Endovascular therapy of central vein stenosis in hemodialysis patients. Venous chimney graft to preserve residual jugular vein

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1 Endovascular therapy of central vein stenosis in hemodialysis patients. Venous chimney graft to preserve residual jugular vein Poster No.: C-2358 Congress: ECR 2015 Type: Scientific Exhibit Authors: R. Corti, P. Quaretti, F. Galli, L. P. Moramarco, G. Leati, I. Fiorina, M. Maestri, F. Calliada; Pavia/IT Keywords: Interventional vascular, Veins / Vena cava, Vascular, Catheter venography, Stents, Angioplasty, Venous access DOI: /ecr2015/C-2358 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 15

2 Aims and objectives Central venous stenosis and obstruction (CVS) is an important and prevalent problem in the management of hemodialysis patients. The risk factors are CVC and other intravascular devices. CVS often results in symptoms due to venous hypertension as arm edema, and complete occlusion renders the extremity unsuitable for vascular access that may require the insertion of a temporary CVC. Diagnosis includes clinical examination, duplex ultrasonography, Contrast media CT and angiography. [1] Endovascular intervention is the only feaseble treatment in HD patients with central vein stenosis. The treatment options include PTA, placement of BMSs and stent grafts. [2-7] One of the major concerns regarding the use of both stent grafts and BMSs for CVS therapy is the preservation of collateral pathways for venous drainage and future vascular access. Particularly is the need to avoid bridging the internal jugular vein (IJV) confluence. [8] We report the feasibility and safety of the chimney graft technique in the endovascular treatment of central vein stenosis in hemodialysis patients. Methods and materials Four patients (mean age 64 y, 2 male, mean dialytic age 15 y) presented indications for endovascular treatment with stent graft placement of symptomatic central vein stenosis after multiple failure of conventional treatments. All patients were carriers of ipsilateral arteriovenous access (2 AVF, 2 AVG) with arm and face edema and malfunctioning hemodialytic venous access, that required the insertion of temporary CVC. Double access was engaged from arm and femoral approaches. In three patients the pull through tecnique was applied to cross the obstruction (fig. 1). A PTA of the brachiocephalicsubclavian lesion was performed, followed by immediate elastic recoil (Fig 2-4). A selfexpandable PTFE stent-graft was transfemorally released in the sublcavian vein with a safety wire in the jugular vein. A similar stent-graft was then released in the distal internal jugular vein with distal ends parallel to the subclavian stent-graft (double barrelchimney graft) (Fig. 5-7). The procedure was completed with intra-stent low pressure kissing ballooning. Images for this section: Page 2 of 15

3 Fig. 1: Pull throgh tecnique. Guide wire introduced through the jugular vein was captured with a 15mm snare. Page 3 of 15

4 Fig. 2: Fistulography showing a critical focal stenosis at the costoclavicular junction in a woman previous failed renal transplantations. The patient had complained of arm and left facial edema and venous hypertension-related bleeding after dialysis. Page 4 of 15

5 Fig. 3: Angioplasty with a 8mm, 6cm balloon catheter of the subclavian vein. (A safe guide wire in the jugular vein) Page 5 of 15

6 Fig. 4: Angioplasty with a 8mm, 6cm balloon catheter of the internal jugular vein (folloed by elatic recoil) Page 6 of 15

7 Fig. 5: Pre-releasing control. A 13mm, 10cm Viabahn in the subclavian vein and a 10mm, 10cm were released across the stenosis. Page 7 of 15

8 Fig. 6: Final venography. Stent-grafts released across the stenosis. The collateral veins have disappeared. The patient remained clinically asymptomatic at six months. Page 8 of 15

9 Fig. 7: CT control at 6 months shows patency of the stent-grafts. Page 9 of 15

10 Results All procedures were successful (technical success 100%). Symptoms cleared in all patients in few days. The mean follow up was of 13 months (8-18 months). Six stent-grafts (Viabahn, Gore, Flagstaff, AZ) (5-10cm long) were released. Two cases necessitated a staged procedure. Jugular thrombolysis was necessary prior to chimney graft in one patient. Stent-grafts remained patent until the end of the follow up in 2 patients and until death in two patients at 8 and 18 months. Reintervention was required in one patient at 6 month follow up due to restenosis with arm edema and access disfunction (primary patency of 86% at 6 months, assisted patency of 100% at 6 months). Two patients are alive at 12 and 13 months. Conclusion The extimated incidence of CVS in the ESRD population is 19-41%. CVS may remain asymptomatic because if the stenosis is not critical or there is development of collateral flow. CVS is associated with central venous catheter and intravascular device or although it can be related to vessel wall shear stress due to AVF or AVG. [1-2] The K/DOQI guidelines recommend PTA, with or without stent placement, as the preferred treatment approach for central venous stenosis. While thoracic surgery is high risky in the HD population due to many comorbidities. The results for PTA and BMS placement in the setting of central venous steno-obstruction demonstrate abetter technical success rate, in the range of 100% for BMS, with variable short- and long-term patencies similar for both treatments. [3] Recently, stent grafts have been shown in some monocentric studies to be effective in the treatment of CVS, with loger primary patency avoiding multiple reintervention to maintein vein patency. [4-7] The disadvantages of CSs include covering collateral veins, which may provide critical outflow in recurrent stenoses or occlusions. [8] The Venous chimney graft technique may extend the limits of central vein stent-grafting by preserving the patency of the internal jugular vein, (Fig. 8-10) that can be used for further CVC insertion. [9,10] Page 10 of 15

11 Images for this section: Fig. 8: Central venous obstruction of the subclavian vein, with AVG malfunctioning and clinical sympthoms, in patients with epicardial PM. Page 11 of 15

12 Fig. 9: Patent jugular vein. Page 12 of 15

13 Fig. 10: Final control. Two stent-grafts released in subclavian and internal jugular vein.the patient remained clinically asymptomatic till the end of the follow up. Page 13 of 15

14 Personal information References [1]Agarwal AK. Central Vein Stenosis. Am J Kidney Dis 2013;(x). [2]Kundu S. Central 2009;26(2): venous obstruction management. SeminIntervRadiol [3]Bakken AM, Protack CD, Saad WE, et al. Long-term outcomes of primary angioplasty and primary stenting of central venous stenosis in hemodialysis patients. J VascSurg 2007;45(4): [4]Verstandig AG, Berelowitz D, Zaghal I, et al. Stent grafts for central venous occlusive disease in patients with ipsilateral hemodialysis access. J VascIntervRadiol 2013;24(9): [5]Kundu S, Modabber M, You JM, et al. Use of PTFE stent grafts for hemodialysisrelated central venous occlusions: intermediate-term results. CardiovascIntervRadiol 2011;34(5): [6]Jones RG, Willis AP, Jones C, McCafferty IJ, Riley PL. Long-term results of stent-graft placement to treat central venous stenosis and occlusion in hemodialysis patients with arteriovenous fistulas. J VascIntervRadiol 2011;22(9): [7] Quaretti P, Galli F, Moramarco LP, Corti R, Leati G, Fiorina I, Maestri M. Dialysis catheter-related superior vena cava syndrome with patent vena cava: long term efficacy of unilateral Viatorr stent-graft avoiding catheter manipulation. Korean J Radiol May;15(3): [8]Turmel-Rodrigues L, Bourquelot P, Raynaud A, Sapoval M. Primary stent placement in hemodialysis-related central venous stenoses: the dangers of a potential "radiologic dictatorship". Radiology 2000;217(2): [9]Vicente S, Glenck M, Mayer D, Veith FJ, Lachat M, Pecoraro F. Chimney and periscope grafts to facilitate endovascular treatment of aortic transection in a patient with aberrant right subclavian artery. J Endovasc Ther Feb;21(1): [10]Donas KP, Pecoraro F, Torsello G, Lachat M, Austermann M, Mayer D, Panuccio G, Rancic Z. Use of covered chimney stents for pararenal aortic pathologies is safe and feasible with excellent patency and low incidence of endoleaks. J Vasc Surg Mar;55(3) Page 14 of 15

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