Long-term outcomes of stenting superior cava and brachio-cephalic vein occlusion in hemodialysis patients with arteriovenous fistulas

Abstract

Objective: Central vein occlusion (CVO) is a significant complication in patients undergoing chronic hemodialysis, often leading to dialysis inefficacy, disabling symptoms, and, most critically, major risk of access failure. Although stenting has been proposed as a technique to maintain vascular access patency following the recanalization of occluded central veins, the data supporting its long-term efficacy remains limited. This study aims to evaluate the long-term effectiveness of stenting occluded superior vena cava (SVC) and/or brachiocephalic veins to preserve vascular access patency, ensure continued dialysis efficacy, and relieve SVC syndrome.

Methods: This study retrospectively reviewed all hemodialysis patients who underwent stent placement for CVO between January 2017 and August 2024 at two vascular centers in Reunion Island. The primary endpoints of the study were the primary, assisted primary, and secondary patency rates of the vascular circuit during follow-up. Additionally, patient demographics, medical comorbidities, postoperative complications, definitive access abandonment, and reinterventions were analyzed.

Results: This study included 21 patients with a mean age of 67 years. CVO stenting initially provided symptomatic relief for all patients, resolving symptoms such as SVC or arm swelling in symptomatic patients. Over a median follow-up period of 41 months (range, 3-80 months), the primary patency rates were 67% at 12 months, 42% at 24 months, and 38% at 36 months, whereas the secondary patency rates were 90%, 79%, and 60% at these same intervals. Twelve patients (62%) experienced clinically significant stent restenosis, necessitating one or several additional percutaneous transluminal angioplasties during follow-up, whereas five patients (24%) developed acute access thrombosis requiring thrombectomy and percutaneous transluminal angioplasty, with central stent involved for three patients. Three patients (14%) required extra-anatomic bypasses due to definitive stent occlusion, five patients (14%) had definitive access failure, and five patients (24%) died from unrelated causes.

Conclusions: This review suggests that hemodialysis patients with symptomatic CVO can often be successfully recanalized and treated with stenting, leading to symptom resolution and, importantly, achieving promising secondary patency rates. Our long-term results highlight the necessity for regular reintervention and close follow-up, as a significant number of patients will experience restenosis, and ultimately definitive access failure. Therefore, CVO stenting should be considered a temporary solution, although for some patients, this strategy may prove highly effective, maintaining long-term patency without any restenosis.

Clinical relevance: We studied central vein stenting for 21 hemodialysis patients with a mean follow-up of 41 months. Long-term results showed primary and secondary patency rate of 38% and 60% at 36 months. Twelve patients needed at least one reintervention, whereas five patients developed access thrombosis. Three patients required extra-anatomic bypasses, five patients had access failure, and five patients died. Hemodialysis patients with symptomatic occlusion of the superior vena cava or brachiocephalic vein can be successfully recanalized and stented, leading to symptom resolution and, notably, an encouraging secondary patency rate with efficient dialysis. However, a majority of patients will require multiple reinterventions including endovascular percutaneous transluminal angioplasty or extra-anatomical bypass due to symptomatic in-stent restenosis and thrombosis, and a significant number will experience definitive access failure. Central venous obstruction stenting is a valuable initial strategy but should only be performed without compromising further access, as it represents a salvage procedure with important risk of failure during prolonged follow-up.

Keywords: AVF; CVO; Cava; Central; Dialysis; Fistula; Occlusion; Stent; Stenting; Syndrome; Vein.

Fig 1

Kaplan-Meyer curve of primary patency.

Fig 2

Kaplan-Meyer curve of primary-assisted patency.

Fig 3

Kaplan-Meyer curve of secondary patency.