4/29/2012. Management of Central Vein Stenoses. Central Venous Stenoses and Occlusions

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1 Central Venous Stenoses and Occlusions Management of Central Vein Stenoses Robert K. Kerlan Jr. M.D. Professor of Clinical Radiology and Surgery University of California San Francisco Key Questions What is the cause? Is treatment always necessary? What is the best way to treat? UCSF Vascular Symposium April 28, 2012 Central Venous Stenoses and Occlusions Central Venous Stenoses and Occlusions Key Questions What is the cause? Is treatment always necessary? What is the best way to treat? By far, the most common cause of central venous stenoses and occlusions in the dialysis patient is previous line placement. Additional factors Entrapment (3 to 80 / 1000 people) 1

2 Venous Catheters and Stenoses Location of Lines Hernandez et al. J Am Soc Nephrol 1998;9: Prospective trial of 42 consecutive dialysis patients with subclavian catheter insertion 52% developed 6 months Multivariate analysis revealed association with Number of lines Duration of lines Line infection Subclavian > Jugular 42% vs 10% Schillinger et al Neph Dial Trans 1991;6:722 83% vs 36% MacRae et al. ASAIO J 2005;51:71 Left Jugular > Right Jugular Central Venous Stenoses are Caused by Lines Central Venous Stenoses and Occlusions The optimal solution for CVSO is to place hemodialysis access prior to initiation of dialysis The only winning move is not to play! WOPR Computer War Games 1983 Key Questions What is the cause? Is treatment always necessary? What is the best way to treat? 2

3 CVSO and Dialysis Access Failure Is Treatment Always Necessary? 15% to 25% of patients with dialysis access failure have CVSO as the only identifiable hemodynamic cause Levit et al. Radiology 2006;238: patients with 86 CVS No patients had arm swelling All patients had access dysfunction 24/86 CVS were not treated These patients had peripheral lesions treated to improve access function 62/86 CVS were treated Follow-up venograms of CVS were analyzed Is Treatment Always Necessary? Is Treatment Always Necessary? Levit et al. Radiology 2006;238:1051 Untreated group 12/24 (50%) CVS s had no f/u venography 12/24 (50%) CVS s had repeat venograms 4 improved, 4 stable, 4 progression No untreated CVS progressed to Symptoms Occlusion Levit et al. Radiology 2006;238:1051 Treated group 36/62 (58%) CVSs had no follow-up venograms 26/62 (42%) had repeat venograms 3 improved, 0 stable, 23 progression (mean diameter reduction reduction) Treated CVS progressed to Arm swelling (1) Additional CVS (4) Lesion requiring stent placement (4) 3

4 Is Treatment Always Necessary? Central Venous Stenoses and Occlusions Maybe not In patients who are minimally symptomatic and have identifiable peripheral causes for access failure consider: Treating the peripheral lesions And not treating CVSO Key Questions What is the cause? Is treatment always necessary? What is the best way to treat? Audience Question Treatment of CVSO What is the optimal way to treat a central venous stenosis in a dialysis patient? Balloon Angioplasty 1. Balloon angioplasty 2. Bare metal stent 3. Stent graft 4. Cutting balloon 5. Surgical bypass 35% 19% 35% 10% Stents Surgical Bypass 0%

5 Treatment of CVSO What is the best way to treat? Balloon Angioplasty Stents Surgical Bypass K/DOQI Guideline 20 Percutaneous transluminal angioplasty with or without stent placement is considered the preferred approach to treat central venous stenosis Guideline 20 Am J Kidney Dis 2001;37:s137-s181 Balloon Angioplasty of CVSO Balloon Angioplasty of CVSO Series (year) n 1-year Primary Patency 2-year Primary Patency 1-year Secondary Patency 2-year Secondary Patency Glanz (1987) 30 35% 10% - - Wisselink (1993) 15 36% 0% 86% 66% Quinn (1995) 10 12% - 100% - Money (1995) 26 7% Lumsden (1997) 17 17% Surowiec (2004) 35 43% 0% 80% 64% 5

6 Treatment of CVSO Treatment of CVSO Balloon Angioplasty Stents Surgical Bypass K/DOQI Guideline 20 Stents should be placed for elastic lesions recurring within three months following initially successful balloon angioplasty Guideline 20 Am J Kidney Dis 2001;37:s137-s181 Stents for CVSO Stents for CVSO 6

7 Bare Metal Stents for CVSO Bare Metal Stents for CVSO Haage et al. Radiology 1999;212: patients Primary Wallstent placement Maya ID et al. Semin Dial 2007;20:78 23 patients with stent placement for failed PTA Wallstents and Luminex stents Stents vs PTA for CVSO Bakken AM et al. J Vasc Surg 2007;45:776 Retrospective cohort study of 73 patients Primary high-pressure PTA 47 patients Primary Wallstent 26 patients Stents vs PTA for CVSO Bakken AM et al. J Vasc Surg 2007;45:776 Retrospective cohort study of 73 patients Primary high-pressure PTA 47 patients Primary Wallstent 26 patients Primary Patency P=.48 Primary Assisted Patency P=.08 7

8 Stents vs PTA for CVSO Stents vs PTA for CVSO Bakken AM et al. J Vasc Surg 2007;45:776 Retrospective cohort study of 73 patients Primary high-pressure PTA 47 patients Primary Wallstent 26 patients Hemodialysis Access Survival P=.13 Bare metal stents offer no advantage to balloon angioplasty in the treatment of central venous stenoses Stents may be useful in selected cases following recanalization of an occluded segment (speculative) Bare metal stents are useful to rescue a failed balloon angioplasty Stent-grafts have better patency than PTA in venous outflow stenoses complicating dialysis access grafts Stent-grafts perform substantially better than bare metal stents in TIPS Haskal ZJ et al. NEJM 2010;362: Bureau C et al Liver Int 2007;27:

9 Stent-grafts perform better than bare metal stents in recurrent cephalic arch stenoses Whether stent grafts will outperform bare-metal stents and balloon angioplasty is unknown P=.0023 Microtrauma induced by stent is likely a contributing issue Shemesh D et al J Vasc Surg 2008;48: Repetitive motion from arms and shoulders lead to endothelial microtrauma inducing an inflammatory response resulting in intimal hyperplasia Stent grafts have greatly improved this problem in TIPS where diaphragmatic motion was responsible for the microtrauma Will this be true in CVSO??? 9

10 Stent-Grafts for CVSO? 42 Viabahn stents in 30 patients Mean f/u 705 days Primary 1-yr 67% 2-yrs 45% Jones RG et al JVIR 2011;22:1240 Balloon Angioplasty Stents Treatment of CVSO Surgical Bypass Possible, but few patients are suitable Axillary vein to right atrium bypass 9 patients, 100% success, mean patency 15.4 months El-Sabrout RA, Duncan JM. J Vasc Surg 1999;29: Mickley V. Eur J Endovasc Surg 2006;32: Surgical Bypass Subclavian artery to right atrium bypass Case report Mickley V. Nephrol Dial Transplant. 1996;11:

11 CVSO in the Dialysis Patient: Conclusions Best treatment is to avoid placement of dialysis lines Create fistula within a year of anticipated dialysis Balloon angioplasty performs equivalent to bare metal stents Both treatments are flawed Stent-grafts may be better, but scientific evaluation has not been performed 11