Central Venous Occlusion in the Hemodialysis Patient

HeRO graft-The results of the cologne single center study

OBJECTIVE

The HeRO graft is a technique for vascular access in patients with limited treatment options; however, the published results with the HeRO graft are diverging. We therefore conducted a single-center study.

METHODS

Patient records between July 2014 and February 2020 from Vascular Access Unit of the Department of Vascular and Endovascular Surgery of University Clinic of Cologne (Germany) were reviewed. Retrospective data was analysed from patients with a HeRo graft (n = 18).

RESULTS

Eighteen patients were enrolled in the study. The mean age of the patients was 62.8 ± 17.24 years. During the follow-up period, no patients died from complications related to the HeRO graft. Each patient had a mean of 1.94 concomitant diseases. The primary patency rates of the HeRO graft at 3, 6, 12, 18, and 24 months were 61.1%, 50%, 16.7%, 11.1%, and 5.6%, respectively. The secondary patency rates at the same time intervals were 77.8%, 72.8%, 55.6% 55.6%, and 55.6%, respectively. There were 44 re-operations per year, or 2.4 operations per patient. The main cause of acute complications was acute graft occlusions after HERO graft implantation. An infection after the graft implantation occurred in five (27.7%) patients, leading to graft explanation in 2 cases.

CONCLUSION

The use of the HERO graft is a valuable alternative method for providing a durable dialysis access in patients with limited access options. The secondary patency and survival are good with a low infection rate.

Tunneled hemodialysis central venous catheters prevalence and bloodstream infection rates in Northern Italy: A survey of the "East Lombardy Nephrological Network"

BACKGROUND

Tunneled central venous catheter (tCVCs) is a vascular access frequently employed in hemodialysis patients. Catheter-related bloodstream infections (CRBSI) are potentially life-threatening complications.

METHODS

We performed a retrospective survey regarding tCVCs prevalence as well as the CRBSI incidence and management within five hospitals in the Brescia province belonging to the "East Lombardy Nephrological Network"; this study was based upon 18 queries regarding the years 2020 and 2021.

RESULTS

The data collected refer to an overall hemodialysis population of 736 patients in 2020 and 745 patients in 2021. The prevalence of tCVCs was respectively 22.1% and 24.2% with the initial placement being performed with fluoroscopy support in 80% of the centers. CRBSI incidence was respectively 0.88 and 0.77 episodes per 1000 days of tCVC use. When the CRBI was caused by Staphylococcus Aureus (SA) or Pseudomonas, differently from the recommendation of the KDOQI guidelines, the removal or the substitution of the tCVC did not occur immediately at the time of the diagnosis of the infection but only when the specific antibiotic therapy failed. A nose swab aimed at identifying SA carriers was performed in 60% of centers. The policy regarding the referral to other specialists (infectious disease specialist and microbiologist) was heterogenous across the centers according to their specific logistics.

CONCLUSIONS

This retrospective survey performed by the "East Lombardy Nephrological Network" within the Brescia province describes the prevalence of tCVCs use as well as the incidence and management of CRBSIs in the hemodialysis patients of this area. The clinical impact of the differences in terms of clinical approach detected compared to the KDOQI guidelines will need to be clarified ideally in prospective studies.

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.

Acute problems of hemodialysis access: Thrombosis, aneurysms, symptomatic high-flow fistulas, and complications related to central lines

Hemodynamic complications frequently affect vascular access and are important causes of morbidity and mortality. We present a review of acute complications affecting vascular accesses, focusing on classical and new treatments. Acute complications in hemodialysis vascular access are often underestimated and undertreated, and can present a challenge for both vascular surgeons and anesthesiologists. Accordingly, we considered different anesthesiologic approaches to both hemorrhagic and nonhemorrhagic patients. A strict collaboration among nephrologists, surgeons, and anesthesiologists can potentially improve prevention and management of acute complications and quality of life.

Challenging, Safe, and Effective Use of External Iliac Vein for Insertion of Tunneled Cuffed Hemodialysis Catheters: A Single-Center Prospective Study

Background

Providing well-functioning vascular access is crucial for patients undergoing chronic hemodialysis. Peripheral arteriovenous fistulas and grafts are the preferred accesses in hemodialysis patients. Patients with bilateral obstruction of internal jugular veins and subclavian veins require a suitable vascular access. Thus, the insertion of iliac vein tunneled cuffed catheters (TCCs) by interventional nephrologists may be a good option for these patients. We aimed to evaluate the outcomes of iliac vein TCCs in patients lacking other vascular options.

Methods

80 tunneled cuffed hemodialysis catheters were inserted through the iliac veins of 80 patients with an end-stage kidney disease. Catheter insertion was guided by Doppler ultrasonography followed by plain radiography to detect the catheter tip and exclude complications.

Results

The insertion success rate was 100%. 25 patients developed catheter-related infections. The mean survival time per catheter was 328 days. At the end of the study, 40 catheters were still functioning, 15 patients were shifted to continuous ambulatory peritoneal dialysis and 5 patients were referred to the interventional radiology department for insertion of transhepatic inferior vena cava tunneled catheters. Resistant catheter-related infection was the main cause of catheter removal in 11 patients (17.5%) in this study. Catheter malfunction was the second most common cause of catheter removal in 9 patients (11.25%).

Conclusion

This study concluded that iliac vein TCCs can provide suitable vascular access in hemodialysis patients with bilateral obstruction of internal jugular veins and subclavian veins.

The outcome of radiocephalic after brachiocephalic and redo arteriovenous fistula

Introduction:

When created in appropriately selected patients, arteriovenous fistula requires fewer interventions and costs compared to arteriovenous graft. The outcome of radiocephalic after brachiocephalic and redo arteriovenous fistula is not studied well in the literature, and this study highlights the outcome of these arteriovenous fistulae.

Methods:

The retrospective, single-center study, based on patient record analysis of 1040 arteriovenous fistula, was created between January 2017 and October 2021. Thirty-nine (3.37%) patients met the inclusion criteria for radiocephalic after brachiocephalic arteriovenous fistula group, and 42 (4.04%) met the inclusion criteria for the redo arteriovenous fistula group. Preoperative Doppler ultrasound was performed by the operating surgeon in all patients. All patients were scheduled for a visit 2 months after surgery for assessment—only 34 of radiocephalic after brachiocephalic arteriovenous fistula and 35 of redo arteriovenous fistula patients presented for follow-up. The arteriovenous fistula was assessed for patency, maturation, and complications. SPSS version 22 (Chicago, USA) was used for data entry and analysis.

Results:

The redo arteriovenous fistula has a significantly lower maturation rate at 2 months of follow-up (62.85%) when compared to other brachiocephalic arteriovenous fistula (79.18%) ( p-value = 0.0245). The radiocephalic after brachiocephalic arteriovenous fistula has no significant difference in maturation rate at 2 months of follow-up (61.67%) when compared to other distal forearms radiocephalic arteriovenous fistula (68.18%) ( p-value = 0.5173). The incidence of some early complications was higher in the redo group.

Conclusion:

The feasibility of doing radiocephalic arteriovenous fistula after failed brachiocephalic arteriovenous fistula is generally overlooked. The redo arteriovenous fistula is more technically challenging, associated with higher complications, but it provides reliable access in a specific group of patients.

A retrospective cohort study comparing high and low balloon inflation pressure on technical success and patency for treating central venous lesions in patients on chronic hemodialysis

Background

We aimed to analyze the success rates and the access patency rates at 12 months between patients on chronic hemodialysis with symptomatic central venous stenosis (CVS) or occlusion (CVO), receiving high or low balloon inflation pressure for treatment.

Methods

We performed a retrospective study in which angioplasty balloons were inflated using a low-pressure or a high-pressure for the management of hemodialysis patients with CVS/CVO. The outcomes of this study were the success rate and the access patency rates at 12 months after balloon angioplasty, and the differences between groups were compared.

Results

We included a total of 74 patients on hemodialysis and assigned them to the low-pressure or the high-pressure groups. Success rates in patients of the high-pressure group (94.12%) were higher than those in patients of the low-pressure group (67.50%) (p = 0.005). With a total of 59 patients with technical success, at 6 and 12 months after angioplasty, the rates of access patency in the low-pressure group were 68 and 48%, respectively; on the other hand, the primary patency rates in the high-pressure group were 86.67% (6-months) and 76.67% (12-months). The 6 and 12 months post-interventional patency rates were higher in patients of the high-pressure group than those in patients of the low-pressure group (p = 0.10 at 6 months and p = 0.03 at 12 months).

Conclusions

Compared to balloon angioplasty using a low inflation pressure, hemodialysis patients with CVS/CVO receiving angioplasty using a high inflation pressure have significantly higher technical success and 12-month patency rates.

Unilateral jugular vein stenosis in five horses and experience with percutaneous transluminal angioplasty

BACKGROUND

Venous stenosis, a possible cause of jugular dilatation and congestion, is well known in human medicine but has poorly been described in horses.

OBJECTIVE

To report unilateral jugular vein stenosis as a cause of jugular vein dilatation in horses and describe treatment by percutaneous transluminal angioplasty (PTA).

STUDY DESIGN

Case report.

METHODS

Details of horses diagnosed with unilateral jugular stenosis were retrieved from medical records.

RESULTS

Five horses were presented with a non-painful, unilateral dilatation of the jugular vein of which two horses showed headshaking during exercise. In one horse an indwelling catheter had been used and jugular dilatation developed 4 weeks later. In the other horses, no intravenous injections had been administered in the months before jugular dilatation developed. Ultrasonographic examination revealed venous stenosis in all horses approximately 5-10 cm cranial to the thoracic inlet. The internal diameter at the level of this stenosis was only 1-3.1 mm. The length of the stenosis was about 15-19 mm with a markedly thickened intima and media on ultrasonography. After enoxaparin treatment, PTA was performed in three horses. During the procedure the stenotic vein was dilated three times with progressively increasing pressures up to 12 atm. The stenotic diameter increased to a maximum of 4.9 mm with improved jugular blood flow. Aftercare included anti-inflammatory and anti-thrombotic therapy.

CONCLUSION

Jugular vein stenosis occurs in horses and should be included in the differential diagnoses of unilateral jugular vein dilatation. It may present in the absence of previous intravenous treatment. PTA of the jugular vein is feasible to improve jugular blood flow.

Hemodialysis as a Risk Factor for Lower Right Internal Jugular Stenosis in Cardiac Surgery Patients: A Retrospective Single-Center Study

Lower right internal jugular vein (RIJ) stenosis has been reported as a common cause of RIJ catheterization failure. However, the risk factors for lower RIJ stenosis in patients undergoing cardiac surgery is unclear. We reviewed the electronic medical records of all adult patients who had undergone cardiac operations in a single tertiary university hospital from January 2014 to January 2016. Patients were excluded if they were lack of preoperative contrast-enhanced chest computed tomography (CT) studies. Lower RIJ stenosis was defined as a ratio of cross-sectional area at the smallest level to cross-sectional area at the largest level less than 25%. Multivariable logistic regression analyses were used to investigate the risk factors for lower RIJ stenosis. A sensitivity analysis was also conducted using a cross-sectional area ratio of under 20%. The analysis included 889 patients, and the incidence of lower RIJ stenosis was 3.9%. The multivariable logistic regression analyses revealed that hemodialysis was an independent risk factor for lower RIJ stenosis (OR, 3.54; 95% CI, 1.472–8.514). Sensitivity analysis provided that hemodialysis (OR, 10.842; 95% CI, 3.589–32.75) was a significant predictor of cross-sectional area ratio <20%. Preoperative hemodialysis are significantly associated with an increased risk of lower RIJ stenosis in patients undergoing cardiac surgery. Extra care is needed during central venous catheterization in hemodialysis patients undergoing cardiac surgery.

A systematic review of venoplasty versus stenting for the treatment of central vein obstruction in ipsilateral hemodialysis access

OBJECTIVE

This review examines the evidence regarding treatment of central vein obstruction (CVO) in the setting of ipsilateral hemodialysis access. The aim of this work is to identify whether long-term venous patency after central vein stenting is superior compared with balloon venoplasty. To date, there are no evidence-based guidelines to direct the management of CVO in the setting of ipsilateral hemodialysis access.

METHODS

An extensive systematic database search was performed using Medline, Embase, and the Cochrane Databases to identify all articles published from January 2000 to November 2019 comparing the management of CVO with venoplasty and/or stenting in the setting of ipsilateral hemodialysis access fistulae/grafts.

RESULTS

There were 655 patients with 456 stenoses and 208 occlusions who were treated; 288 underwent venoplasty and 345 underwent stenting. Twenty-two patients failed intervention owing to an inability to traverse the occlusion. The most affected vein was the brachiocephalic vein. A superior primary patency (PP) is noted in those treated with stenting compared with venoplasty in the first 2 years. Overall, both treatments are suboptimal demonstrating a 12-month PP rate of less than 60%. Assisted PP and secondary patency rates were similar for both venoplasty and stenting with a 12-month secondary patency rate of 77.8% to 91.6% for venoplasty and 89.6% to 98.4% for stenting. Periprocedural and long-term complications were rare for both interventions, occurring in 2% of patients.

CONCLUSIONS

Although both treatments demonstrated poor patency rates, greater PP is noted for stenting in the first 2 years. Coupled with low complication rates, this finding highlights a potential benefit of stenting as a first-line treatment for CVO. Allowing for the overall poor quality of current studies, even this short-term improvement in PP may benefit patients undergoing hemodialysis. Further research with randomised control trials as well as assessment of adjuvant techniques such as drug-coated stents and balloons, anticoagulant therapy, and the role of intravascular ultrasound use is required.

Intracranial hemorrhage due to central venous occlusion from hemodialysis access: A case report

Central venous stenosis in hemodialysis patients rarely causes venous hypertension and intracranial hemorrhage. A 54 year-old male with right arm arteriovenous fistula was transferred to our institution in a comatose state following right parietal venous infarction. Fistulography showed right brachiocephalic vein (BCV) occlusion with reflux into the right transverse sinus and obstruction of left internal jugular vein outflow due to the styloid process. Balloon venoplasty of the right BCV occlusion failed to improve the patient's status because of the delayed diagnosis. Headaches and neurologic symptoms in hemodialysis patients can herald intracranial hypertension due to central venous occlusion and needs prompt assessment with fistulography.

Malfunctioning temporary hemodialysis catheters in patients with novel coronavirus disease 2019

Objective

The hypercoagulability seen in patients with novel coronavirus disease 2019 (COVID-19) likely contributes to the high temporary hemodialysis catheter (THDC) malfunction rate. We aim to evaluate prophylactic measures and their association with THDC patency.

Methods

A retrospective chart review of our institutions COVID-19 positive patients who required placement of a THDC between February 1 to April 30, 2020, was performed. The association between heparin locking, increased dosing of venous thromboembolism (VTE) prophylaxis and systemic anticoagulation on THDC patency was assessed. Proportional hazards modeling was used to perform a survival analysis to estimate the likelihood and timing of THDC malfunction with the three different prophylactic measures. We also determined the mortality, rate of THDC malfunction and its association with d-dimer levels.

Results

A total of 48 patients with a mortality rate of 71% were identified. THDC malfunction occurred in 31.3% of patients. Thirty-seven patients (77.1%) received heparin locking, 22 (45.8%) received systemic anticoagulation, and 38 (79.1%) received VTE prophylaxis. Overall, the rate of THDC malfunction was lower at a trend level of significance, with heparin vs saline locking (24.3% vs 54.6%; P = .058). The likelihood of THDC malfunction in the heparin locked group is lower than all other groups (hazard ratio [HR], 0.07; 95% confidence interval [CI], 0.01-0.45]; P = .005). The rate of malfunction in patients with subcutaneous heparin (SQH) 7500 U three times daily is significantly lower than of the rate for patients receiving none (HR, 0.03; 95% CI, 0.001-0.74; P = .032). A trend level significant association was found for SQH 5000 U vs none (P = .417) and SQH 7500 vs 5000 U (P = .059). Systemic anticoagulation did not affect the THDC malfunction rate (P = .240). Higher d-dimer levels were related to greater mortality (HR, 3.28; 95% CI, 1.16-9.28; P = .025), but were not significantly associated with THDC malfunction (HR, 1.79; 95% CI, 0.42, 7.71; P = .434).

Conclusions

Locking THDCs with heparin is associated with a lower malfunction rate. Prospective randomized studies will be needed to confirm these findings to recommend locking THDC with heparin in patients with COVID-19. Increased VTE prophylaxis suggested a possible association with improved THDC patency, although the comparison lacked sufficient statistical power.

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.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

[Thoracic Central Venous Occlusive Disease and Haemodialysis Access]

Benign central venous thoracic occlusion is a frequent issue in haemodialysis patients. Symptomatic stenosis affects quality of life and can cause dysfunction of arteriovenous access or make it impossible to implant a haemodialysis catheter. Common risk factors for the development of the occlusions are central venous catheters and cardiac rhythm devices. The gold standard for diagnosis is venous angiography. Treatment of asymptomatic lesions can lead to clinical deterioration and should be avoided. The primary method of treatment for symptomatic patients is endovascular therapy. Repeat balloon angioplasty is a standard therapy. In case of elastic recoiling or early recurrence, placement of bare metal stent or stent graft could be considered. Surgical options should be preserved only for refractory cases. Further randomised trials are needed to prove the efficacy of new devices, such as dedicated venous stents and drug coated balloons.

Outcomes of the Gore Excluder abdominal aortic aneurysm leg endoprosthesis for treatment of central vein stenosis or occlusion in patients with chronic hemodialysis

OBJECTIVE

Central venous occlusive disease is a critical complication in long-term hemodialysis patients with arteriovenous (AV) dialysis circuits. The purpose of this retrospective, single-arm cohort study was to evaluate the effectiveness of an abdominal aortic aneurysm (AAA) contralateral leg endoprosthesis to treat symptomatic central venous occlusive diseases in patients with chronic hemodialysis.

METHODS

A prospective cohort study included 60 patients on hemodialysis presenting with central venous stenosis or occlusion, who were treated with a Gore Excluder AAA contralateral leg stent graft between December 2013 and July 2018. Follow-up angiography was obtained at 3, 6, and 12 months. The outcomes and duration of primary circuit and target site patency were measured from the time of the stent graft implantation to the first reintervention for AV circuit dysfunction and target site restenosis. Secondary patency was calculated from stent graft implantation to the point when AV access was no longer attainable.

RESULTS

Circuit primary patency rate was 54.9% at 1 year of Gore Excluder AAA contralateral leg or iliac extender stent grafts, implanted in 60 hemodialysis patients with central vein occlusive disease. Cumulative target site primary patency rate was 88.3% at 1 year. Secondary patency rate was 95% during follow-up. Patients with concomitant lesions had a significantly higher risk of circuit primary patency dysfunction.

CONCLUSIONS

Treatment of central vein obstructions in hemodialysis patients with stent grafts has been appealing owing to the tapered shape with a larger diameter and the availability of various lengths.

Clinical relevance of the left brachiocephalic vein anatomy for vascular access in dialysis patients

INTRODUCTION

Most hemodialysis patients start renal replacement therapy with a central venous catheter (CVC). The left internal jugular vein (LIJV) is the second-choice vein for CVC positioning, after the right IJV. However, to reach the right atrium, the CVC must pass through the left brachiocephalic vein (LBV), which also drains blood from the left arm through the subclavian vein. The purpose of this study is to describe how the anatomy of the central venous system and in particular that of the LBV affects vascular access in hemodialysis patients.

MATERIALS AND METHODS

Three-dimensional (3D) virtual model reconstructions of the central thoracic veins of three hemodialysis patients were obtained from contrast-enhanced computed tomography scans acquired in the venous phase. The images were exported as DICOM files and loaded on open-source software for visualizing and analyzing the medical imaging (3D Slicer, Windows version 4.8.1).

RESULTS

As expected, the 3D reconstructions showed that the LBV has a tortuous path with three main angulations that could be associated with external compression and stenosis. These could determine the difficulties and increased risks of venous injury during CVC placement, and an increased risk of medium to long-term catheter-associated vein thrombosis and stenosis.

CONCLUSIONS

The anatomical features of the LBV indicate that the path of a CVC from the LIJV to the right atrium is tortuous and can easily be complicated by vein injury, negatively affecting the creation of future arterio-venous vascular accesses in the left arm.

Comparison of Percutaneous Transluminal Angioplasty with Stenting for Treatment of Central Venous Stenosis or Occlusion in Hemodialysis Patients: A Systematic Review and Meta-analysis

OBJECTIVES

A common cause of hemodialysis vascular access dysfunction, a primary cause of morbidity and mortality in patients undergoing hemodialysis, is central venous stenosis or occlusion. The present study compared percutaneous transluminal angioplasty (PTA) with percutaneous transluminal angioplasty and stent placement (PTS) for treatment of central venous stenosis or central vein occlusion in hemodialysis patients.

METHODS

A systematic literature review was conducted using database searches of PubMed, Cochrane, and Embase. Articles were selected using the Population/Intervention/Comparator/Outcomes (PICO) process. Outcomes included the rate of procedural success, primary patency, assisted primary patency, re-intervention subjects, re-intervention rate, and adverse events.

RESULTS

A total of eight studies were included in the meta-analysis with subjects in the PTA group (n = 281) or PTS group (n = 192). Primary patency rate between PTA and PTS groups at 3-, 6-, 12-, or 24-month follow-up was not different (all p > 0.05). Patients treated with PTA had greater assisted primary patency rates than the PTS group (OR = 1.03, 1.73, 1.03, and 2.00 at 3, 6, 12, and 24 months, respectively). However, the statistical assessment only showed significantly at 24-month follow-up (p = 0.01).

CONCLUSIONS

The present meta-analysis revealed that, compared to PTS, PTA may provide increased assisted primary patency for endovascular treatment of central vein stenosis or occlusion in patients undergoing hemodialysis.

LEVEL OF EVIDENCE

Level 3a.

Efficacy and safety of a mother-child technique for recanalization of chronic central venous occlusive disease in hemodialysis patients

OBJECTIVE

There is no optimal treatment for central vein occlusive disease that remains a major contributor to vascular access impairment. This study aimed to review the outcomes of percutaneous treatment with a mother-child technique in the treatment of symptomatic central venous stenosis (CVS) and central venous occlusion (CVO) in patients on hemodialysis.

METHODS

Data were collected retrospectively and included all consecutive patients with CVS or CVO who were treated with percutaneous angioplasty and stenting. The occlusive lesions were crossed using the mother-child technique with an angiographic catheter-in-guiding catheter system.

RESULTS

A total of 36 patients with symptomatic CVS and 45 patients with total CVO were included. The average age and gender composition were similar between the two groups. Patients with CVO had higher prevalence of diabetic nephropathy than CVS (24.4% vs 5.6%; P < .05). Lesion success, device success, and procedural success were achieved in 36 (100%), 1 (100%), and 36 (100%) patients in the CVS group and in 43 (95.6%), 11 (100%), and 43 (95.6%) patients in the CVO group, respectively. There were no severe complications or procedure-related deaths in either group. During follow-up (median, 6 months), the primary patency rates were 89.7% (CVS) and 81.0% (CVO) at 6 months and were 54.2% (CVS) and 47.1% (CVO) at 12 months. The assisted primary patency rates were 100% (CVS) and 91.2% (CVO) at 6 and 12 months.

CONCLUSIONS

With extra backup support of the mother-child technique, percutaneous treatment provides an effective and safe method for recanalization of chronic venous occlusion in patients on hemodialysis.

Long-segment central venous occlusion in a hemodialysis patient treated by segmented sharp recanalization strategy: A case report

INTRODUCTION

Among hemodialysis population, central vein occlusion (CVO) is a common complication. Percutaneous transluminal angioplasty has become the mainstay treatment these days. But the treatment of long-segment central venous occlusion remains difficult.

PATIENT CONCERNS

We presented a 73-year-old man on maintenance hemodialysis complaining of swelling of the right arm and face for 20 days. The patient underwent maintenance hemodialysis via a right internal jugular vein catheter for first 2 months of dialysis while the initial right radiocephalic wrist arteriovenous fistula (AVF) blood flow had been unsatisfactory (below 180 mL/min) for 1 month.

DIAGNOSIS

Digital subtraction angiography revealed long-segment CVO extending from the right subclavian vein (SV) to the right innominate vein (IV), forming an obvious included angle at the right jugular angle.

INTERVENTIONS

Since conventional guide wire transversal failed, segmented sharp recanalization was performed by separate transversal of the obstructive right SV and right IV, therefore crossing the whole lesion segment by segment, followed by balloon dilation and stent placement.

OUTCOMES

No procedure-related complication was recorded during or after the operation. After a follow-up period of 5 months, the patient's AVF maintained satisfactory in blood flow, while the edema in his ipsilateral limb and face also notably ameliorated.

CONCLUSION

The segmented sharp recanalization is a practical strategy in treating angled long-segment CVO which is refractory to traditional guide wire transversal in hemodialysis patients.

Inter-observer agreement of color duplex ultrasound of central vein stenosis in hemodialysis patients

Purpose

To assess the inter-observer agreement of color duplex ultrasound of central vein stenosis in hemodialysis patients.

Patients and methods

This prospective study was conducted on 35 hemodialysis patients with suspected central vein stenosis. All patients underwent color flow duplex examination of the subclavian, internal jugular and brachiocephalic veins in hemodialysis patients. Image analysis was performed by two reviewers for diameter reduction, peak venous velocity ratio, post-stenotic turbulent flow, waveform changes, and thrombus formation.

Results

There was no significant difference between both observers for diameter reduction ( p = 0.105) and for the mean peak systolic velocity ratio ( p = 0.515). The overall inter-observer agreement of color duplex ultrasound of central vein stenosis was excellent ( k = 0.84, percent agreement = 89.7%, P = 0.001). There was excellent inter-observer agreement of both reviewers for diameter reduction ( k = 0.928, percent agreement = 97.14%), peak venous velocity ratio ( k = 0.7, percent agreement = 85.7%), waveform changes ( k = 0.62, percent agreement = 77.14%), post-stenotic turbulent flow ( k = 0.866, percent agreement = 88.6%), thrombus formation ( k = 1, percent agreement = 100%).

Conclusion

We concluded that color duplex ultrasound is a reliable and reproducible method for diagnosis of central vein stenosis in hemodialysis patients.

Intracranial Venous Reflux Caused by Occlusion of the Brachiocephalic Vein Mimicking Dural Arteriovenous Fistula

BACKGROUND

High signal intensity of cerebral venous sinuses on magnetic resonance angiography (MRA) indicates high flow of shunt from arterial blood, suggesting dural arteriovenous fistula (dAVF). Herein, we describe the cases of 2 patients with intracranial venous reflux caused by brachiocephalic vein occlusion (BVO) mimicking dAVF on MRA.

CASE DESCRIPTION

Case 1 was a 71-year-old woman who had received arteriovenous graft (AVG) surgery for hemodialysis and presented with headache. MRA depicted high signal intensities in the left jugular vein, inferior petrosal sinus, and ophthalmic vein suggesting intracranial dAVF. However, cerebral angiography revealed intracranial venous reflux through the jugular vein caused by BVO. After balloon angioplasty with stenting for BVO, normal venous drainage was restored and her symptoms resolved. Case 2 was a 62-year-old woman who had received AVG for hemodialysis and was hospitalized due to seizure. MRA revealed high signal intensities of the left transverse-sigmoid sinus and jugular vein, and it was suspected that they were associated with BVO. She did not receive immediate intervention because of her septic condition. The patient ultimately died of fatal intracranial hemorrhage and subarachnoid hemorrhage.

CONCLUSIONS

Central venous occlusion may occur in patients with end-stage renal disease who are receiving AVG for hemodialysis. Intracranial venous reflux resulting from BVO can induce various neurologic disorders including intracranial venous hypertension or hemorrhage. Prompt recognition and implementation of endovascular treatment can be beneficial in cases of symptomatic central venous occlusion.

Leadless pacemaker placement in a patient with chronic kidney disease: A strategy to preserve central veins

Cardiac rhythm disorder is frequently encountered in hemodialysis patients and is often treated with a cardiovascular implantable electronic device (CIED). The conventional CIED requires placement of transvenous leads resulting in subclinical central venous stenosis, which can adversely affect the successful creation of a permanent dialysis vascular access. The technological advancement of a leadless pacemaker provides an opportunity to implement a strategy to preserve central veins in patients with chronic kidney disease. We report a case of successful placement of a leadless pacemaker in a dialysis patient to preserve the central veins for future vascular access creation.

A technique for the salvage of megafistulas allowing immediate dialysis access

OBJECTIVE

Almost two million individuals are undergoing renal replacement therapy worldwide, with hemodialysis being the common form. Many factors influence the primary patency of an arteriovenous fistula (AVF), including vessel size, fistula flow rates, cannulation practice, and thrombotic tendencies. Excess dilation of the AVF, resulting in the development of a megafistula, is a complication that can result in a need for AVF revision and subsequent failure.

METHODS

The charts of patients who underwent autogenous AVF revision because of the development of a megafistula with aneurysmectomy and vein transposition by a single surgeon during a 7-year period from 2009 through 2016 were reviewed. A technique is described in which after aneurysmorrhaphy, the repaired venous component of the AVF is transposed through a new tunnel while the vein is rotated 90 degrees. This allows the AVF to be accessed immediately, making placement of a tunneled dialysis catheter unnecessary.

RESULTS

There were 102 patients included in the study, with follow-up ranging from 7 to 95 months. In our cohort, 92 of the 102 revised AVFs (90.2%) maintained primary functional patency. Of the 102 patients who underwent this revision technique, there were 10 fistulas that subsequently failed after a mean of 29 months. There were only seven patients who experienced recurrent fistula dilation requiring repeated aneurysmectomy.

CONCLUSIONS

We describe a technique for management of the development of a megafistula that uses only autogenous tissue and, perhaps most important, eliminates the need for temporary dialysis catheter placement.

Recommended Clinical Trial End Points for Dialysis Catheters

Central venous catheters are used frequently in patients on hemodialysis as a bridge to a permanent vascular access. They are prone to frequent complications, including catheter-related bloodstream infection, catheter dysfunction, and central vein obstruction. There is a compelling need to develop new drugs or devices to prevent central venous catheter complications. We convened a multidisciplinary panel of experts to propose standardized definitions of catheter end points to guide the design of future clinical trials seeking approval from the Food and Drug Administration. Our workgroup suggests diagnosing catheter-related bloodstream infection in catheter-dependent patients on hemodialysis with a clinical suspicion of infection (fever, rigors, altered mental status, or unexplained hypotension), blood cultures growing the same organism from the catheter hub and a peripheral vein (or the dialysis bloodline), and absence of evidence for an alternative source of infection. Catheter dysfunction is defined as the inability of a central venous catheter to (1) complete a single dialysis session without triggering recurrent pressure alarms or (2) reproducibly deliver a mean dialysis blood flow of >300 ml/min (with arterial and venous pressures being within the hemodialysis unit parameters) on two consecutive dialysis sessions or provide a Kt/V≥1.2 in 4 hours or less. Catheter dysfunction is defined only if it persists, despite attempts to reposition the patient, reverse the arterial and venous lines, or forcefully flush the catheter. Central vein obstruction is suspected in patients with >70% stenosis of a central vein by contrast venography or the equivalent, ipsilateral upper extremity edema, and an existing or prior history of a central venous catheter. There is some uncertainty about the specific criteria for these diagnoses, and the workgroup has also proposed future high-priority studies to resolve these questions.

Left Brachiocephalic Vein Stenosis due to the Insertion of a Temporal Right Subclavian Hemodialysis Catheter

Central vein stenosis/occlusion is a common well-described sequel to the placement of hemodialysis catheters in the central venous system. The precise mechanisms by which central vein stenosis occurs are not well known. Current concepts in central vein stenosis pathophysiology focus on the response to vessel injury model, emphasizing the process of trauma. A case of left brachiocephalic vein stenosis due to the insertion and function of a temporary right subclavian hemodialysis catheter is presented. The purpose of the manuscript is to emphasize that, with the introduction of a temporary subclavian hemodialysis catheter via the right subclavian vein apart from causing concurrent stenosis/infarction of the right subclavian and right brachiocephalic vein, it is also possible to cause stenosis of the left brachiocephalic vein (close to its contribution to the superior vena cava) although the catheter tip is placed in the correct anatomical position in the superior vena cava.

Central venous catheters for chronic hemodialysis: Is "last choice" never the "right choice"?

Since the publication of the first vascular access clinical practice guidelines in 1997, the global nephrology community has dedicated significant time and resources toward increasing the prevalence of arteriovenous fistulas and decreasing the prevalence of central venous catheters for hemodialysis. These efforts have been bolstered by observational studies showing an association between catheter use and increased patient morbidity and mortality. To date, however, no randomized comparisons of the outcomes of different forms of vascular access have been conducted. There is mounting evidence that much of the difference in patient outcomes may be explained by patient factors, rather than choice of vascular access. Some have called into question the appropriateness of fistula creation for certain patient populations, such as those with limited life expectancy and those at high risk of fistula-related complications. In this review, we explore the extent to which catheters and fistulas exhibit the characteristics of the "ideal" vascular access and highlight the significant knowledge gaps that exist in the current literature. Further studies, ideally randomized comparisons of different forms of vascular access, are required to better inform shared decision making.

Cytokine Signature in End-Stage Renal Disease Patients on Hemodialysis

Hemodialysis is a modality of blood filtration in which accumulated toxins and water are removed from the body. This treatment is indicated for patients at the end stage of renal disease. Vascular access complications are responsible for 20–25% of all hospitalizations in dialyzed patients. The occurrence of thrombosis in the vascular access is a serious problem that may severely compromise or even make the hemodialysis impossible, which is vital for the patient. The aim of this study was to investigate inflammatory profile in patients undergoing hemodialysis as well as the association between these alterations and vascular access thrombosis. A total of 195 patients undergoing hemodialysis have been evaluated; of which, 149 patients had not experienced vascular access thrombosis (group I) and 46 patients had previously presented this complication (group II). Plasma levels of cytokines including interleukin (IL-) 2, IL-4, IL-5, IL-10, TNF-α, and IFN-γ were measured by cytometric bead array. Our results showed that patients with previous thrombotic events (group II) had higher levels of the IL-2, IL-4, IL-5, and IFN-γ when compared to those in group I. Furthermore, a different cytokine signature was detected in dialyzed patients according to previous occurrences or not of thrombotic events, suggesting that elevated levels of T-helper 1 and T-helper 2 cytokines might, at least in part, contribute to this complication.