MO767CENTRAL VEIN STENOSIS: FROM DIAGNOSTICS TO TREATMENT STRATEGY

Abstract

Abstract Background and Aims To analyze the screening and prognostic value of various diagnostic signs of central vein stenosis (CVS). Method The retrospective study included 549 patients with AVF/AVG dysfunction. 211 patients were diagnosed with CVS, other patients had lesions of peripheral venous segments. In case of vascular access dysfunction, patients were examined according to the local protocol: ultrasound examination of peripheral (to exclude damage of the peripheral AVF segments) and central veins (at an accessible length) was performed, followed by CT angiography or percutaneous angiography, if necessary. Results Among various clinical signs only limb edema and dilated veins on the chest demonstrated high sensitivity. Aneurysmal dilatation of an AVF was more common in peripheral lesions (CVS RR<1). It should be considered that the clinical signs itself are more likely to be associated with the peripheral lesion than CVS (high NPV value) – table 1. “Indirect dialysis signs” also have very low screening efficacy (Se and Sp) and prognostic values – table 2. Ultrasound signs have low screening accuracy, but high prognostic values. In other words, in the presence of ultrasound signs, patient is likely to have CVS with high probability – table 3. When comparing the frequency of correct and incorrect classifications for different types of lesion, ultrasound accuracy exceeds the clinical picture for types of lesion 1C and 1D (according to the types of lesion in Society of Interventional Radiology Reporting Standards for Thoracic Central Vein Obstruction, doi: 10.1016/j.jvir.2017.12.013): RR= 3,433 [95% CI 2,074; 6,132], p<0.0001 and RR= 2,538 [95% CI 1,592; 4,265], p<0.0001, respectively, but not for lesion types 2B and 3: RR=1.583 [95% CI 0.935; 2.779], p=0.0883 and RR=1 [95% CI 0.231; 4.325], p >0.9999, respectively. In total, incorrect CVS type classifications is noted in 30.7% of cases when using ultrasound imaging. CT angiography and percutaneous angiography are almost 100% effective in the diagnosis of CVS. However, CT angiography is not always informative when AVF is functioning and the volume blood flow is high. In turn, percutaneous angiography does not always allow to assess the condition of the veins of the contralateral side. At the same time, correct detection of lesion type is pivotal to determine the future strategy of providing the patient with permanent vascular access. For example, the patient has very little chance to get functional AVF in case of with two-sided subclavian vein stenosis. Conclusion The CVS diagnostics should be comprehensive, using different methods for screening, confirming CVS and determining of it type.