Treatment Of Central Venous Occlusion Research Articles

Non-surgical Treatment of Central Venous Occlusion in Haemodialysis Patients

Background: Central venous stenosis (CVS) is often found in patients on hemodialysis. Prior ipsilateral central venous catheterization and cardiac rhythm insertion are major risk factors, however the lack of this history may potentially lead to CVS. Chronic CVS may lead to thrombosis at the point of stenosis with partial or total blockage of the central vein. Objective: To assess in patency, complication rate and death rates the impact of the endovascular repair of central vein blockage following arteriovenous fistula formation. Methods and patients: This potential non-randomized research will be carried out at the Nasr Insurance hospitals vascular chirurgy department. The trial will involve 20 individuals with chronic renal disease and limb edoema after the development of fistula. In accordance with the inclusion criteria listed below, the Ethical Committee shall receive permission. Results: Only 11 patients had balloon angioplasty. There were no immediate difficulties. Six patients with restenosis. One in six patients with PTA with stenting had restenosis. One patient developed recurrence in the stent on diagnostic venography (stenosis). All recurring patients had repeat PTA. Conclusion: Endovascular therapy in individuals who are hemodialysed is an effective and safe approach for the treatment of CVD. Without severe morbidity or death, there is a high technical success rate. Multiple re-interventions for the treatment of restenosis are nonetheless necessary.

Invited Commentary Open Venous Bypass in the Era of Endovascular Therapy

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.

Evaluating a Novel Telescoping Catheter Set for Treatment of Central Venous Occlusions

Central venous occlusive disease (CVOD) is a prevalent problem in patients with end-stage renal disease (ESRD) and can lead to access malfunction or ligation for symptomatic relief. The purpose of this study is to evaluate the efficacy of the TriForce® Peripheral Crossing Set (Cook Medical), a novel reinforced telescoping catheter set designed to provide additional support for crossing difficult central venous occlusions. This is a single-center retrospective study from a quaternary referral center. We identified 37 patients over a 17-month period who underwent 56 attempts at endovascular recanalization for the treatment of central venous occlusion. Technical success rates, procedural data, and outcomes were compared between those undergoing recanalization using traditional wire/catheter sets versus the TriForce catheter set. Average age was 48±2years. Comorbidities were similar between the two cohorts and included ESRD (61%), deep venous thrombosis (30%), and May-Thurner syndrome (7%). Forty attempts were made with traditional wire/catheter sets and 16 attempts with the TriForce catheter set to treat 2.1±0.2 and 1.9±0.3 occluded venous segments, respectively (P=0.74). Technical success rates were significantly higher for the group undergoing recanalization using the TriForce catheter (69% versus 38%, P=0.04) and 4 patients were successfully recanalized using the TriForce catheter set after a failed attempt with traditional wire/catheter sets. Mean fluoroscopy time and radiation dose were 13±3min and 14,623±2,775μGy∗m2 for traditional techniques versus 30±6min and 30,408±10,433μGy∗m2 for the novel telescoping catheter set (P=0.01 and 0.09, respectively). Freedom from reintervention at 1year was 60% for the TriForce cohort versus 44% for the traditional wire/catheter cohort (P=0.25). The novel TriForce reinforced telescoping catheter set is a useful adjunct that may improve recanalization rates of CVOD compared with traditional wire/catheter sets.

Percutaneous Extraanatomic Bypass for Treatment of Central Venous Occlusions in Patients Undergoing Hemodialysis.

OBJECTIVE. The pipeline technique has been described for percutaneous creation of a long extraanatomic bypass for a thrombosed hemodialysis vascular access in patients with outflow veins that cannot be recanalized. However, when we used the pipeline technique in nonthrombotic vascular access sites to create a bypass to treat central venous occlusion, we encountered two technical challenges not mentioned in previous reports: bleeding from the peripheral incision and difficulty in pushing the stent-graft catheter through the subcutaneous track. CONCLUSION. We report our solutions for these two technical challenges and the treatment outcomes of percutaneous extraanatomic bypass for central venous occlusion in patients undergoing hemodialysis with access-related upper limb swelling.

Surgical and endovascular central venous reconstruction combined with thoracic outlet decompression in highly symptomatic patients

BackgroundSubclavian vein stenosis or occlusion at the thoracic outlet is a problem associated with certain anatomic and environmental stresses (venous thoracic outlet syndrome [VTOS]), the presence of central venous catheters, and the high flows associated with arteriovenous (AV) access in the limb. We describe our experience with open and endovascular techniques for restoring patency in highly symptomatic patients. MethodsA prospectively collected database of patients was queried for patients treated for central venous obstructive disease in the setting of highly symptomatic VTOS and ipsilateral AV access from October 2011 to August 2016. ResultsDuring the study period, 54 procedures were performed in 53 patients (68% male; mean age, 50.1 years). Indications for operation were venous outflow obstruction in patients with conventional VTOS (n = 19) or costoclavicular junction stenosis associated with ipsilateral dialysis access (n = 34). All patients had significant symptoms of swelling or pain. Eight patients underwent on-table pharmacomechanical thrombolysis for acute occlusion. All patients underwent costoclavicular junction decompression, 48 by infraclavicular first rib resection and 5 by claviculectomy; 6 patients underwent sternoclavicular rotation (Molina procedure) in addition to rib resection for further exposure. Surgical reconstruction of the vein was employed in 18 patients (33%); 9 underwent interposition grafting, 1 had jugular turndown, and 8 had patch angioplasty. The one patient undergoing two procedures suffered acute occlusion after patch repair followed by jugular turndown. Four patients underwent surgical reconstruction after thrombolysis. Endovascular procedures were performed in 36 patients (67%); 23 underwent venous angioplasty alone, and 13, all with hemodialysis access-associated stenosis, underwent stenting. Mean operative time was 135 (±63.5) minutes, and mean estimated blood loss was 238 (±261) mL. Median length of stay was 4 days. Perioperative complications were noted in 14 (26.4%) patients, including wound complications (n = 6), cardiac complications (n = 4), reocclusion (n = 3), and hemothorax requiring chest tube placement (n = 1) in a patient undergoing on-table thrombolysis. Mean follow-up was 13.6 (0.6-58.5) months. Initial clinical symptom relief was experienced in 100% of patients at the time of hospital discharge. During follow-up, 5 (9.4%) patients developed recurrent symptoms, 6 (11.3%) had reocclusion of the central system, and 16 (30.2%) required reintervention for restenosis, all but 2 in patients with ipsilateral hemodialysis access. Mean time to reintervention was 134 (±285) days. ConclusionsGiven our decision-making threshold, both open and endovascular procedures are associated with relatively low morbidity and high efficacy for treatment of central venous occlusion in both symptomatic VTOS and AV access-associated subclavian vein disease. Restenosis is common in patients with a patent ipsilateral hemodialysis access.

Abstract No. 677 Outback re-entry device for the treatment of central venous occlusion in hemodialysis patients

To report our institutional experience with the Outback re-entry device for the treatment of central venous occlusion in hemodialysis patients. Since January 2013, 8 consecutive patients (4 males and 4 females, mean age: 63.2 years) receiving hemodialysis underwent endovascular treatment for central venous occlusion using the Outback re-entry device after failed attempts of guidewire traversal. The patients had been referred for percutaneous angioplasty due to increased venous pressure during hemodialysis in 4 patients and upper extremity swelling in 4 patients. The mean age of their fistulas since creation was 21.3 months. Six patients had previously received endovascular treatment for malfunctioning fistulas. Occlusion sites were in the subclavian vein (n=4) and brachiocephalic vein (n=4). In all patients, the guidewire was passed into the subintimal plane but could not be re-directed into the distal true lumen. The Outback re-entry device was used as a bail-out measure with technical success in all cases. All patients underwent balloon angioplasty; 6 of them had provisional bare metallic stent placement due to elastic recoil. The fistulas were functionally restored and arm swelling was relieved in all cases. Excluding three patients who were lost to follow-up, the fistulas were functional up to a mean period of 8.3 months. During this time, 4 patients underwent repeated intervention. There were no complications related to the procedure. The Outback re-entry device is a feasible and safe bail-out option in patients who fail conventional techniques for wire traversal during endovascular treatment of central venous occlusion.

Outcomes of Venous Bypass Combined With Thoracic Outlet Decompression for Treatment of Central Venous Occlusion

Outcomes of Venous Bypass Combined With Thoracic Outlet Decompression for Treatment of Central Venous Occlusion

Success Rate and Complications of Sharp Recanalization for Treatment of Central Venous Occlusions.

To evaluate success and safety of needle (sharp) recanalization as a method to re-establish access in patients with chronic central venous occlusions. Thirty-nine consecutive patients who underwent this procedure were retrospectively reviewed to establish success rate and associated complications. In all cases, a 21- or 22-gauge needle was used to restore connection between two chronically occluded segments after conventional wire and catheter techniques had failed. The needle was guided toward a target placed through a separate access by fluoroscopic guidance. When successful, the procedure was completed by placing a catheter, ballooning the segment, and/or stenting. The procedure was successful in 37 of the 39 patients (95%). The vast majority of the treated lesions were in the SVC and/or right innominate vein. Occlusions ranged in length between 10 and 110mm, and the average length of occluded venous segment was 40mm in the treated group. There were four minor (SIR classification B) complications involving pain management after the procedure. There were two major (SIR classification D) complications both of which involved hemorrhage into the pericardium treated with covered stents (5.1%). Sharp recanalization is a viable procedure for patients who have exhausted standard wire and catheter techniques. The operator performing this procedure should be familiar with potential complications so that they can be addressed urgently if needed.

Percutaneous management of chronic central venous occlusive disease.

Stenosis or occlusion of the central veins and/or vena cava can cause painful and debilitating symptoms for affected patients. Superior vena cava syndrome (SVCS) can develop acutely or progressively from external compression or intrinsic obstruction. The clinical signs and symptoms result from venous hypertension and reduced blood flow in the superior vena cava (SVC) or central veins emptying into the SVC. Depending on the anatomic location of the narrowing, clinical symptoms, and presentation will vary. Clinical signs include cyanosis, plethora, distention of subcutaneous veins, and edema of the upper extremities, head and neck. Edema may compromise laryngeal or pharyngeal function, causing dyspnea, stridor, cough, hoarseness, and dysphagia.1 Although there may be symptom overlap with congestive heart failure, a physical examination will usually delineate between the two diagnoses. The etiology of SVCS varies and can be broadly grouped into benign and malignant causes, with most strictures of the caval system and venous tributaries being malignant.2 3 Non–small-cell lung cancer (NSCLC) is the most common malignant cause of SVCS, followed by small-cell lung cancer (SCLC) and non-Hodgkin lymphoma.4 The most common causes of benign venous stenosis involve the presence of an indwelling intravascular device (i.e., catheters, pacemaker/defibrillators, ports). Arteriovenous fistula related obstruction, mediastinal fibrosis, and prior thoracic external bean radiation therapy are additional benign causes. Treatment of central venous occlusions depends on the etiology and clinical presentation. The ultimate goal of therapy is to correct the obstruction and alleviate the symptoms. Conservative measures depend on the etiology and include limb elevation, steroids, anticoagulation, chemotherapy and/or radiation therapy, and diuretics.5 Interventional therapies include surgical bypass and/or endovascular stent placement. Guide wire recanalization and endovascular stenting is a minimally invasive procedure that can be performed on an outpatient basis with standard equipment available in an angiography suite. The procedure below describes the authors approach to treating chronic central venous occlusive disease.

Development of High-Output Heart Failure after Correction of Central Venous Occlusion: A Case Report

Temporary or permanent central venous catheter (CVC) insertion has been performed frequently for hemodialysis treatment. One of the most important long-term complications of CVC is the central venous occlusion (CVO). Treatment of CVO consists of percutaneous angioplasty (PTA), PTA and stent implantation, or surgical procedure for resistant occlusions. Clinical outcome and long-term results of the revascularization procedures are well documented. However, there is no clear information about acute medical complications of the procedures. High-output heart failure (HOHF) is associated with several diseases including chronic anemia, psoriasis, systemic arteriovenous fistula, sepsis, hypercapnia, multiple myeloma, and hyperthyroidism. Herein, we report a case of chronic kidney disease with CVO that developed acute HOHF immediately after the revascularization procedure (PTA and stenting).

Sharp Recanalization of Central Venous Occlusions

To describe a sharp puncture technique for recanalization of chronic central venous occlusions that could not be traversed by a guide wire. Five patients presented with six longstanding central venous occlusions that could not be traversed with a guide wire after thrombolysis. The occlusions occurred following radiation for lung carcinoma (n = 2) and indwelling venous catheters (n = 4). The length of venous occlusion was determined by simultaneously advancing transbrachial and transfemoral catheters to the site of occlusion. Initially, a curved guiding catheter with a Rosch-Uchida needle and, in subsequent patients, a coaxial sheathed needle with a 21-gauge stylet were used for recanalization. The recanalized veins were then balloon dilated and stents were placed. With use of this technique, recanalization was successful in five of the six occlusions. One occlusion was too long to traverse safely in one patient. Two patients were asymptomatic 16-18 months after the recanalization. This new technique offers an effective alternative to surgery in the treatment of central venous occlusion.