Single-Center Retrospective Review of Radiofrequency Wire Recanalization of Refractory Central Venous Occlusions

Systemic Central Venous Rehabilitation in Congenital Heart Disease

Chronic venous obstructions resulting from indwelling lines, surgery and instrumentation, and congenital anomalies are increasingly common in patients with congenital heart disease (CHD) and other chronic illnesses. Venous obstruction results in threatened long-term vascular access and congestive symptoms. Endovascular therapies are safe and can be effective at rehabilitating obstructed and even occluded veins. The risk of recurrent obstruction is high, however. Post-rehabilitation monitoring and anticoagulation therapy are important, and reinterventions are common. Here, the authors describe techniques to address a variety of venous obstruction lesions that may be encountered in CHD patients and provide illustrative cases.

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.

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.

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.

Managing systemic venous occlusions in children

Pediatric venous disease is increasing in incidence in both inpatient and outpatient populations. The widespread use of central venous access devices as well as the rising incidence of thromboembolic events in pediatrics is leading to more systemic venous occlusions in both the central and peripheral veins. This review focuses on the etiology, presentation, workup, and general technical considerations of recanalization as well as procedural complications related to pediatric systemic venous occlusive disease. The potential role for pediatric interventional radiology guided treatments will be discussed in detail.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Transjugular Intrahepatic Portosystemic Shunt Creation Using a Radiofrequency Wire: Prospective Clinical Safety and Feasibility Trial in Cirrhosis

PURPOSE

To assess the safety and feasibility of using a radiofrequency (RF) wire for portosystemic shunt creation.

MATERIALS AND METHODS

Ten patients undergoing elective creation of a transjugular intrahepatic portosystemic shunt (TIPS) or a direct intrahepatic portosystemic shunt (DIPS) were prospectively enrolled. Primary outcomes were the safety and feasibility of RF wire used for the creation of TIPS and DIPS. Median age was 66.5 ± 6.1 years. Causes of liver disease included alcohol (n = 5), nonalcoholic steatohepatitis (n = 2), hepatitis C virus (n = 1), primary biliary cirrhosis (n = 1), autoimmune hepatitis (n = 1). The median score for model for end-stage liver disease was 11 ± 4.3. The Rosch-Uchida TIPS set was used with intravascular ultrasonography guidance in all cases. A 0.035-inch RF wire was used in lieu of the trocar needle through the 5-F TIPS set catheter to create a track between the hepatic vein and the portal vein. All shunts were created using stent grafts.

RESULTS

Technical success rate was 100%. In 7 of 10 patients, portal vein access was achieved with a single pass. A DIPS was created in 2 patients based on anatomic favorability. Median fluoroscopy time was 13.3 ± 3.8 min, and median total procedure time was 102 ± 19 min. The wire passed through parenchyma without subjective deflection. There was 1 case of extracapsular puncture with no clinical consequence. The RF wire was too stiff to curve into the main portal vein, requiring wire exchange in all but 1 case. Mean portosystemic gradient decreased from 13.9 ± 3.3 to 5.9 ± 2.1 mm Hg. No immediate complications were encountered. Shunt patency was 100% at 30 days.

CONCLUSIONS

Creation of TIPS and DIPS using an RF wire was safe and feasible, enabling creation of an intrahepatic track without subjective deflection in cirrhotic patients.

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.

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

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

Transjugular Intrahepatic Portosystemic Shunt Creation Using a Radiofrequency Wire: Acute Feasibility Study in Swine

The feasibility of a radiofrequency (RF) wire to replace the needle trocar for the creation of a transjugular intrahepatic portosystemic shunt (TIPS) was assessed in 3 swine by using fluoroscopy and intravascular ultrasonography (IVUS). RF wire passes were successful from hepatic to portal vein and from inferior vena cava to portal vein. Technical success was achieved using both IVUS guidance and carbon dioxide portography. The wire tracked a straight course under RF energy application without subjective deflection and, when centrally advanced, served as the working wire for completing the TIPS in 2 attempts with stent graft deployment. No procedural adverse events from the use of RF wire were observed.