Subclavian Vein Stenosis Research Articles

Combination treatment of venous thoracic outlet syndrome: Open surgical decompression and intraoperative angioplasty

Residual subclavian vein stenosis after thoracic outlet decompression in patients with venous thoracic outlet syndrome is often treated with postoperative percutaneous angioplasty (PTA). However, interval recurrent thrombosis before postoperative angioplasty is performed can be a vexing problem. Therefore we initiated a prospective trial at 2 referral institutions to evaluate the safety and efficacy of combined thoracic outlet decompression with intraoperative PTA performed in 1 stage. Over 3 years 25 consecutive patients (16 women, 9 men; median age, 30 years) underwent treatment for venous thoracic outlet syndrome with a standard protocol at 2 institutions. Twenty-one patients (84%) underwent preoperative thrombolysis to treat axillosubclavian vein thrombosis. First-rib resection was performed through combined supraclavicular and infraclavicular incisions. Intraoperative venography and subclavian vein PTA were performed through a percutaneous basilic vein approach. Postoperative anticoagulation therapy was not used routinely. Venous duplex ultrasound scanning was performed postoperatively and at 1, 6, and 12 months. Intraoperative venography enabled identification of residual subclavian vein stenosis in 16 patients (64%), and all underwent intraoperative PTA with 100% technical success. Postoperative duplex scans documented subclavian vein patency in 23 patients (92%). Complications included subclavian vein recurrent thrombosis in 2 patients (8%), and both underwent percutaneous mechanical thrombectomy, with restoration of patency in 1 patient. One-year primary and secondary patency rates were 92% and 96%, respectively, at life-table analysis. Residual subclavian vein stenosis after operative thoracic outlet decompression is common in patients with venous thoracic outlet syndrome. Combination treatment with surgical thoracic outlet decompression and intraoperative PTA is a safe and effective means for identifying and treating residual subclavian vein stenosis. Moreover, intraoperative PTA may reduce the incidence of postoperative recurrent thrombosis and eliminate the need for venous stent placement or open venous repair.

Axillary to saphenous vein bypass for treatment of central venous obstruction in patients receiving dialysis

Venous hypertension due to subclavian or innominate vein stenosis coexisting with a functioning arteriovenous access in the ipsilateral arm is a complex problem in patients undergoing hemodialysis. Therapeutic solutions must optimally relieve symptoms, permit use of the angioaccess, and carry minimal surgical risk. The purpose of this study was to evaluate a simple surgical option, bypassing central venous obstruction to the great saphenous vein. Eight patients undergoing hemodialysis with severe symptoms and signs of venous hypertension due to subclavian or innominate vein obstruction and ipsilateral arteriovenous fistula or graft underwent axillosaphenous bypass via a subcutaneous 8-mm polytetrafluoroethylene bridge graft. No intraoperative or immediate postoperative morbidity was observed. Early and 6-month patency rates were 100% and 87.5%, respectively. All patients reported improvement of symptoms, and the angioaccess was usable in all cases. Average follow-up was 21.5 months. One patient had a relapse at 5 months, which necessitated revision of the graft-saphenous vein anastomosis. Bypassing a central vein occlusion to the saphenous vein relieves symptoms of venous hypertension and prolongs use of the hemodialysis angioaccess.

Cases from the Osler Medical Service at Johns Hopkins University

PRESENTING FEATURES: A 36-year-old African American woman was admitted with a history of chills, fever, productive cough, and malaise of several days' duration, as well as an increase in baseline dyspnea on exertion. Her past medical history was notable for hemodialysis-dependent end-stage renal disease due to hypertension. Two years before admission, she successfully underwent angioplasty for a right subclavian vein stenosis due to a dialysis catheter. Nine months before admission, she had a new arteriovenous fistula placed in her right forearm because the fistula in her left arm had repeated complications, including pseudoaneurysm formation and thrombosis. Since placement of the new fistula, she noticed a steady, gradual increase in the size of her right breast and right upper arm. She also slowly developed worsening dyspnea on exertion, as well as back pain associated with her enlarged breast. A mammogram performed 3 months before admission revealed substantial vascular and lymphatic engorgement in the right breast but no distinct mass. The left breast had similar, although less dramatic, changes, as well as a 2.0- × 1.5-cm mass in the left lower quadrant. On physical examination, the patient was febrile (103.9 oF), with a heart rate of 123 beats per minute, blood pressure of 192/114 mm Hg, and oxygen saturation of 99% on room air. She was a moderately obese woman in mild distress. Her left breast was dysplastic. Her right breast was massively enlarged (Figure 1), about eight times the size of her left breast, with peau d'orange skin changes (Figure 2). There were no palpable masses in either breast. Numerous large subcutaneous veins were visible over her right breast, right arm, upper abdomen, and posterior chest. She had posterior cervical subcentimeter lymphadenopathy with no palpable axillary lymph nodes. Breath sounds were markedly diminished in the lower half of her right lung field with dullness to percussion in this area. Heart sounds were normal with an elevated jugular venous pressure to the level of the jaw. Her abdomen was benign. Extremities were normal except for an edematous, enlarged right arm. Neurologic examination was normal. Laboratory studies were normal except for an elevated blood urea nitrogen concentration and creatinine levels that were consistent with chronic renal failure. A chest radiograph showed a moderate right pleural effusion and small left pleural effusion. Chest computed tomographic (CT) scan with contrast confirmed these findings and also revealed dependent atelectasis overlying both pleural effusions, asymmetrical thickening, enlargement of soft tissue in the right breast, multifocal nodular opacities in bilateral lung fields, and dilation of the internal mammary vein, azygous venous system, and chest wall veins. A right thoracentesis revealed transudative fluid with negative cultures and normal cytopathology. What is the diagnosis?

Symptomatic Subclavian Vein Stenosis and Occlusion in Hemodialysis Patients with Transvenous Pacemakers

The objective of this study was to determine the incidence and timing of complications associated with ipsilateral transvenous pacemakers and hemodialysis access, including subclavian vein stenosis and occlusion, and assess their impact on dialysis access patency. All patients who had pacemakers placed at St. Francis Medical Center were reviewed during the 10-year period from 1988 to 1998. Patients requiring chronic hemodialysis were identified and their demographic data, the presence of arm swelling, and fistula patency were noted. Development of subclavian vein stenosis and occlusion was documented by venography in symptomatic patients. The ultimate outcome of dialysis access was recorded. During the 10-year period 495 patients had transvenous pacemakers placed. Twenty patients were identified with renal failure requiring hemodialysis and 14 had hemodialysis access in the extremity ipsilateral to the pacemaker. Ten (10/14, 71%) patients developed symptoms of subclavian stenosis, including venous hypertension, high recirculation rate, arm swelling, pain, and neurologic symptoms. Eighty percent (8/10) of symptomatic patients had subclavian vein occlusion. All 10 symptomatic patients required ligation of the hemodialysis access to control symptoms. The four asymptomatic patients expired within 6 months of placement of the pacemaker or hemodialysis access from unrelated causes. There is a high incidence of complications in patients who have ipsilateral pacemakers and hemodialysis access. The presence of pacemaker electrodes in the subclavian vein and the flow associated with hemodialysis may accelerate the occurrence of subclavian venous stenosis and occlusion. Patients who did not develop symptoms may have expired before venous outflow obstruction could develop. Vascular surgeons and cardiac surgeons/cardiologists need to coordinate their procedures to avoid ipsilateral transvenous pacemakers and hemodialysis access.

Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients

Objective: To evaluate the efficacy of stent placement for treating upper extremity central venous obstruction in chronic hemodialysis patients. Methods and Material: Between January 1999 and October 2001, we inserted metallic stents into the upper extremity central veins of 14 patients with shunt dysfunction and/or arm swelling. The indications for stent placement were stenosis or occlusion of the central vein in the upper extremity used for dialysis. Six of the individuals were diagnosed with subclavian vein stenosis, and 5 with brachiocephalic vein stenosis. Of the remaining 3 patients, 2 had subclavian vein occlusion, and 1 had left brachiocephalic vein occlusion. Results: All the stent placement procedures were technically successful, and there were no major complications. Follow-up ranged from 2 weeks to 29 months. The 1-, 3-, 6- and 12-month primary stent patency rates were 92.8, 85.7, 50 and 14.3%, respectively. Repeat interventions, including percutaneous transluminal angioplasty and additional stent placement, were required in 9 patients. The 3-, 6-, 12-month, and 2-year assisted primary stent patency rates were 100, 88.8, 55.5 and 33.3%, respectively. Conclusion: Endovascular stent placement is an effective alternative to surgery in patients with shunt dysfunction due to obstruction of an upper extremity central vein. Repeated interventions are usually required to prolong stent patency.

Unilateral breast enlargement: a rare complication of subclavian vein catheterization for hemodialysis

Radiologic findings of an unusual uremic case of marked unilateral breast enlargement due to subclavian vein stenosis after subclavian catheterization for hemodialysis are presented.

Prevalence of central venous occlusion in patients with chronic defibrillator leads

Background Many patients with previously implanted ventricular defibrillators are candidates for an upgrade to a device capable of atrial-ventricular sequential or multisite pacing. The prevalence of venous occlusion after placement of transvenous defibrillator leads is unknown. The purpose of this study was to determine the prevalence of central venous occlusion in asymptomatic patients with chronic transvenous defibrillator leads. Methods Thirty consecutive patients with a transvenous defibrillator lead underwent bilateral contrast venography of the cephalic, axillary, subclavian, and brachiocephalic veins as well as the superior vena cava before an elective defibrillator battery replacement. The mean time between transvenous defibrillator lead implantation and venography was 45 ± 21 months. Sixteen patients had more than 1 lead in the same subclavian vein. No patient had clinical signs of venous occlusion. Results One (3%) patient had a complete occlusion of the subclavian vein, 1 (3%) patient had a 90% subclavian vein stenosis, 2 (7%) patients had a 75% to 89% subclavian stenosis, 11 (37%) patients had a 50% to 74% subclavian stenosis, and 15 (50%) patients had no subclavian stenosis. Conclusions The low prevalence of subclavian vein occlusion or severe stenosis among defibrillator recipients found in this study suggests that the placement of additional transvenous leads in a patient who already has a ventricular defibrillator is feasible in a high percentage of patients (93%). (Am Heart J 2001;141:813-6.)

Failure of Wallstents in the subclavian vein due to stent damage

Subclavian vein stenosis and thrombosis are common problems in hemodialysis patients and in the Paget–von Schrötter syndrome. Besides surgery, several less-invasive strategies as balloon angioplasty, drug-induced or mechanical thrombolysis and stenting are used in the treatment of this condition. Three cases of recurrent venous obstruction of the subclavian vein treated with placement Wallstents are described. In all three patients, rethrombosis occurred due to stent failure, two involving stent fragmentation and one, stent collapse.

Use of the Superficial Femoral-Popliteal Vein to Salvage Dialysis Access

Long-term angioaccess for patients with chronic renal failure remains a serious challenge for the vascular surgeon. This report is of a 69-year-old man who had a well-functioning left Brescia fistula at the time of his pacemaker placement for life-threatening cardiac dysrhythmias. Following pacemaker placement, the patient developed left arm swelling, which involved the entire upper limb and failure of the hemodialysis access secondary to a left subclavian vein stenosis. After failed attempts at angioplasty and other endovascular procedures, the patient underwent successful placement of a left axillary vein to left internal jugular vein interposition graft using the left superficial femoral popliteal vein to salvage the dialysis access.

Hemodialysis for end-stage renal disease in children weighing less than 10 kg.

Hemodialysis (HD) of infants with end-stage renal disease (ESRD) is technically difficult and labor intensive, although there are few data in the literature to document the outcomes of this treatment. We retrospectively reviewed all patients with ESRD who received HD between 1983 and 1997 who weighed <10 kg at the beginning of HD. A total of ten patients aged 2-27 months, weighing 3.5-9.5 kg, were identified. All patients were dialyzed through a central venous line; three had a failed sapheno-femoral loop and one a failed brachial shunt. Line clot was observed in nine and line sepsis in six patients. Subclavian vein stenosis was documented in one patient following removal of a clotted subclavian line. The mean urea reduction ratios calculated during the 1st and 3rd month of HD were only 54% and 49%, respectively. Anemia was a frequent problem, despite the use of erythropoietin in seven of the infants. Outcomes included: successful renal transplant in four, switch back to peritoneal dialysis in two, improved renal function and dialysis discontinuation in one, and death after withdrawal of treatment in three patients. All three patients who died were <5 months of age, weighed <5 kg, and were anuric; two of the three had congenital nephrotic syndrome. In conclusion, successful HD is possible in small children with ESRD, but morbidity is substantial and mortality is high.

Hemodialysis Shunts-related Subclavian Vein Stenosis: Treatment with Self-expandable Metallic Stent

Purpose: To evaluate the usefulness of placement of self-expandable stents in hemodialytic shunt-related subclavian vein stenosis. Materials and Methods: Self-expandable metallic stent was placed in nine patients with hemodialytic shunt-related subclavian vein stenosis. In seven cases, angioplasty was attempted before stentplacement; in five, stents were placed immediately after failed angioplasty; and in two, due to restenosis after angioplasty. Procedures involved a 10mm diameter, 7-10cm length Wallstent in eight cases, and a 10mm diameter, 8cm length Hanaro stent in one. In all cases, clinical follow-up, which included physical examination and the measurement of venous resistance pressure during hemodialysis, was performed. The follow-up period was between 5months and 1 year 7 months. Repeated intervention was performed if restenosis was detected. Results : The stenoticsites were in eight cases the site of a previous subclavian venous line, and in one, the site of anatomic narrowing at the thoracic inlet of the subclavian vein. The technical success rate was 100%; a resulting complication was stent migration into the right atrium in one case in which a Hanaro stent had been used; this was removed by snaring. During follow-up of the eight patients in whon stent placement was successful, restenosis developed in three cases. This occurred during the 7th, 8th, and 15th month, respectively. Two such cases were treated by balloon dilatation. Conclusion: In hemodialytic shunt-related subclavian vein stenosis, treatment involving the use of a self-expandable metallic stent is useful, especially for treating a lesion which has not responded to angioplasty with a high patency rate.

Unilateral breast enlargement: Four case reports of an [ldquo ]unusual[rdquo ] presentation of central vein stenosis in patients undergoing hemodialysis

Subclavian vein stenosis is the most common late complication of subclavian vein catheterization for access for hemodialysis.1 Stenosis of the superior vena cava can also occur in this clinical setting.2 Patients with a concomitant ipsilateral arteriovenous fistula or prosthetic bridge graft and proximal venous stenosis may have upper extremity, neck, or chest wall edema.1 In female patients a stenotic lesion proximal to the junction of the internal mammary and subclavian veins with a concomitant arteriovenous shunt may cause unilateral breast edema that resembles inflammatory breast carcinoma in its presentation, thus posing a diagnostic dilemma.

Subclavian Vein Stenosis: A Potentially Serious Complication in Chronic Hemodialysis Patients with Permanent Cardiac Pacemakers

We report on two hemodialyzed patients in whom subclavian and brachiocephalic vein stenosis secondary to permanent cardiac pacemakers led to massive congestive edema of the same arm after arteriovenous fistula/grafts were created. Therapeutic solutions regarding hemodialysis access are discussed in these patients with permanent pacemakers requiring hemodialysis.

Initial experience with venous stents in exertional axillary-subclavian vein thrombosis.

Exertional thrombosis of the axillary and subclavian veins, also known as Paget-Schrötter syndrome, has been increasingly recognized in recent years as a cause of long-term morbidity. Recent aggressive approaches to treating Paget-Schrötter syndrome have suggested the association of early failure with residual subclavian vein stenosis. As a result, the use of endoluminal stents has been proposed as an aid to venous percutaneous transluminal angioplasty for this disorder. This report outlines the therapy of 11 consecutive patients with Paget-Schrötter syndrome who were treated at our institution between October, 1992, and December, 1995. Stents were placed when percutaneous transluminal angioplasty was unsuccessful at achieving an adequate residual lumen. Stents were placed after initial thrombolysis in six patients and in late follow-up in two patients. Of the six patients who had stents placed at initial thrombolysis, first-rib resection was eventually performed in four. In two patients first-rib resection was not performed, and stent fracture occurred in both. Late patency was achieved in the stents of six of the eight patients. Trials to evaluate stents as an adjunct to conventional therapy seem warranted. The use of stents alone without first-rib resection, however, appears to be associated with stent fracture.

Unsuspected subclavian vein stenosis resulting from a permanent pacing wire

Unsuspected subclavian vein stenosis resulting from a permanent pacing wire

Unsuspected subclavian vein stenosis resulting from a permanent pacing wire

Unsuspected subclavian vein stenosis resulting from a permanent pacing wire

Hemodialysis-associated axillary and subclavian vein stenosis: The failure of percutaneous angioplasty

Hemodialysis-associated axillary and subclavian vein stenosis: The failure of percutaneous angioplasty

Infection of a subclavian venous stent in a hemodialysis patient

Endovascular stent placement to prevent restenosis after angioplasty is being increasingly employed. A 63-year-old hemodialysis patient with a right forearm gortex graft developed ipsilateral arm edema, and a right subclavian vein stenosis was diagnosed. This vascular stenosis was presumably secondary to previous placement of temporary access catheters. The subclavian vein stenosis was treated with angioplasty, endovascular stenting, and warfarin, which resulted in resolution of the arm edema. Three weeks after stenting, the patient developed fever to 104°F, chills, and right arm and shoulder edema. All blood cultures grew Staphylococcus aureus, and an Indium-labeled white blood cell scan was positive at the sight of the subclavian stent. Infectious disease consultants recommended urgent removal of the infected stent, but the extensive surgery required posed considerable risk of major morbidity. We elected to conservatively treat the patient. With loss of all upper-extremity access sites, the patient was converted to peritoneal dialysis. Despite the patient's ambulatory status, a femoral venous Hickman catheter was placed and tunneled through the abdominal subcutaneous soft tissue. The patient received 9 weeks of antibiotics by the Hickman catheter with an infusion pump, and warfarin was continued. There has been complete clinical resolution of infection and subclavian thrombosis. Endovascular stents are being used more commonly, and this is the first description, to our knowledge, of a stent infection. The stent infection was successfully managed without surgical removal.

Subclavian Vein Repair in Patients With an Ipsilateral Arteriovenous Fistula

Management of subclavian vein occlusive disease in persons with an ipsilateral arteriovenous fistula can be challenging. From July 1991 to May 1993, nine patients underwent direct exploration and repair of an obstructed subclavian vein following medial claviculectomy. Eight patients had polytetrafluoroethylene (PTFE) grafts; one patient had a Brescia-Cimino fistula. Intractable arm edema was the major symptom in five of eight. The site of the occlusive disease ranged from the midsubclavian vein to the proximal innominate vein. Pathology varied from a focal occluding web to a long segment of intimal fibroplasia. Five veins were occluded; four were stenotic. Surgical procedures consisted of endovenectomy and vein patch (four), endovenectomy and PTFE patch (one), resection of a focal stricture with end-to-end anastomosis (two), resection with PTFE interposition (one), and end-to-end internal jugular to subclavian vein transposition (one). Postoperative contrast venograms revealed a patent subclavian vein in eight of eight patients. One patient died postoperatively from unrelated causes; two patients died with a functioning fistula 8 and 12 months, respectively, after surgery. Two grafts were removed for infection and one deteriorated graft was abandoned because of repeated thrombosis. Only three of nine original grafts are currently in use, including one in which the ipsilateral subclavian vein rethrombosed. Although stent placement may now be the preferred treatment for subclavian vein stenosis, vein repair may still have a role in the treatment of subclavian vein occlusion, particularly in patients with a Brescia-Cimino fistula.

The incidence of subclavian vein stenosis using silicone catheters for hemodialysis.

Complications related to the use of silicone subclavian catheters for hemodialysis were prospectively studied in 21 consecutive patients with acute and chronic renal failure. Between July 1991 and December 1992, 34 double-lumen silicone catheters (Medcomp; 12 French; 20 or 24 cm) were inserted in 21 patients. The mean duration of catheterization was 20 days (range, 2-58 days). Venograms were performed in 16 patients (22 subclavian veins) within 6 months following removal of the catheter. Excluded from angiography were patients whose catheters had been in place less than 1 week or who underwent fewer than 3 dialysis sessions because of minor risk of stenosis. Patients who had ipsilateral repeated catheters were also excluded. Two angiographies showed subclavian vein stenosis, both occurring in the same patient. One showed 50% stenosis with collaterals; one showed 50% stenosis without collaterals. One other complication was a pneumothorax. Catheter thrombosis was observed in 3 patients; catheter sepsis did not occur. We conclude that use of silicone catheters for subclavian cannulation is safe and effective to provide temporary vascular access for acute hemodialysis. The incidence of subclavian vein stenosis is lower compared with polytetrafluoroethylene and polyurethane catheters.