Review of Sharp Recanalization Techniques in Central Venous Occlusions

Abstract

Benign central venous occlusions are frequently associated with long-term central venous access. Most of these occlusions can be recanalized with conventional endovascular technique. When conventional technique fails, sharp recanalization techniques (SRTs) can increase technical success. The SRTs include single low-profile needles, needle coaxial systems, re-entry catheter, the back end of stiff guidewires, and systems that can deliver radiofrequency energy or laser. This review on SRTs presents technical details and outcomes of the most common techniques used in central venous recanalization.

Keywords: Central venous occlusion; Outcomes; Sharp recanalization.

Fig. 1

SVC recanalization using the stiff end of a guidewire. A SVC venogram demonstrates complete occlusion associated with venous collaterals (arrow); B, C Multiple fluoroscopic projections are used to check appropriate alignment of the guide wire and the target pigtail catheter (arrow) when crossing the occlusion from a caudal–cranial approach; C Note when the guide wire already had crossed the occlusion and it is overlaying the pigtail catheter; D Final SVC venogram shows successful stenting and recanalization of the SVC, without filling of venous collaterals [12]

Fig. 2

SVC recanalization with Chiba needle. A Central venogram through the external jugular vein demonstrates SVC occlusion with collaterals; B The Chiba needle (arrow) is advanced toward the target balloon under fluoroscopic guidance; C The Chiba needle (arrow) reaches the target patent vessel past the occlusion, and an 0.018 in. wire is passed into the IVC (arrowhead); D Tract dilation using balloon angioplasty; E Placement of a tunneled central venous catheter at the conclusion of the case [16]

Fig. 3

RUPS-100 recanalization of a right subclavian vein occlusion. A Simultaneous venograms from the right axillary vein and right BCV demonstrate a complete occlusion of the right subclavian vein-BCV transition; B Note a 9 Fr Rösch-Uchida (RUPS-100) curved sheath and trocar stylet in the right subclavian vein (single arrow) and a 5 Fr diagnostic catheter is placed in the right BCV as a marker (double arrows); C After checking the alignment between them in multiple orthogonal views, the RUPS-100 needle was advanced toward the right BCV catheter D Final venogram following angioplasty and stenting of the right subclavian vein [21]

Fig. 4

Central venous recanalization using a transseptal needle. A Simultaneous central venogram shows occlusion of the BCV; B A snare is placed in the right BCV-subclavian transition to serve as a marker for the transseptal needle using a caudal–cranial approach. A 0.018 in. wire was passed through the needle and snared out for through-and-through access; C Final venogram after right BCV stenting demonstrates patent central veins without collateralization; D One month follow up right upper extremity venography demonstrating continued patency of the right BCV stent [26]

Fig. 5

Chiba needle through a coaxial system right BCV recanalization. A Initial central venograms from the right external jugular vein (EJV) and from the cranial aspect of the SVC demonstrates an occluded right BCV (white arrowheads); B Through the EJV, an 18 G trocar needle was manually curved to optimize trajectory toward sheath positioned in the SVC (marker). The dotted line demonstrates the path the Chiba needle would have taken without use of the coaxial system; C After checking alignment using multiple orthogonal views, a 22 G Chiba needle is inserted through the trocar, traversing the occlusion to meet the target; D Venogram after crossing demonstrates contrast pooling in the CVO, without extravasation into adjacent vital structures; E Note a tunneled central venous catheter was placed in the right EJV for later transition to a surgically placed HeRO graft [6]

Fig. 6

Recanalization of a right BCV using an Outback-LTD re-entry catheter. A, B Initial central venograms demonstrate right BCV occlusion. The double headed arrow designates the length of occlusion, and the red box indicates the location of the cranial venous stump. Incidentally noted pacemaker lead and the patent SVC are labeled; C The Outback-LTD device was advanced to the right subclavian vein and positioned so that the “L” locator marker is pointed toward the guidewire used to cross the occluded segment into the cranial venous stump. Through the lateral exit port of the Outback catheter, the curve needle tip exits with an 0.014 in. wire traveling through the recanalized track; D Final venogram of the recanalized right BCV after stenting, without evidence of collateral venous filling or contrast extravasation [27]

Fig. 7

Sniper technique for recanalization of a long segment superior vena cava occlusion. A Coronal CTA of the chest demonstrates a long segment occlusion of the superior vena cava, which extends from the brachiocephalic confluence to the right atrium. Faint linear contrast opacification is noted extending from the brachiocephalic confluence, which was the sequela of a prior recanalization attempt (white arrow); B Central venogram performed simultaneously from above (top white arrow) and below (bottom arrow) the occluded SVC (middle white arrow); C, D The radiofrequency wire (upper white arrows) and the target snare (bottom arrows) in alignment with incremental advancement toward the snare, ensuring proper trajectory with multiple fluoroscopic projections; E–G Successful traversal of the radiofrequency wire through the occlusion, which was snared out (left white arrow) for through-and-through access for subsequent angioplasty (middle white arrow) and stenting (right white arrow) of the SVC, which demonstrated patent stent without extravasation on final venogram [8]