Invited Commentary Open Venous Bypass in the Era of Endovascular Therapy

Abstract

Central venous disease and obstruction in dialysis patients is a common problem and a cause of upper extremity access failure. Endovascular therapy, angioplasty and stenting, is the first line of therapy nowadays in treating central venous disease. However high failure rates and need for re-intervention due to external compression at the thoracic outlet led many to perform other salvage procedures like clavicle or rib resection 1. Glass C. Maevsky V. Massey T. et al. Subclavian vein to right atrial appendage bypass without sternotomy to maintain arteriovenous access in patients with complete central vein occlusion, a new approach. Ann Vasc Surg. 2009; 23: 465-468 Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar and even more creative ideas like percutaneous bypass. 2. Chiung-Yu Chen M. Weng M.J. Percutaneous extraanatomic bypass for treatment of central venous occlusions in patients undergoing hemodialysis. AJR Am J Roentgenol. 2020; 214: 477-481 Crossref PubMed Scopus (2) Google Scholar Open central venous bypass should be considered in patients, particularly younger patients, as their life depends on a functioning upper extremity bypass. In addition, most of them have symptoms related to superior vena cava syndrome. The big questions are who should get it? What algorithm should we follow? What is the long-term patency? In the current paper, 3. Uceda P.V. Feldtman R.W. Ahn S.S. Long term results of bypass graft to the right atrium in the management superior vena cava syndrome in fialysis patients. Ann Vasc Surg. 2021; (accepted for publication) Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar the authors provide the readers with some answers to all these questions based on their experience. The authors present a mix of 5 patients (3 with fistulas, 1 with dialysis graft and 1 with dialysis catheter) treated with atrial bypass with no mortality. From the authors’ affiliation, two are vascular surgeons and one is a cardiac surgeon. Having a multidisciplinary approach, vascular and cardiac surgeons along with other interventionlists, would identify and increase the enthusiasm for this open and durable procedure and help some of the dialysis patients who need it the most.