Left innominate vein stenosis in an asymptomatic population: a retrospective analysis of 212 cases

Clinical characteristics of hemodialysis patients with left brachiocephalic vein obstruction due to extrinsic compression or prior catheterization

BACKGROUND

Left brachiocephalic vein (LBCV) stenosis is a common complication in hemodialysis patients and is a heterogenous disorder associated with either prior catheterization or extrinsic compression. This study aimed to characterize patients with LBCV stenosis or occlusion with and without a history of central venous catheterization.

METHODS

We performed a retrospective study in 84 hemodialysis patients with LBCV stenosis or occlusion with (n = 22) or without (n = 62) prior catheterization. We compared the clinical features, anatomical factors, restenosis after balloon venoplasty, and patency rates of patients in these two groups.

RESULTS

In the cohort of 84 patients with LBCV stenosis or occlusion, 73.8% (62 patients) of them had no history of catheterization. Patients without prior catheterization had more stenotic lesions (p < 0.05) but less occlusive lesions (p < 0.05) than patients with prior catheterization. The space between the sternum and the aorta was narrower in patients without prior catheterization than that in patients with prior catheterization (p < 0.05). Percutaneous venography was performed in 81 patients, and the occurrence of recoil after venoplasty in patients without prior catheterization was significantly higher than that in patients with prior catheterization (p < 0.05). The rate of stent implantation was significantly higher in patients without prior catheterization than patients with prior catheterization (p < 0.05), whereas there was no significant difference in primary patency between the two groups.

CONCLUSIONS

LBCV stenosis and occlusion are mainly due to extrinsic compression rather than prior central venous catheterization. Stent implantation is frequently required after venoplasty to treat LBCV obstructive lesions in patients without prior catheterization.

Prevalence of Central Venous Stenosis among Black and White ESKD Patients with Dysfunctional Dialysis Access

In the United States, significant racial and ethnic disparities exist in chronic kidney disease (CKD) and its management. Hemodialysis constitutes the main stay of renal replacement therapy for end-stage kidney disease (ESKD), which is initiated using central venous catheters (CVC) in most CKD patients in the United States. Black ESKD patients have higher usage and greater time on CVC for hemodialysis compared to White patients. This trend places Black patients at a potentially higher risk for CVC-related complications such as central venous stenosis (CVS). We posited that Black patients would have a higher prevalence and a greater risk of CVS. A retrospective review was performed of ESKD patients who underwent a fistulogram for dialysis access malfunction. CVS was defined as > 50% stenosis in the central veins. Fistulograms of 428 ESKD patients were adjudicated, and CVS was noted in 167 of these patients. Of the entire cohort, 370 fistulograms belonged to self-reported unique Black and White ESKD patients, of whom 137 patients were noted to have CVS. There was no difference in the of CVS between Black (40%) and White (41%) ESKD patients. However, a higher severity of stenosis (>70%) (P = 0.03) was noted in White ESKD patients. An unadjusted model showed a significant association between CVS and cardiovascular disease and the use of CVCs. The risk-adjusted model showed a significant association between diabetes and CVS. Unlike arterial stenotic lesions, this work for the first time demonstrated higher prevalence of severe venous stenotic lesions in White ESKD patients and linked diabetes to stenotic venous disease. This work paves the way for future studies investigating the risk and influence of race and ethnicity on CVS using a larger and diverse data set.

A Rare Cause of Difficult Catheterization to the Left Brachiocephalic Vein during Transfemoral Transvenous Embolization

Objective

We experienced a case of difficult catheterization to the left brachiocephalic vein (LBCV) during transfemoral transvenous embolization for traumatic carotid-cavernous fistula. We discussed the cause of this phenomenon.

Case Presentation

A 78-year-old woman with a traumatic carotid-cavernous fistula was treated with combined transarterial and transvenous embolization; however, catheterization to the LBCV was very difficult. A balloon guiding catheter (BGC) already placed in the left common carotid artery (LCCA) caused displacement of the LCCA and further compression of the originally stenotic LBCV.A CT investigation of 104 cases of neuroendovascular treatment in our hospital revealed that the distance between the ventral bones and the dorsal arteries sandwiching the LBCV was significantly negatively correlated with age (r = -0.41, p = 0.000020). Aging and arteriosclerotic change are possibly related to the LBCV stenosis.

Conclusion

When catheterization to the LBCV is difficult during transfemoral transvenous embolization, not only the presence of anatomical variations and stenosis or occlusion of LBCV itself but also compression from surrounding structures should be considered, especially in elderly patients. In rare cases, a catheter inserted in an adjacent artery may cause further compression of the LBCV.

Analysis of the positional relationship between the left brachiocephalic vein and its surrounding vessels via computed tomography scan: A retrospective study

OBJECTIVES

This study aimed to clarify the positional relationship between the left brachiocephalic vein and its surrounding vessels and to analyse the association between this positional relationship and ageing.

METHOD

Chest contrast-enhanced computed tomography was performed for 100 adults. The contact number between left brachiocephalic vein and surrounding vessels (aorta, brachiocephalic artery, left common carotid artery and left subclavian artery) was determined. The correlations of ageing with the cross-sectional areas of left brachiocephalic vein crossing brachiocephalic artery and left common carotid artery and peripheral end of left brachiocephalic vein were analysed.

RESULTS

LBV was in contact with aorta in 19, brachiocephalic artery in 97, left common carotid artery in 90 and left subclavian artery in 21 patients. There were significant negative correlations of ageing with the cross-sectional areas of left brachiocephalic vein crossing brachiocephalic artery and left common carotid artery and peripheral end of left brachiocephalic vein.

CONCLUSIONS

Brachiocephalic artery and left common carotid artery have easy contact with left brachiocephalic vein. There was a negative relationship between the cross-sectional area of left brachiocephalic vein and age.

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.

The left brachiocephalic vein 'spur': A cadaveric and contrast computed tomography study

Objectives

This study investigated the presence of the ‘spur’ which separates the lumen in the left brachiocephalic vein (LBV).

Method

We macroscopically observed the lumen of the bilateral brachiocephalic veins and the superior vena cava in 56 cadavers. The samples were treated with haematoxylin and eosin staining and immunostaining using an α-smooth muscle action antibody. Contrast-enhanced computed tomography images from 170 subjects were analysed.

Results

The septal structure was found in only 7% of LBVs included in the cadaveric study and 1.2% of LBVs included in the contrast-enhanced computed tomography image analysis. In the cadaveric study, the septal structure was identified as a ‘spur’ using histopathology. In both studies, a non-septal structure was found in the right brachiocephalic vein.

Conclusions

This is the first report indicating the existence of an LBV ‘spur’.

Central Venous Stenosis, Access Outcome and Survival in Patients undergoing Maintenance Hemodialysis

BACKGROUND AND OBJECTIVES

Central venous catheters have traditionally provided access for urgent hemodialysis, but are also sometimes advocated as an option for older or more comorbid patients. Adverse effects of this type of dialysis access include central venous stenosis, for which the risk factors and consequences are incompletely understood.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted two studies within the same population cohort, comprising all patients starting hemodialysis in a single center from January 2006 to December 2013. First, patients were retrospectively analyzed for the presence of central venous stenosis; their access outcomes are described and survival compared with matched controls drawn from the same population. Second, a subset of patients with a history of catheter access within this cohort was analyzed to determine risk factors for central venous stenosis.

RESULTS

Among 2811 patients, central venous stenosis was diagnosed in 120 (4.3%), at a median dialysis vintage of 2.9 (interquartile range, 1.8-4.6) years. Compared with matched controls, patients with central venous stenosis had similar survival (median 5.1 versus 5.2 years; P=0.54). Among a subset of 500 patients, all with a history of catheter use, 34 (6.8%) developed central venous stenosis, at a rate of 2.2 per 100 patient-years. The incidence of central venous stenosis was higher with larger number of previous catheters (relative risk [RR], 2.2; 95% confidence interval [95% CI]. 1.6 to 2.9), pacemaker insertion (RR, 3.9; 95% CI, 1.7 to 8.9), and was lower with older age (RR, 0.7 per decade; 95% CI, 0.6 to 0.8). In a Cox proportional hazards model, the catheter number, pacemaker, and younger age at dialysis initiation were all significant independent risk factors for central venous stenosis.

CONCLUSIONS

Central venous stenosis occurred in a minority of patients on hemodialysis, and was associated with compromised future access, but unchanged survival. Among patients with a history of catheter use, risk related to both the number of catheters and the total catheter duration, although nondialysis factors such as pacemakers were also important. Central venous stenosis risk was lower in older patients, supporting the selective use of tunneled catheters in this group.

Ultrasound-Guided Pharmacomechanical Thrombolysis and Angioplasty for Treatment of Acute Thrombotic Prosthetic Arteriovenous Access: 5-Year Experience with 154 Procedures in a Single Center

Pharmacomechanical thrombolysis (PMT) and percutaneous transluminal angioplasty (PTA) for the treatment of acute thrombotic prosthetic arteriovenous access (PAVA) are conventionally guided by radiography, which may cause radiation injury and requires the use of radiographic contrast media. The aim of the present study was to summarize our experience with ultrasound-guided PMT and PTA as an alternative to radiographic guidance. Between December 2012 and October 2016, 114 patients with acute thrombosis of PAVA were treated urgently with ultrasound-guided PMT and PTA to restore blood flow. The patients were followed up every 3 mo postoperatively. The 114 included patients underwent 154 episodes of ultrasound-guided PMT and PTA and were followed up for a mean of 20.7 ± 9.1 mo. The technical success rate was 91.6%, and the clinical success rate was 97.4%. Post-intervention-assisted primary patency rates at 3, 6, 12 and 24 mo were 90.8%, 78.8%, 66.3% and 50.9%, respectively. Post-intervention secondary patency rates at 3, 6, 12 and 24 months were 96.3%, 94.5%, 90.6% and 85.4%, respectively. PMT and PTA for the treatment of PAVA were performed successfully under the guidance of ultrasound with a success rate similar to that under radiographic guidance, thus avoiding radiation injury and contrast medium use, although close surveillance and timely intervention are imperative to ensure long-term patency.