cannula and guide wire followed by percutaneous puncture of an open snare from a right supraclavicular approach and dilation of the tract for a tunneled central venous catheter insertion. Of 9 patients, all had a successful placement of a tunneled central venous catheter using this method. Although this 2-step, inside-out technique is effective for creating access in the presence of central venous occlusion, further clinical evaluation is warranted.

Central Venous Interventions

Central venous stenosis or occlusion is a common and vexing problem in patients undergoing hemodialysis. Typical presenting symptoms include arm swelling and prolonged bleeding after hemodialysis. Despite multiple treatment approaches, these stenoses tend to recur and progress over time. A thorough preprocedure evaluation, methodical procedural approach and awareness of potential complications are all essential to try to preserve vascular access and improve patients' quality of life.

Automated implantable cardioverter defibrillator lead infection in a patient with previous superior vena cava thrombosis

We present a case of a 44-year-old woman who presented with cough, pleuritic chest pain and fever leading to a diagnosis of pneumonia±pulmonary embolism. She had a history of familial hypertrophic obstructive cardiomyopathy (HOCM), for which an automated implantable cardioverter defibrillator (AICD) had been implanted, and a subsequent superior vena cava (SVC) thrombus, for which she was anticoagulated with warfarin. On admission, blood cultures grew a coagulase-negative Staphylococcus. CT pulmonary angiogram and transoesophageal echocardiography (TOE) were performed and revealed large vegetations adherent to the AICD leads with complete occlusion of the SVC. The infected leads were the source of sepsis. Open surgery was planned. For cardiopulmonary bypass, the venous cannula was inserted in the inferior vena cava (IVC) and a completely bloodless field was obtained in the right atrium allowing for the extraction of the AICD leads completely, along with the adherent vegetations from within.

Endovascular Interventions for Acute and Chronic Lower Extremity Deep Venous Disease: State of the Art

The societal and individual burden caused by acute and chronic lower extremity venous disease is considerable. In the past several decades, minimally invasive endovascular interventions have been developed to reduce thrombus burden in the setting of acute deep venous thrombosis to prevent both short- and long-term morbidity and to recanalize chronically occluded or stenosed postthrombotic or nonthrombotic veins in symptomatic patients. This state-of-the-art review provides an overview of the techniques and challenges, rationale, patient selection criteria, complications, postinterventional care, and outcomes data for endovascular intervention in the setting of acute and chronic lower extremity deep venous disease. Online supplemental material is available for this article.

Safety and Efficacy of Radiofrequency Wire Recanalization of Chronic Central Venous Occlusions

Purpose

The purpose of this study is to evaluate the safety and efficacy of using a radiofrequency wire (RF) for central venous occlusion (CVO) recanalization after failure using conventional techniques.

Materials and methods

A retrospective analysis of all central venous recanalization procedures using an RF wire from January 2007 to December 2012 was performed. This comprised 13 consecutive procedures in 12 patients. The electronic medical record and radiologic imaging studies were reviewed to obtain information regarding patient demographics, indication for revascularization, duration of vascular occlusion, procedure outcome, and complications.

Results

Technical success was achieved in nine of 13 (69%) occluded vessels in nine of 12 (75%) patients. Lengths of successfully crossed lesions (mean 29.8 ± 29.3 mm) were significantly less than those of unsuccessfully crossed lesions (mean 90 ± 73.7 mm), p = 0.039. Of the nine patients with technically successful procedures, three died with patent stents of causes unrelated to the procedure, one had a patent stent at 547 days, two had stent patency of 94 days and 345 days, and three were lost to follow-up. One patient (8.3%) experienced a major complication wherein tracheal perforation by the RF wire contributed to the patient's death.

Conclusions

RF recanalization is a viable option in patients with central vein occlusion refractory to traditional procedures. However, it does not guarantee successful revascularization and is not without the potential for harm.

A wire transposition technique for recanalization of chronic complex central venous occlusions

PURPOSE

A minimal-invasive interventional technique for recanalization of complex chronic central venous total occlusions is described to overcome difficulties in case of failure of common approaches.

METHOD

We present a patient with a central venous occlusion that caused severe venous congestion of her upper extremity and significant impairment of her forearm hemodialysis shunt. Since the usual transbrachial and transfemoral attempts for recanalization of occluded right subclavian, brachiocephalic, superior vena cava, and proximal internal jugular veins (IJV) failed, the approach was changed to a transjugular access. Only the IJV and subclavian vein occlusions were passed from transjugular.

RESULTS

The key procedure was the switch of a jugular-brachial wire to a femoral-brachial setting. The wire transposition was achieved by snaring the looped stiff end of the jugular-brachial wire outside the jugular sheath from the opposite femoral access.

CONCLUSION

Different approaches should be considered for the recanalization of challenging central venous occlusions. After failed attempts via common access sites, a guidewire transposition maneuver using a combined approach may be particularly helpful for safe and effective endovascular treatment of complex situations.

Superior Vena Cava Syndrome: Role of the Interventionalist

Superior vena cava syndrome results from the obstruction of blood flow through the superior vena cava and is most often due to thoracic malignancy. However, benign etiologies are on the rise secondary to more frequent use of intravascular devices such as central venous catheters and pacemakers. Although rarely a medical emergency, the symptoms can be alarming, particularly to the patient. Traditionally, superior vena cava syndrome has been managed with radiotherapy and chemotherapy. But interventional endovascular techniques have made inroads that offer a safe, rapid, and durable response. In many cases, it may be the only reasonable treatment. Because of this, an approach to endovascular treatment of this condition must be in the armamentarium of the interventional radiologist. This review will provide the reader with an insight into the etiology, pathophysiology, and various management principles of superior vena cava syndrome. The focus will be on understanding the techniques used during various endovascular interventions, including angioplasty, stenting, and pharmacomechanical thrombolysis. Discussion will also be centred on possible complications and current evidence as well as controversies regarding these approaches.

Long Segment Recanalization and Dedicated Central venous Stenting in an Ultimate Attempt to Restore Vascular access Central Vein Outflow

Purpose

Maintaining vascular access in patients undergoing chronic hemodialysis is a challenging process, especially in patients enduring multiple central line placements and in whom peripheral options have been exhausted.

Case

We present a case of a 60-year-old male without options for peripheral vascular access due to multiple failed arteriovenous fistulas for hemodialysis. Furthermore, bilateral subclavian, brachiocephalic veins and iliac veins were occluded or significantly obstructed. After long segment central vein recanalization, an upper arm loop arteriovenous graft was implanted. The recanalized segment was stented with a 12-mm dedicated venous nitinol stent.

Conclusion

Chronic central vein obstructions demand stents with both high radial force and flexibility. We recommend dedicated venous stents to improve technical success and reduce stent-related complications like early re-occlusion due to fracturing, kinking or straightening.

Superior vena cava syndrome in lung cancer

Summary Superior vena cava syndrome (SVCS) consists of various symptoms and signs due to intrinsic obstruction or extrinsic compression of the superior vena cava. The most common etiology is thoracic malignancy, with lung cancer being the leading cause (80%). It usually presents with edema of the head, neck and arms, often associated with cyanosis, plethora and distended subcutaneous vessels. The diagnosis is commonly made from physical examination and confirmed by imaging, such as CT scan. SVCS is usually not a medical emergency, but can, in rare cases, cause cardiac or airway compromise, or cerebral edema, which may require urgent interventions such as thrombectomy or endovascular stenting. In lung cancer-related SVCS, radiation and/or chemotherapy are the main treatment options, and tissue diagnosis should be obtained before the initiation of definitive treatment if SVCS is the initial presentation. Randomized controlled trials are still lacking for optimal management of SVCS.