Surgical management of central venous occlusive disease in hemodialysis patients

Abstract

Background Central venous disease is a common and complex problem that compromises functioning access in patients undergoing hemodialysis which may result in loss of the access. Prior ipsilateral insertion of central venous catheters is a common risk factor. Percutaneous angioplasty with or without stenting is considered the primary method to treat central venous stenosis. However, it carries poor long-term patency rates and require multiple and repetitive interventions. Surgical options could be the choice if endovascular approaches are refractory or impossible. Aim The purpose of this retrospective, observational study is to report our experience in the surgical management to maintain hemodialysis access compromised by venous hypertension (VHTN) due to central venous occlusive disease. Patients and methods This is a retrospective analysis of 14 patients with existing upper extremity hemodialysis access who underwent extra-anatomic surgical bypass to treat symptomatic VHTN due to central vein occlusive disease after failure of endovascular management. Results Technical success was achieved in the 14 (100%) cases while clinical success occurred in 13 (92.6%) cases; 12 (85.7%) patients had performed their hemodialysis sessions via their preexisting access within 24 h postprocedurally. Maximum postoperative hospital stay was 3 days. No in-hospital morbidity or death was recorded. The mean primary and secondary patency were 18.3 and 22.7 months, respectively. Primary patency rates at 6, 12, 18, and 24 months were 85, 78, 64, and 57%, respectively. Secondary patency rates at 6, 12, 18, and 24 months were 92, 85, 71, and 64%, respectively. Conclusion Extra-anatomic surgical bypass of central venous obstruction is an effective and safe method to provide symptomatic relief of VHTN and salvage of existing access in hemodialysis patients when endovascular solutions are unfeasible.