Management of concomitant central venous disease

Abstract

Symptomatic central venous disease (CVD) is a significant common problem in patients with end-stage renal disease given its adverse impact on hemodialysis (HD) vascular access (VA). The current mainstay management is percutaneous transluminal angioplasty (PTA) with or without stenting which is typically reserved for unsatisfactory angioplasty or more challenging lesions. Despite factors such as target vein diameters and lengths and vessel tortuosity that may determine the choice of bare-metal versus covered stents (CS), current scientific literature is pointing out the superiority of the latter one. Alternative management options such as hemodialysis reliable outflow (HeRO) graft showed favorable results in terms of high patency rates and fewer infections, however, complications such as a steal syndrome and, to a lesser extent, graft migration and separation are major concerns. The surgical reconstruction approaches such as bypass, patch venoplasty, or chest wall arteriovenous graft with or without endovascular interventions as a hybrid procedure are still viable options and may be considered. However, further long-term investigations are needed to highlight the comparative outcomes of these approaches. Open surgery might be an alternative before proceeding to more unfavorable approaches such as lower extremity vascular access (LEVA). The appropriate therapy should be selected based upon a patient-centered interdisciplinary discussion utilizing the locally available expertise in the area of VA creation and maintenance.

Keywords: Central venous disease (CVD); end-stage renal disease (ESRD); hemodialysis (HD); hemodialysis reliable outflow (HeRO); vascular access (VA).

Figure 1

Hemodialysis Reliable Outflow (HeRO) graft; ©Merit Medical, Reprinted by Permission.

Figure 2

A hybrid case of a chest wall AVG creation with central venous stenting. (A) Typical infraclavicular incision for chest wall AVG. (B) Central vein oriented access through the venous limb of the Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ) stretch vascular graft. (C) 1, crossing of the subclavian vein stenosis; 2, balloon angioplasty of subclavian vein stenosis; 3, covered self-expanding stent extending from within the graft to the central vein beyond the stenosis. AVG, arteriovenous graft. Reprinted with permission, Cleveland Clinic Foundation ©2023. All Rights Reserved.