Superior vena cava syndrome caused by chronic hemodialysis catheters: autologous reconstruction with a pericardial tube graft

Internal Jugular Central Venous Catheter Tip Migration: Patient and Procedural Factors

Background: The ideal central venous catheter (CVC) tip position placement is controversial, and CVCs do not remain in a fixed position after placement. This study evaluates both patient and procedural factors which may influence CVC tip migration and subsequent catheter dysfunction. Materials and Methods: This study evaluates CVC placements at a single institution. Patient age, gender, body mass index (BMI), catheter laterality, CVC type and indication for central venous access were recorded. Catheter tip location relative to the carina was measured at time of placement and removal utilizing supine fluoroscopic imaging. Patients’ electronic medical records were reviewed for evidence of catheter dysfunction. Statistical analysis was performed utilizing odds ratios and two tailed Student’s t-test. Results: 177 patients were included (101 female; mean age 55; mean BMI 29.2). Catheter types included 122 ports, 50 tunneled large bore central venous catheters (≥9 French), and 5 tunneled small bore central venous catheters (<9 French). 127 were right sided catheters, and 50 were left sided. Left sided CVCs had a mean cranial tip migration of 3.2 cm (standard deviation ±2.9 cm) compared to 0.8 cm (standard deviation ±1.9 cm) for right sided catheters (p = 0.000008). Catheters that migrated cranially by >2 cm had more than 7× greater risk of dysfunction compared to catheters that migrated ≤2 cm (odds ratio of 7.2; p = 0.0001). Left sided CVCs were significantly more likely to have >2 cm of cranial migration (odds ratio 6.9, 95% CI 3.4−14.2, p < 0.0001) and had a higher rate of dysfunction, likely due to this cranial migration (32% vs. 4.7%; p = 0.00001). Gender and BMI were not found to be associated with catheter dysfunction or an increased odds ratio of >2 cm cranial migration. Conclusions: Left-sided CVCs migrate an average of 2.4 cm cranially more than right-sided catheters. Additionally, when migration occurs, left-sided catheters are more likely to be dysfunctional. These suggest that lower initial placement may be beneficial in left-sided catheters.

Superior Vena Cava Reconstruction Using Femoropopliteal Vein as a Panel Graft

There has been an increase in superior vena cava (SVC) syndrome secondary to the growing use of indwelling catheters and pacemaker wire insertions. These 2 factors can account up to 74% cases of benign SVC syndrome. Endovascular therapy is considered the first line of treatment. Surgery is an excellent option and is generally reserved for SVC syndrome not amenable to traditional endovascular procedures. We report a case of central venous reconstruction including an SVC reconstruction using the femoropopliteal vein as a panel graft in a patient with SVC syndrome due to pacemaker wires who failed multiple endovascular interventions.

Surgical Treatment of Benign Superior Vena Cava Syndrome

The obstruction of blood flow through the superior vena cava (SVC) into the right atrium may present as a severe clinical syndrome. One of the benign causes of SVC obstruction is the long-term use of indwelling catheters and wires, increasing the chances of SVC thrombosis. The treatment of the benign SVC syndrome is focused on achieving long-term durability and patency of the superior venocaval system and normal life expectancy. We report the successful surgical management of a patient with severe symptomatic SVC syndrome and emphasize technical details that might be of value in treating this challenging pathologic condition.

Alternative venous outflow by brachial to jugular vein vascular access for hemodialysis in the exhausted upper extremities

BACKGROUND

A shunt is usually created from the distal arm (wrist) to the proximal arm (axillary loop) as long as no central stenosis has occurred. Creating vascular access in a patient with central vein stenosis could induce venous hypertension in the upper extremities. In such patients, an ipsilateral internal jugular vein (IJV) as an arteriovenous (AV) outflow vein should be the last option for using a particular arm.

METHODS

Thirty-two patients who had AV hemodialysis access via a jugular vein were analyzed retrospectively from 2001 to 2011. All patients had an ipsilateral subclavian or axillary vein stenosis. The preserved IJV and innominate veins were preoperatively confirmed with Doppler echocardiography and contrast venography.

RESULTS

Mean age of the patients was 57.6 ± 12.3 years, and the mean follow-up period was 43.5 ± 27.4 months. Primary patency was 74%, 54%, 32%, 15% and 5% at 6 months, 1, 2, 3 and 4 years, respectively. Secondary patency was 97%, 93%, 93%, 89%, 79% and 72% at 6 months, 1, 2, 3, 4, and 5 years, respectively. One case of steal syndrome, 2 of seroma, 1 hematoma, 3 swollen arm, 2 infections, 1 pseudoaneurysm, 1 bleeding from puncture site, 8 stenoses and 13 thrombosis cases were noted.

CONCLUSIONS

A brachial-jugular AV graft showed satisfactory results in terms of patency and complication rate. The IJV could be a good outflow vein for an AV fistula if the IJV is preserved in patients with chronic renal failure who have subclavian or axillary vein stenosis or occlusion.

Anesthetic management of superior vena cava syndrome due to anterior mediastinal mass

Anesthetic management of superior vena cava syndrome carries a possible risk of life-threatening complications such as cardiovascular collapse and complete airway obstruction during anesthesia. Superior vena cava syndrome results from the enlargement of a mediastinal mass and consequent compression of mediastinal structures resulting in impaired blood flow from superior vena cava to the right atrium and venous congestion of face and upper extremity. We report the successful anesthetic management of a 42-year-old man with superior vena cava syndrome posted for cervical lymph node biopsy.

Unusual cause of superior vena cava syndrome diagnosed with transesophageal echocardiography

PURPOSE

An unusual case of superior vena cava (SVC) syndrome caused by an infected right atrial-SVC junction thrombus may be diagnosed using transesophageal echocardiography.

CLINICAL FEATURES

A 59-yr-old male with end-stage renal disease requiring hemodialysis presented with fungemia and later developed facial and bilateral upper extremity edema. Transesophageal echocardiography revealed subtotal occlusion of the SVC at its junction with the right atrium. The mass was surgically removed with cardiopulmonary bypass support. Pathological examination of the mass confirmed the presence of a large fungal colony of Candida species mixed in the thrombus. The patient's signs and symptoms of SVC obstruction resolved, and he was discharged from the hospital four weeks later in stable condition.

CONCLUSION

Although usually caused by extrinsic tumour compression, SVC syndrome can result from intravascular caval obstruction. This etiology should also be considered in the differential diagnosis, particularly in patients with intravascular devices. Transesophageal echocardiography is a valuable diagnostic tool in these cases.

Migration of an endovascular stent from superior vena cava to the right ventricular outflow tract in a patient with superior vena cava syndrome

Migration of endovascular stents is a rare problem but can be fatal. We report an unusual case of an endovascular stent in the right ventricular outflow tract, which migrated from superior vena cava in a patient with superior vena cava syndrome.

Vascular Access in Hemodialysis Patients with Central Venous Obstruction or Stenosis: One Center's Experience

The purpose of this study was to evaluate the value of complex hemodialysis access procedures among patients with central venous obstruction who were running out of access sites. Between September 2002 and December 2003 we performed a total of 640 new hemodialysis access procedures in 3 renal units. Ten of these patients presented central vein stenosis or obstruction and were not suitable for peritoneal dialysis. Each of the 10 patients had 3 or 4 previous failed access procedures and numerous infected central lines and their dialysis catheters were not functioning adequately. Nine patients presented with a severely stenosed or occluded superior vena cava and 1 had both subclavian veins occluded. Three patients were diabetics, 2 were obese and 6 had hypertension. We performed 12 procedures on these 10 patients. Saphenous veins were used 6 times, twice as a loop to the femoral artery and 4 times as a transposition to the popliteal artery above the knee. Femoral vein transposition to the popliteal artery was carried out in 2 cases. We performed 3 axillary artery to popliteal vein polytetrafluoroethylene (PTFE) bypasses, 1 on an obese woman who had no saphenous vein and was not suitable for a femoral vein transposition, 1 on a diabetic woman whose saphenous vein loop clotted after 5 months and 1 on a female patient with severe peripheral vascular disease. The patient with bilateral subclavian vein occlusion had a brachial artery to internal jugular vein PTFE graft. The PTFE graft to the jugular vein has been patent and regularly needled with a follow-up of 4 months. Four saphenous vein fistulae were regularly used for dialysis; 2 were never used. Five saphenous fistulae clotted after an average life span of 4 months (range 3 weeks-9 months) and 1 is still patent and in use (5 months). Both femoral vein transpositions have been patent and have been needled 3 times a week with a follow-up of 10 and 4 months; one had to be revised surgically after 9 months. Of the 3 axillary artery to popliteal vein grafts, 1 had to be tied off after a week because of severe steal syndrome and 2 have been patent (20 months follow-up) and have been needled regularly ever since. Seventy percent of these patients have been dialyzed line-free through their fistula despite severe central vein stenosis or obstruction for periods of 9-18 months when this review was undertaken. Although the follow-up needs to be longer, we discuss the surgical, radiologic, and dialysis features of these patients and propose a management pathway for central vein stenosis or occlusion.

Candida sepsis following infected iliocaval thrombosis: a case report

The authors report the case of a patient who developed a thrombosis of the right iliac vein involving also the inferior vena cava (IVC), in association with Candida sepsis. Despite adequate and prolonged antimycotic treatment, the patient recovered from the fungal sepsis only following the surgical removal of the infected thrombus.

Endovascular stenting of nonmalignant superior vena cava syndrome

Superior vena cava (SVC) syndrome is associated with advanced malignancy of the chest. Extensive experience is published in the literature regarding the use of endovascular intervention for symptomatic relief in these individuals with limited survival. Symptomatic SVC obstruction may occur from benign conditions that may not alter life expectancy. There are few data regarding endovascular therapy in this setting. We retrospectively analyzed our experience using endovascular intervention for benign SVC obstruction in 19 patients. In our series, the mean age was 46.4 years; 58% were female and 14/19 cases were due to an intravascular device. All patients experienced symptomatic relief. Median follow-up was 28.8 months. Three patients required secondary procedures to maintain patency. Four patients had procedural complications, which did not affect the outcomes. One patient died from complications of anticoagulation at 24 months. Endovascular procedures aimed at relieving SVC stenosis seem to be effective in patients with benign disease.

Open surgical and endovascular treatment of superior vena cava syndrome caused by nonmalignant disease

OBJECTIVES

The purpose of this study was to evaluate the role of endovascular and open surgical reconstructions in patients with superior vena cava (SVC) syndrome caused by nonmalignant disease.

METHODS

Clinical data from 32 consecutive patients who underwent endovascular or open surgical reconstruction of central veins because of symptomatic benign SVC syndrome between November 1983 and June 2001 were retrospectively reviewed.

RESULTS

The study included 17 male and 15 female patients (mean age, 38 years; range, 5-69 years). Presenting symptoms were head fullness (n = 26), dyspnea or orthopnea (n = 23), headache (n = 17), or dizziness (n = 11); physical signs were head swelling (n = 31), chest wall collateral vessels (n = 29), facial cyanosis (n = 18), or arm swelling (n = 17). Etiologic factors included mediastinal fibrosis (n = 19), indwelling catheter (n = 8), idiopathic thrombosis (n = 4), or post-surgery (n = 1). Two patients were heterozygous for factor V Leiden; 1 patient had antithrombin III deficiency. Twenty-nine patients underwent surgical reconstruction with 31 bypass grafts: spiral saphenous vein (n = 20), superficial femoral vein (n = 4), human allograft (n = 1), or expanded polytetrafluoroethylene (ePTFE, n = 6). Eleven patients underwent percutaneous transluminal angioplasty or stenting; 3 primary and 8 secondary endovascular procedures were performed to treat graft stenosis (n = 7) or occlusion (n = 1). There were no early deaths. Five early graft failures in 3 ePTFE grafts and 2 bifurcated vein grafts (thrombosis, n = 4; stenosis, n = 1) were successfully treated with open surgical revision. Over a mean follow-up of 5.6 years (range, 0.4-16.6 years) in surgical patients, 17 additional secondary interventions were performed in 8 patients, 14 endovascular and 3 surgical. Primary, assisted primary, and secondary patency rates of surgical bypass grafts were 63%, 79%, and 85%, respectively, at 1 year, and 53%, 68%, and 80%, respectively, at 5 years. Graft patency was significantly higher in vein grafts compared with ePTFE grafts (P =.02). Mean follow-up after percutaneous transluminal angioplasty or stenting was 3.1 years (range, 1 day-11.7 years). Twelve secondary endovascular interventions were performed in 6 patients (primary group, 3 of 3; secondary group, 3 of 9 grafts in 8 patients) to maintain patency in 11 of 12 reconstructions. Mean follow-up in the entire patient cohort was 5.3 years (range, 0.4-16.6 years). In 79% of patients symptoms had resolved or were significantly improved at last follow-up.

CONCLUSIONS

Surgical treatment of benign SVC syndrome is effective over the long term, with secondary endovascular interventions to maintain graft patency. Straight spiral saphenous vein graft remains the conduit of choice for surgical reconstruction, with results superior to those with bifurcated vein and ePTFE. Endovascular treatment is effective over the short term, with frequent need for repeat interventions. It does not adversely affect future open surgical reconstruction and may prove to be a reasonable primary intervention in selected patients. Patients who are not suitable for or who fail endovascular intervention merit open surgical reconstruction.

Dialysis Access-Induced Superior Vena Cava Syndrome

Vascular thrombosis is a complication of dialysis access and thrombosis of the superior vena cava by indwelling dialysis catheters access can cause superior vena cava syndrome. We describe a case of superior vena cava syndrome resulting from a dialysis access catheter placed in the internal jugular vein. Although surgical intervention is often needed to treat dialysis access-related superior vena cava syndrome this patient required only conservative measures for resolution of the syndrome. In this paper we describe the presentation, diagnosis, and management of this case. A review of dialysis access thrombosis complications and treatment options is also presented.

Endovascular management of venous thrombotic diseases of the upper torso and extremities

Central venous thrombosis in the upper torso can be either primary, occurring as a result of longstanding extrinsic compression, or secondary, resulting from an acquired intrinsic occlusive disease or foreign body. As in lower extremity deep vein thrombosis (DVT), anticoagulation therapy is the mainstay of therapy in upper torso and upper extremity DVT. However, in the presence of severely symptomatic acute thrombosis, pharmacologic and/or mechanical thrombolytic therapy represent the main invasive form of therapy for these conditions. After clearance of the acute thrombotic component, definitive management in patients with underlying anatomic abnormalities can be undertaken. Primary subclavian axillary vein thrombosis caused by extrinsic obstruction at the thoracic outlet is treated with thrombolytic therapy and anticoagulation followed by surgical decompression, whereas secondary causes of central venous obstruction and thrombosis are usually amenable to endovascular treatment with balloon angioplasty and stent placement. Postoperative interval anticoagulation is usually recommended. In addition to clinical follow-up, imaging follow-up with duplex sonography or conventional venography is usually recommended to assess the presence of restenosis and/or residual compression.

Crushed stents in benign left brachiocephalic vein stenoses

Two hemodialysis patients presenting with left venous arm congestion due to benign catheter-induced stenosis of the left brachiocephalic vein were treated by angioplasty and stent placement. External compression of the stents was responsible for rapid recurrence of the symptoms. No osseous or vascular malformation could be identified. Mechanical constraints induced by respiratory chest wall motion and aortic arch flow-related pulsation are proposed to explain this observation. This potential hazard should be considered when stent placement into the left brachiocephalic vein is advocated.