Proximal Venous Outflow Obstruction Research Articles

Persistent symptoms after endovenous thermal ablation may suggest proximal venous outflow obstruction

ObjectiveProximal venous outflow obstruction (PVOO) in the iliac veins and superficial venous disease are inter-related in ways not fully understood. We observed among our patients undergoing vein stent placement for PVOO a significant number having had prior endovenous thermal ablations (EVTA) in their history. This study was undertaken to better characterize these patients and develop an algorithm in their management. MethodsIn a combined retrospective and prospective data registry of 682 patients who underwent vein stent placement for chronic PVOO at a single institution from March 2013 to November 2017, 100 limbs of 99 patients (14.5% of all patients) had a history of EVTA or other superficial venous procedures before their vein stenting. Limbs with dilated truncal veins on ultrasound examination or limbs that underwent poststent EVTA or superficial venous procedures were excluded. The mean age of these 99 patients was 60.2 years (range, 28-88 years; standard deviation, 13.855). Fifty-one percent of the patients were male. The most common presenting symptom of the patient cohort was edema (n = 59), followed by venous-related skin changes (n = 22). ResultsBilateral stents were performed in 58%, with a mean number of 2.06 stents per patient. EVTA was the primary superficial vein procedure in 97%. Bilateral EVTA were performed in 53% and unilateral EVTA in 47%. The mean time between the first EVTA to vein stenting was 1202.7 days. Patients were followed at 30 days, 90 days, 6 months, 1 year, and >1 year. The outcome for each patient at each postoperative visit was compared with preoperative parameters (subject's assessment, physical examination, and provider assessment) and was scored as follows: -1 (worse than preoperative), 0 (no change), +1 (mildly improved), +2 (significantly improved), or +3 (completely recovered). The mean outcome score at 30 days was 1.63 (84 patients), 2.05 at 90 days (62 patients), 2.09 at 6 months (74 patients), 1.93 at 1 year (54 patients), and 1.97 at >1 year (39 patients). ConclusionsApproximately 15% of patients undergoing vein stent placement for chronic PVOO have an antecedent history of superficial venous disease and EVTA. PVOO should be considered and the patient evaluated accordingly if symptoms persisted or recurred after EVTA. Vein stent placement among these patients with PVOO will result in further symptomatic relief, but complete symptomatic relief is not observed in everyone. The algorithm for the management of these patients warrants further investigation.

Virchow’s triad in “silent” deep vein thrombosis

ObjectiveWhile determining the incidence of chronic deep vein thrombosis (DVT) and the hypercoagulation profiles of patients who underwent venous stenting for symptomatic venous insufficiency, we assessed the significance of Virchow's triad in the setting of proximal venous outflow obstruction and DVT. MethodsWithin our registry of 500 patients who underwent venous stenting for proximal venous outflow obstruction between 2013 and 2016, we selected the first 152 consecutive patients who had routine hypercoagulation profile testing performed preoperatively. Statistical analysis was performed using independent t-tests, χ2 tests, and multiple logistic regressions. ResultsBy history or intraoperative chronic postphlebitic changes (CPPCs), 77 patients (50.7%) were positive for remote DVT; 51 (33.6%) had intraoperative findings of CPPCs without a history of DVT, 20 (13.2%) had intraoperative CPPCs with a history of DVT, and 6 (3.9%) had a history of DVT without intraoperative findings. The χ2 tests were significant for increased findings of CPPCs among patients with a history of DVT (81% vs 38%; P < .01). The χ2 tests were also significant for increased rates of intraoperative findings of CPPCs in patients with one or more positive hypercoagulation markers (67% vs 42%; P < .01). The most significant predictor for findings of CPPCs or DVT history was the presence of at least one hypercoagulation marker (n = 148; odds ratio, 2.41; P = .022). ConclusionsRemote history of DVT and intraoperative findings of CPPCs were prevalent. CPPC findings were found in many patients with no history of DVT. Hypercoagulation markers conferred significant predictive value for DVT. This information may influence our understanding of Virchow's triad and DVT etiology.

Secondary interventions after iliac vein stenting for chronic proximal venous outflow obstruction

ObjectiveIliac vein stent placement is an increasingly common procedure in the treatment of chronic proximal venous outflow obstruction (PVOO), but secondary interventions after vein stent placement remain poorly characterized. Our goal was to identify the incidence, indications, operative findings, and outcomes of secondary interventions after the primary iliac vein stent procedure at a single institution. MethodsWe retrospectively reviewed the clinical history of 490 patients (57.6% female, 42.4% male; mean age, 60.77 years [range, 18-92 years]; 93.28% follow-up, with a mean follow-up of 308.59 days) who underwent iliac vein stent placement for PVOO between October 2013 and January 2016. We evaluated the clinical presentation, intraoperative findings, and outcomes of those patients requiring a secondary intervention after an initial iliac vein stent procedure. ResultsSecondary interventions after an initial stent placement were identified in 50 of 490 patients (10.2%; mean age, 61.54 years [range, 19-92 years]; 58% female [n = 29]). At the time of each individual intervention, 1, 18, 17, 1, and 13 patients had Clinical, Etiology, Anatomy, and Pathophysiology class 2, 3, 4, 5, and 6 disease, respectively. Of these 50 patients, 58% (n = 29) of secondary interventions were due to recurrence of symptoms after the initial stent surgery, 18% (n = 9) were due to the development of new symptoms, and 24% (n = 12) were due to persistence of symptoms. The primary cause of PVOO in the patient cohort was 52% (n = 26) extrinsic iliac vein compression, 28% post-thrombotic, and 20% mixed. Intraoperative findings during the secondary intervention included malposition or angulation of the stent (6% [n = 3]); acute deep venous thrombosis/thrombosis (14% [n = 7]); an additional lesion, that is, stenosis in a native iliac vein proximal or distal to the original lesion (68% [n = 34]); stenosis within the stent, that is, stent stenosis without finding of thrombus or isolated, focal intrastent thrombosis (38% [n = 19]); and impairment of flow of the contralateral vessel from the previously placed stent (6% [n = 3]). The types of secondary interventions included placement of a new stent (86% [n = 43]), isolated balloon angioplasty alone (10% [n = 5]), and catheter pharmacomechanical thrombectomy (14% [n = 7]). Symptomatic improvement was observed after the secondary intervention in 90% of patients (n = 45), whereas only 2% (n = 1) of patients experienced only a transient improvement, and 8% of patients (n = 4) reported no improvement in their symptoms after the secondary interventions. ConclusionsThis study establishes a secondary intervention rate of 10.2% after iliac vein stent placement for chronic PVOO and identifies discrete and definable intraoperative findings as targets for quality improvement. The very good results strongly suggest that an aggressive approach to treatment of these complications is warranted.

Anticoagulation after Iliofemoral Vein Stenting - Old Versus New.

In recent years, there has been an increasing interest in endovascular iliofemoral vein stenting to prevent/ alleviate symptoms related to proximal venous outflow obstruction. Maintaining long-term stent patency is one of the main challenges, and risk factors for the development of re-thrombosis are not well understood. Published data on the safety and efficacy of the procedure predominantly come from cohort studies mainly focusing on mechanical aspects relating to stent placement and flow. Aetiology of thrombus formation and thrombotic tendencies of patients due to underlying medical conditions are not captured well or linked to clinical outcomes, and the impact of choice and length of antithrombotic therapy have not been specifically investigated. Here, we review different procedure-related factors and patient characteristics that might increase the risk of re-thrombosis and the utility of antithrombotic treatment options currently available.

Secondary Interventions after Vein Stent Placements: Why Do Venous Stents Fail?

This study was undertaken to better characterize the secondary interventions after venous stenting for chronic, proximal venous outflow obstruction. A retrospective study of 486 patients (mean age, 59.7 years; range, 19-91 years; SD 13.5 years; 56% female; 91% had edema; CEAP class III 66.7%; CEAP class VI 11.1%; bilateral iliac stents placement 58%; 30-day follow-up 89.4%; mean follow-up duration >320 days) who underwent 545 consecutive venous stenting for chronic proximal venous outflow obstruction between January 2013 and October 2016 at single institution. Wilcoxon Mann-Whitney tests used in categorical variables (comorbidities). Simple logistic regressions for interval variables (total stent length). Multiple logistic regressions used to analyze 6-month, 1-year, and 3-year reintervention rates. Reintervention rates were 5.7% (n = 31), 10.8% (n = 59), and 16.5% (n = 90) at 6 months, 1 year, and 3 years, respectively. The most common findings during reinterventions were new or previously missed lesions in the native vessel (n = 56, 10.3%) and in-stent stenosis (n = 24, 4.4%). Other findings included contralateral iliac venous outflow obstruction owing to unilateral inferior vena cava iliac stents 3.5% (n = 19), stent malposition 2.4% (n = 13), and acute stent thrombosis 1.5% (n = 8). Univariate analysis revealed postthrombotic state (28.2% vs 12.7%; P < .001), hypertension (20.8% vs 12.9%; P = .017), diabetes (26.1% vs 14.5%; P = .003), higher CEAP classes (OR, 1.28; P = .017) were associated with a higher risk of reintervention. Patients who had larger stent diameters (18-20 mm vs 16 mm; OR, 0.94; P < .001) and a higher number of stents placed during initial intervention (OR, 0.63; P = .001) were at a lower risk of reintervention. Multivariate analysis showed that patients who are postthrombotic (OR, 2.35; P = .001), diabetic (OR, 1.85; P = .033), and with smaller stent diameters (OR, 1.06; P = .003) were at a higher risk of reintervention. Assessment for 3 years after vein stenting for chronic proximal venous outflow obstruction demonstrates an acceptable incidence of reinterventions. Stenosis in a native vein, either new or missed from initial stent procedure, was the most common finding. Impairment of contralateral venous outflow infrequently complicated unilateral inferior vena cava/common iliac stents placed for May-Thurner syndrome. Acute stent thrombosis was an infrequent finding. Many reinterventions seemed preventable with modifications in the initial procedure.

Venous Stenting in Proximal Venous Outflow Obstruction: Outcome Predictors

The objective of this study was to identify risk factors, including patient and surgical characteristics, associated with postoperative outcomes after iliac vein stenting for chronic proximal venous outflow obstruction (PVOO). The study is based on a composite retrospective and prospective database of 628 patients who underwent iliac vein stent placement for chronic PVOO at a single institution from January 2013 to April 2017. Patient characteristics, clinical presentation, and outcomes at 30 days, 90 days, 6 months, 1 year, and >1 year were queried. Univariate and multivariate ordinal regression, with stepwise backward elimination, was used to determine predictors of postoperative outcomes at various time points. Demographic characteristics included 351 (55.9%) women and mean age of 59.7 years. Edema was present in 568 (93%) patients. History of varicose veins or presence of varicose veins at the time of surgery was observed in 431 (70.4%) patients. Active ulceration was present in 94 (15%) patients. Clinical, Etiology, Anatomy, and Pathophysiology class 3 was noted for 69.4%. Bilateral stenting was performed in 385 (63.2%) patients. Univariate analysis showed that improvement in outcomes at 30 days was associated with edema (odds ratio [OR], 2.7; confidence interval [CI], 1.4-5.0; P = .002) and active ulceration (OR, 1.6; CI, 1.0-2.6; P = .03). Poorer outcomes at 30 days were associated with bilateral stenting (OR, 0.62; CI, 0.44-0.88; P = .007). At 90 days, improvement was associated with varicose veins (OR, 1.6; CI, 1.0-2.4; P = .03), edema (OR, 3.2; CI, 1.5-6.8; P = .002), and history of vein surgery (OR, 1.7; CI, 1.2-2.5; P = .008). At 6 months, univariate analysis demonstrated that being female (OR, 0.62; CI, 0.40-1.00; P = .03) resulted in poorer outcomes. Patients who had edema had better outcomes at 1 year (OR, 5.5; CI, 1.8-17.4; P = .003) and at >1 year (OR, 6; CI, 1.5-24.5; P = .013). At 30 days, multivariate analysis showed that the effects of edema and bilateral stenting persisted. At 90 days, the effects of edema and history of vein surgery persisted. In addition, multivariate analysis revealed that a history of deep venous thrombosis (DVT; OR, 0.405; CI, 0.213-0.771; P = .0059) resulted in poorer outcomes at 90 days, whereas active ulcerations (OR, 2.447; CI, 1.337-4.479; P = .0037) resulted in better outcomes. The effect of sex on outcomes at 6 months persisted. At outcomes >1 year, multivariate analysis revealed that acute DVT (OR, 0.111; CI, 0.015-0.838; P = .0331), DVT history (OR, 0.313; CI, 0.116-0.843; P = .0216), and bilateral stenting (OR, 0.349; CI, 0.132-0.921; P = .0335) were associated with poorer outcomes. Outcomes of iliac vent stenting are affected by multiple factors. Patients with edema are likely to benefit from iliac vein stenting. The benefits of venous stenting in active ulcers warrant further investigation as unreported here is the frequency of negative venography and IVUS among patients with active ulcers. Our findings may guide selection of patients and better counsel patients about the outcomes of venous stents in chronic PVOO.

Experience With Vein Stent Placement for Proximal Venous Outflow Obstruction at One Center

Experience With Vein Stent Placement for Proximal Venous Outflow Obstruction at One Center

PC186 Silent Deep Venous Thrombosis: Associations With Proximal Venous Outflow Obstruction and Hypercoagulation Markers

PC186 Silent Deep Venous Thrombosis: Associations With Proximal Venous Outflow Obstruction and Hypercoagulation Markers

PC188 Outcomes of Iliac Vein Stenting in Proximal Venous Outflow Obstruction

PC188 Outcomes of Iliac Vein Stenting in Proximal Venous Outflow Obstruction

IP259 Persistent Symptoms After Endovenous Thermal Ablation: Proximal Venous Outflow Obstruction in Superficial Venous Disease

IP259 Persistent Symptoms After Endovenous Thermal Ablation: Proximal Venous Outflow Obstruction in Superficial Venous Disease

PC184 Delayed Conversion to Kissing Stent Configuration in the Setting of Unilateral Iliac Vein Stenting

Iliac vein stents are being increasingly used to treat chronic proximal venous outflow obstruction. Among patients with unilateral stenting in the proximal common iliac vein with extension into the inferior vena cava (IVC), a small number of patients presented with venous symptoms related to outflow obstruction of the contralateral common iliac vein. While the incidence of this complication of iliac vein stenting is unknown, this abstract presents one technical approach to this complication. We present 11 patients with outflow obstructive symptoms in the contralateral iliac vein after a prior IVC common iliac vein stent placement. Postanesthesia, ultrasound guidance is used to obtain access to the common femoral vein bilaterally. Inferior vena cavograms and venograms of the iliac veins are undertaken using contrast in digital subtraction mode. Intravascular ultrasound (IVUS) using a Volcano Visions PV .035 Digital IVUS catheter (Volcano Corporation, San Diego, Calif) is then used to evaluate the iliac veins and assess the degree of stenosis in each vein segment. The use of IVUS is critical to locate the narrow channel present between the contralateral stent and wall of the IVC, assist passage of the guidewire through this narrow channel, and ensure that the guidewire does not pass through the interstices of the stent (Fig 1). Balloon angioplasty is seldom necessary. The initial guidewire is then exchanged for a stiff 0.35-inch × 180-cm guidewire. Next, a 16-mm or 18-mm stent is positioned alongside the existing stent in a kissing iliac stents configuration. After the newly placed stent is deployed, both stents are simultaneously dilated with either 16-mm or 18-mm balloons (Fig 2). Finally, a completion venogram and IVUS confirm fully expanded stents. This procedure was performed in 11 patients (6 males, 5 females), with three performed on the right iliac vein and eight on the left iliac vein. The mean time to development of contralateral occlusive symptoms was 626 days from the initial stenting. Average follow-up time from the second stenting was 167 days, with no postoperative complications. Eight patients reported significant symptomatic improvement in their newly treated limb at 30 days postoperatively, while 10 patients did at 90 days postoperatively. No patients reported any worsening symptoms in either limb. Delayed conversion to a kissing stent configuration can be considered for treatment of contralateral iliac vein outflow obstruction in the setting of previous unilateral iliac vein stenting.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Secondary Interventions After Iliac Vein Stenting for Chronic Proximal Venous Outflow Obstruction

Iliac stent placement is an increasingly common procedure in the treatment of chronic proximal venous outflow obstruction (PVOO), but secondary interventions after vein stent placement remain poorly characterized. Our goals were to identify the incidence, indications, operative findings, and outcomes of secondary interventions after the primary iliac vein stent procedure in a single institution. We retrospectively reviewed the clinical history of 490 patients (42.41% male; mean age, 60.77 years [range, 18-92 years]; 93.28% follow-up with a mean follow-up of 308.59 days) who underwent iliac stent placement (Wallstent; Boston Scientific, Marlborough, Mass) for PVOO between October 2013 and June 2016. We specifically evaluated the clinical presentation, intraoperative findings, and outcomes among those patients who required a secondary intervention after an initial iliac vein stent procedure. Secondary interventions after an initial stent placement were identified in 50 of 490 patients (10.2%; mean age, 61.54 years [range, 19-92 years]; 58% female [n = 29]). Among these 50 patients, 56% (n = 28) of secondary interventions were due to recurrence of symptoms after the initial stent surgery, 24% (n = 12) were due to the development of new symptoms, and 20% (n = 10) were due to persistence of symptoms. Intraoperative findings during the secondary intervention included migration of the stent (8% [n = 4]), acute deep venous thrombosis/thrombosis (12% [n = 6]), an additional lesion (ie, stenosis in a native iliac vein proximal or distal to the original lesion; 50% [n = 25]), stenosis within the stent (stent stenosis without finding of thrombus or isolated, focal intrastent thrombosis; 16% [n = 8]), impairment of flow of the contralateral vessel from the previous stent (12% [n = 6]), and no finding (2% [n = 1]). The types of secondary interventions were placement of a new stent (80% [n = 40]), isolated balloon angioplasty alone (6% [n = 3]), and catheter PMT (14% [n = 7]). Significant symptomatic improvement was observed after the secondary intervention in 90% of patients (n = 45); 2% (n = 1) of patients experienced only a transient improvement, and 8% of patients (n = 4) reported no improvement in their symptoms. This study establishes a secondary intervention rate of 10% after iliac vein stent placement for chronic PVOO, identifies discrete and definable intraoperative findings as targets for quality improvement, and indicates that secondary interventions after vein stent placement are associated with a good outcome.

Magnetic Resonance Imaging in Proximal Venous Outflow Obstruction

Proximal venous outflow obstruction (PVOO) in the abdomen and pelvis is increasingly recognized as an important contributor to venous disease of the lower extremity. There are currently no guidelines regarding a noninvasive screening tool for PVOO, although magnetic resonance venography (MRV) is commonly used in many practices. The objective of this study was to determine the value and utility of MRV in diagnosis and screening for PVOO. This retrospective study consisted of 46 consecutive patients, all of whom presented with signs and/or symptoms of PVOO and were evaluated with MRV followed by intravascular ultrasound (IVUS) and venography. Of these 46 patients suspected to have PVOO based on clinical evaluation, 24 patients had PVOO confirmed with IVUS and venography and PVOO was not observed on IVUS and venography in the remaining 22 patients. The MRV of these 46 patients was retrospectively reviewed in a blinded fashion and then correlated with IVUS and venography by 1 vascular surgeon. A scoring system was developed to define the types of radiography findings that were observed: normal, suspicious, and abnormal. When compared with IVUS and multiplane venography, the interpretation of MRV had a sensitivity of 100% and a specificity of 22.7%. The positive predictive value of MRV was 58.5%, and the negative predictive value was 100%. The high sensitivity (100%) and low specificity (22.7%) of MRV suggest that it can be a screening tool at best, used only to rule out PVOO; it cannot be used to confirm PVOO, given its a 41.5% false positive rate. Thus, the development of a different, noninvasive diagnostic test that can more accurately assess patients with suspected PVOO during the initial evaluation of their lower-extremity venous disease should be explored.

Prevention and treatment of venous ulcers in primary chronic venous insufficiency

Prevention and treatment of venous ulcers in primary chronic venous insufficiency

Surgical Bypass of Symptomatic Central Venous Obstruction for Arteriovenous Fistula Salvage in Hemodialysis Patients

Venous hypertension due to proximal central venous outflow obstruction coexisting with a functioning arteriovenous fistula in the ipsilateral arm presents with a complex management problem in hemodialysis patients. Ligation of the arteriovenous communication is the simplest procedure to relieve symptoms; however, this sacrifices the patient's hemodialysis access, which may be the only available access in that patient. Surgical bypass of the occlusion is a potential option as it obviates the symptoms of venous hypertension while preserving dialysis access. Our objective was to evaluate our experience and outcome with dialysis patients undergoing surgical bypass for symptomatic central venous obstruction and dialysis access salvage. There were three hemodialysis patients with severe venous hypertension secondary to subclavian vein obstruction who had functioning ipsilateral arteriovenous fistulae. All underwent cephalic vein (n = 2) or axillary vein (n = 1) to internal jugular vein bypass of the obstructed subclavian segment via an 8-mm polytetrafluoroethylene bridge graft. All patients had unsuccessful percutaneous transluminal angioplasty (PTA) attempts prior to surgical bypass. In two patients, a wire could not be passed through the occlusion; in the third, PTA was only transiently successful despite four repeated procedures. All patients had complete resolution of symptoms without operative mortality. The bypass grafts remained patent, allowing the arteriovenous fistulae to provide functional access for the entire duration of follow-up after surgery (3-8 months). Surgical bypass of a central vein obstruction relieves the symptoms of venous hypertension and prolongs the use of the existing hemodialysis access. This surgical option should be well recognized within the dialysis community.

Proximal lower extremity chronic venous outflow obstruction: Recognition and treatment

As postthrombotic disease becomes better understood, the importance of venous outflow obstruction is recognized increasingly. It appears that obstruction of the iliac vein is particularly important and results in more severe symptoms than more distal segmental blockages. Unfortunately, no accurate invasive or noninvasive test for the evaluation of obstruction is available. In fact, it is not known what degree of venous stenosis should be considered hemodynamically "critical." Thus, currently it is impossible to detect borderline obstructions of potential hemodynamic significance. A high index of suspicion must be maintained. The diagnosis relies on clinical signs and symptoms, and treatment must be based on results of morphologic investigations such as transfemoral phlebography or, preferably, intravascular ultrasonography. Percutaneous iliac venous balloon dilation and insertion of a stent offers a safe and efficient method to correct pelvic venous obstruction. It is less invasive and relatively safer than open surgery and can, therefore, be offered to a larger group of patients. Furthermore, initial percutaneous management does not preclude subsequent bypass or reflux surgery. Although the technique is recent and follow-up relatively short, there is cautious optimism that this treatment will be useful and replace bypass surgery for iliac venous obstruction.

Proximal lower extremity chronic venous outflow obstruction: Recognition and treatment

Proximal lower extremity chronic venous outflow obstruction: Recognition and treatment

Efficacy of color flow duplex imaging for proximal upper extremity venous outflow obstruction in hemodialysis patients

Purpose: The efficacy of color flow duplex imaging (CFDI) in detecting proximal upper extremity venous outflow obstruction in hemodialysis patients was compared with that of traditional contrast venography. Methods: From 1993 through 1997, all hemodialysis patients who were evaluated for upper extremity venous outflow obstruction of the axillary, subclavian, or brachiocephalic veins with both CFDI and venography were identified. Medical history, hemodialysis access procedures, and indications for imaging were reviewed. The diagnostic accuracy of CFDI was compared with that of venography for proximal venous outflow obstruction, including focal stricture, partial obstruction, or complete occlusion. Results: Sixty upper extremities in 42 hemodialysis patients were imaged with both CFDI and venography. Previous ipsilateral intravenous dialysis catheters had been present in 33 (55%) of the extremities imaged; current catheters were present in 16 (27%) of the extremities imaged; and 28 (67%) of the extremities imaged had a current ipsilateral arteriovenous (AV) shunt. Five (8%) of the 60 duplex scans were nondiagnostic because of artifact from intravenous dialysis catheters (3) or incomplete visualization of the subclavian or brachiocephalic veins (2) and were excluded from further analysis. In the remaining 55 duplex scans, proximal venous outflow obstruction was found in 18 (33%), compared with 21 (38%) identified by means of venography ( P = not significant [NS]). Overall sensitivity, specificity, positive predictive value, and negative predictive value for CFDI were 81%, 97%, 94%, and 89%, respectively. Conclusion: CFDI is a reliable means of detecting proximal upper extremity venous outflow obstruction and should replace contrast venography as the initial imaging study in hemodialysis patients. (J Vasc Surg 1998;28:869-75.)

Efficacy of color flow duplex imaging for proximal upper extremity venous outflow obstruction in hemodialysis patients

Efficacy of color flow duplex imaging for proximal upper extremity venous outflow obstruction in hemodialysis patients

Proximal Venous Outflow Obstruction in Patients With Upper Extremity Arteriovenous Dialysis Access

To evaluate the impact of central venous obstruction on upper extremity hemodialysis access failure, we retrospectively analyzed our recent experience in managing this problem. We reviewed 158 upper extremity hemodialysis access procedures performed in 122 patients during a 1-year period. Fourteen (11.5%) patients had central vein obstruction as the cause of severe arm swelling, graft thrombosis, or graft malfunction. All 14 patients had had bilateral temporary subclavian vein dialysis catheters and failed upper extremity arteriovenous access. Seventeen lesions were treated in 14 patients including eight subclavian vein occlusions, six subclavian vein stenoses, two internal jugular vein stenoses, and one superior vena cava stenosis. Twenty-one procedures were performed including 17 percutaneous transluminal balloon angioplasties (PTAs) with stent placement in 13, two axillary to innominate vein bypasses, and two axillary to internal jugular vein bypasses. All patients had resolution of symptoms. Thirteen (76%) PTAs were initially successful but in four (24%) cases it was impossible to recanalize the vein. Eight (47%) PTAs provided functional hemodialysis access for 2 to 9 months, two (12%) restenosed at 3 and 10 months and were successfully redilated, two occluded at 2 and 4 months and were unable to be recanalized, and one failed immediately after a successful PTA. Four PTA failures were followed by venous bypass, which remained patent and provided functional access 7 to 13 months after surgery. Of nine stenotic venous lesions six (67%) were successfully dilated without restenosis, whereas of eight occluded veins only two (25%) were successfully treated without recurrence. Temporary central hemodialysis catheters produce a significant number of symptomatic central vein obstructions in patients with upper extremity arteriovenous access.(ABSTRACT TRUNCATED AT 250 WORDS)