Management of Central Venous Stenosis and Occlusion in Dialysis Patients

Abstract

Central venous occlusions (CVOs) of the major intrathoracic veins (jugular, subclavian, brachiocephalic, superior vena cava) can cause debilitating symptoms, negatively impact arteriovenous fistula/graft function, or limit potential access creation options in end-stage kidney disease (ESKD) utilizing hemodialysis (HD). This review summarizes the incidence, pathophysiology, indications/contraindications, and management options of CVOs in the ESKD on HD population and concludes with considerations and examples when planning endovascular central recanalization procedures, which have risen as the first-line management when appropriate.

Keywords: central venous stenosis; hemodialysis; interventional radiology; recanalization; superior vena cava.

Fig. 1

Surfacer Inside-Out Access Catheter System. Schematic ( a ) and fluoroscopic intraprocedural images ( b–d ) of the Surfacer Inside-Out Access Catheter System.

Fig. 2

Standard recanalization technique with self-expandable covered stent. A 47-year-old man on hemodialysis via a left upper arm brachiocephalic arteriovenous graft presented with left neck, chest, and arm swelling. ( a ) Left brachiocephalic venogram demonstrating occlusion of the mid brachiocephalic vein (black arrow). This was recanalized with a standard wire/catheter combination. ( b ) After obtaining “flossing” access, serial venoplasty demonstrates improved but persistent brachiocephalic stenosis (black arrow). Note the patent right brachiocephalic vein. ( c ). Self-expandable covered stent placement with improved patent left brachiocephalic venous outflow (black arrow). Note the central aspect of stent is not covering the patent right brachiocephalic venous outflow.

Fig. 3

Radiofrequency (RF) wire recanalization with balloon-expandable covered stent. A 52-year-old man on hemodialysis via a right upper arm brachiocephalic arteriovenous graft presented with 2 years of right facial, neck, chest wall, and arm swelling. ( a ) Despite placement of a right-left axillary venous bypass graft (black arrowheads), the patient had persistent symptoms caused by a right brachiocephalic occlusion (black arrow). ( b ) Simultaneous right brachiocephalic and superior vena cava venogram demonstrates the length of occlusion. ( c ) From the femoral access, an RF wire was used to recanalize the tract while using a snare (black arrow) as a right brachiocephalic venous target. After advancing a 5-Fr catheter through the recanalized tract, the wire was snared and “flossing” access obtained. ( d ) Following balloon-expandable covered stent placement, improved patent right brachiocephalic venous outflow is present. Note the central aspect of stent is not covering the patent left brachiocephalic venous outflow.

Fig. 4

Pericardial leak and management during recanalization. A 61-year-old man with history of right port placement presented with intermittent facial swelling and dizziness with preoperative imaging confirming superior vena cava (SVC) syndrome. Right upper extremity venogram ( a ) demonstrating SVC occlusion with an enlarged azygous vein. Standard wire/catheter technique was performed and “flossing” access obtained ( b ). Angioplasty up to 12 mm ( c ) and subsequent venogram ( d ) demonstrate improved flow; however, angioplasty up to 16 mm ( e ) and subsequent venogram ( f ) demonstrate venous pericardial leak (black arrowheads) likely due to partial SVC rupture ( f ). Due to intraprocedural hypotension and concern for cardiac tamponade, a pericardial drain was placed ( g ) and a balloon-expandable 10-mm stent (with angioplasty to 14 mm) placed ( h ). Note, flossing access allowed balloon tamponade of the leak via the upper extremity access while stent advancement and deployment from the lower extremity access, minimizing extravasation time.