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Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients
European Journal of Radiology 49 (2004) 81–85
Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients Cüneyt Aytekin a,∗ , Fatih Boyvat a , Mahmut Can Ya˘gmurdur b , Gökhan Moray b , Mehmet Haberal b a
Department of Radiology, Ba¸s kent University Faculty of Medicine, 06490 Ankara, Turkey Department of Surgery, Ba¸s kent University Faculty of Medicine, 06490 Ankara, Turkey
b
Received 27 June 2002; received in revised form 25 November 2002; accepted 26 November 2002
Abstract Objective: To evaluate the efficacy of stent placement for treating upper extremity central venous obstruction in chronic hemodialysis patients. Methods and Material: Between January 1999 and October 2001, we inserted metallic stents into the upper extremity central veins of 14 patients with shunt dysfunction and/or arm swelling. The indications for stent placement were stenosis or occlusion of the central vein in the upper extremity used for dialysis. Six of the individuals were diagnosed with subclavian vein stenosis, and 5 with brachiocephalic vein stenosis. Of the remaining 3 patients, 2 had subclavian vein occlusion, and 1 had left brachiocephalic vein occlusion. Results: All the stent placement procedures were technically successful, and there were no major complications. Follow-up ranged from 2 weeks to 29 months. The 1-, 3-, 6- and 12-month primary stent patency rates were 92.8, 85.7, 50 and 14.3%, respectively. Repeat interventions, including percutaneous transluminal angioplasty and additional stent placement, were required in 9 patients. The 3-, 6-, 12-month, and 2-year assisted primary stent patency rates were 100, 88.8, 55.5 and 33.3%, respectively. Conclusion: Endovascular stent placement is an effective alternative to surgery in patients with shunt dysfunction due to obstruction of an upper extremity central vein. Repeated interventions are usually required to prolong stent patency. © 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Dialysis; Shunts; Veins; Grafts; Prostheses
1. Introduction Adequate venous outflow is important for proper function of hemodialysis access in chronic hemodialysis patients. Central venous obstruction in the upper extremity usually occurs secondary to previous subclavian catheter placement procedures, and may lead to dysfunction of the arteriovenous fistula and arm swelling in the affected limb. Angioplasty has been the treatment of choice for venous obstruction. However, a stent must be deployed when results with angioplasty are suboptimal, or when there is rapid restenosis or vessel perforation. The purpose of this study was to determine the effectiveness of metallic stents for treating subclavian or bra∗ Corresponding author. Present address: Ba¸skent Universitesi Tip Fakültesi, Radyoloji Bölümü, Fevzi Çakmak Cad. 10. Sok. No. 45, Bahçelievler, 06490 Ankara, Turkey. Tel.: +90-312-2126868/1015; fax: +90-312-2237333. E-mail address: [email protected] (C. Aytekin).
chiocephalic venous obstruction in chronic hemodialysis patients with shunt dysfunction.
2. Methods and material Between January 1999 and October 2001, 14 chronic hemodialysis patients (6 men and 8 women) with shunt dysfunction due to central venous obstruction were treated with stent placement. The average age in the group was 45 years (range, 16–75 years). Six patients had polytetrafluoroethylene grafts, and 8 had native arteriovenous fistulae. Based on the indications of arm swelling and/or insufficient hemodialysis, all 14 patients had undergone ipsilateral upper extremity venography. Six of the individuals were diagnosed with subclavian vein stenosis (right side in 5 cases, left side in 1 case), and 5 with brachiocephalic vein stenosis (right side in 1 case, left side in 4 cases). The degree of stenosis in these 11 cases ranged from 80 to 95%. Of the remaining 3 patients, 2 had subclavian vein occlusion (right
0720-048X/$ – see front matter © 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0720-048X(02)00370-4
82
C. Aytekin et al. / European Journal of Radiology 49 (2004) 81–85
Fig. 1. (a) Venogram obtained via transjugular route shows occlusion of left brachiocephalic vein in a 61-year-old chronic hemodialysis patient with shunt dysfunction. (b) After deployment of a 14×40-mm self-expandable stent (Memotherm stent), good filling of the vein is seen. (c) Six months after the procedure, the patient returned with left arm swelling. High-grade restenosis with collateral filling is demonstrated on a selective left brachiocephalic venogram. (d) Restenosis is managed by balloon dilation. There is another stenotic lesion (arrow) is seen at proximal end of cephalic vein. (e) This new stenosis is also treated with stenting in the same session.
C. Aytekin et al. / European Journal of Radiology 49 (2004) 81–85
side in 1 case, left side in 1 case), and 1 had left brachiocephalic vein occlusion. The indications for stent placement were suboptimal angioplasty (defined as >50% narrowing with persistent filling of the venous collaterals) and recurrent stenosis within 2 months after successful angioplasty. The venous access locations for stent placement were the cephalic vein in 8 cases, the basilic vein in 3 cases, and the left internal jugular vein in 3 cases. After insertion of a 7F or 8F vascular sheath (Terumo, Tokyo, Japan) at the venous access site, a hydrophilic guide wire (Terumo) was passed through the stenotic or occluded segment of the problem vein. Angioplasty was done initially in all cases. The required stent size was determined during this procedure, based on the balloon diameter and the diameter of the adjacent normal vein. The selected stent diameter was the same or 1 mm larger than the balloon diameter. The stent length required was determined based on the extent and location of the lesion. Fifteen stents, including self-expandable ones (10 Memotherm stents, Bard Angiomed, Karlsruhe, Germany (10–16 mm diameter, 4–6 cm length); 3 Wallstents, Boston Scientific, Watertown, MA (12 mm diameter, 50–89 mm length); and balloon-expandable stents (2 Palmaz stents, Cordis (12 mm diameter, 25–30 mm length)), were inserted in the 14 patients. One patient received two overlapping stents. In this case, the first stent (a 16-mm diameter, 60-mm long Wallstent) slipped backward after expansion so that it no longer completely covered the stenotic segment. As a result, a second stent (a 12-mm diameter, 25-mm long Palmaz stent) was deployed. After insertion, 3 of the 14 patients’ stents had to be redilated by balloon angioplasty in order to achieve full expansion. Our criterion for technically successful stent placement was less than 30% residual stenosis with no filling of the venous collaterals.
83
Follow-up screening for stent patency was done using routine upper extremity venography at 3-month intervals. This procedure was also performed when a patient had abnormal hemodialysis and/or arm swelling. When necessary, further interventions were carried out to prolong stent patency (Fig. 1). We evaluated both primary stent patency and assisted primary stent patency. Primary patency was defined as the interval between the day of stent placement and the day of first redilation, or the day the patient was lost to follow-up due to renal transplantation or death. Assisted primary stent patency is a term we applied to cases in which redilation or thrombolysis were needed, and was defined as the interval between stent placement and permanent stent occlusion or loss of the extremity for hemodialysis.
3. Results All the stent placement procedures were successful (procedural success rate 100%), and there were no major complications such as venous rupture or thrombosis. Early thrombosis (within 2 weeks) occurred in 1 case. In the other 13 patients, follow-up ranged from 4 to 29 months (Table 1). One patient died 5 months after stent placement due to aneurysmal rupture of the arteriovenous fistula. One individual underwent renal transplantation 25 months after the procedure. Four patients were lost to follow-up due to loss of the extremity for hemodialysis. The stents were patent from 14 days to 29 months. The 1-, 3-, 6- and 12-month primary patency rates were 92.8, 85.7, 50 and 14.3%, respectively. During follow-up, 9 patients underwent 22 repeat interventions (angioplasty (n=14) and additional stent placement (n=8)) to prolong stent patency. In these 9 cases, the 3-, 6-, 12-month, and 2-year assisted primary stent patency rates were 100, 88.8, 55.5 and 33.3%, respectively.
Table 1 Procedural data and follow-up Patient no.
Age (year)/sex
Location
Stent size (mm)a
Reintervention
Follow-up
1
31/M
Subclavian vein (L)
12 × 40
PTA (10, 21, 23 mo)
2 3 4
62/F 38/M 40/F
Brachiocephalic vein (L) Brachiocephalic vein (L) Brachiocephalic vein (R)
PTA (5, 11 mo) – –
5 6 7 8 9 10 11 12 13 14
64/F 16/F 58/M 36/F 24/F 50/M 53/F 61/M 75/M 28/F
Subclavian vein Subclavian vein Subclavian vein Subclavian vein Subclavian vein Subclavian vein Brachiocephalic Subclavian vein Brachiocephalic Brachiocephalic
14 × 40 12 × 50 16 × 60 12 × 25 14 × 60 10 × 60 10 × 40 12 × 30 12 × 89 14 × 50 16 × 60 12 × 40 14 × 40 14 × 60
Patient received renal transplant at 25 mo Patent stent, 17 mo Patent stent, 4 mo Patent stent, 6 mo
a
Listed as diameter × length.
(R) (R) (R) (R) (L) (R) vein (L) (R) vein (L) vein (L)
Additional Additional Additional Additional – Additional – Additional Additional –
stent stent stent stent
(3 mo) (7 mo), PTA (10 mo) (5, 9 mo), PTA (7 mo) (9 mo), PTA (11 mo)
stent (11 mo), PTA (3, 6, 19 mo) stent (4 mo) stent (4 mo), PTA (7, 16, 25 mo)
Patent died at 5 mo Loss of hemodialysis access after 11 mo Loss of hemodialysis access after 10 mo Stent occlusion after 17 mo Stent thrombosis after 2 weeks Patent stent, 29 mo Patent stent, 7 mo Loss of hemodialysis access after 7 mo Stent occlusion after 26 mo Patent stent, 7 mo
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C. Aytekin et al. / European Journal of Radiology 49 (2004) 81–85
The reasons for the end of primary patency were permanent stent thrombosis in 1 case, balloon angioplasty in 3 cases, and additional stent insertion in 6 cases. The reasons for the end of assisted primary stent patency included loss of hemodialysis access in 3 patients, stent occlusion in 2 patients, renal transplantation in 1 patient, and death in 1 case. At the time of writing, the stents in the remaining 6 patients were patent. In 1 case, venography at 3 months after the procedure revealed slight displacement of a stent located in the left brachiocephalic vein. However, since the device was still covering the lesion, there was no need for repeat intervention.
4. Discussions and conclusion Central venous obstruction is one of the most common reasons for shunt dysfunction in chronic hemodialysis patients. In most cases, this problem occurs as a chronic complication of subclavian dialysis catheters used for temporary hemodialysis access [1,2]. Subclavian or brachiocephalic vein stenosis may cause reduced vascular access flow, increased venous pressure, and subsequent graft thrombosis. These patients usually present with ipsilateral arm swelling and insufficient hemodialysis [3,4]. If the problem is not solved, it can make the extremity unusable for hemodialysis access. Surgical management of upper extremity central venous obstruction tends to be difficult because the vessels are deep in the thorax [5]. Percutaneous endovascular methods, including percutaneous transluminal angioplasty (PTA) and stent placement, are gaining popularity as therapeutic alternatives to open surgery. Endovascular approach can be done under local anesthesia, is well-tolerated by the patient, and is associated with shorter hospitalization time than surgery. Upper extremity central venous stenosis or occlusion can be treated with balloon angioplasty alone. However, because of the high frequency of elastic recoil, the recurrence rate for central venous lesions after PTA is higher than that for peripheral lesions. As a result, in patients with these lesions, it is very difficult to achieve long-term patency after PTA [6–8]. Patients with extensive stenosis, cases in which PTA fails, and lesions that recur after multiple PTA procedures are usually treated with stent placement [9–13]. Stenting of subclavian and brachiocephalic vein stenosis and occlusions extends the duration of hemodialysis access. However, after 1–2 years, restenosis is seen frequently. In their study of 20 hemodialysis patients who had stents placed in central veins, Vessely et al. [9] noted 1-, 3-, 6- and 12-month primary patency rates of 90, 67, 42 and 25%, respectively. In one of the largest series published to date (50 patients), Haage et al. reported 3-month, 6-month, 1-year, and 2-year primary patency rates of 92, 84, 56 and 28%, respectively. After stent placement, multiple re-interventions are often needed to prolong patency. Re-obstruction usually occurs
due to intimal hyperplasia at or near the stent site, or due to stenosis at a remote location. Restenosis can usually be treated with angioplasty alone in most cases, but additional stent placement is sometimes required. In several reports, the 1-year assisted primary patency rates have ranged from 33 to 97% [9–13]. Stent shortening and stent movement are rare causes of re-obstruction that are most often observed during the stent placement procedure. The rate of shortening increases with increasing nominal stent diameter [14]. As well, central venous contraction and expansion during respiration may facilitate both stent shortening and stent movement [9]. In a report on 52 patients who underwent stent placement, Gray et al. [13] observed stent shortening in 6 cases. Four of these individuals had an additional stent placed so that the original lesion was completely covered. In our study, although we noted stent shortening in 2 patients, the rate of shortening was not so much to uncover the lesion. In 1 patient with brachiocephalic vein stenosis, stent was minimally moved distally without shortening. None of our 3 cases of stent displacement required insertion of a second stent. Bridging of vascular side-branches during stent placement is controversial. In cases where the lesion is located at the junction between the central subclavian vein and the peripheral brachiocephalic vein it is usually not possible to avoid bridging the jugular venous junction. Under these circumstances, temporary catheterization of the ipsilateral patent jugular vein may carry some risk; however, it is possible to place the catheter through the meshwork of a stent. In conclusion, endovascular stent placement is a valuable means of ensuring hemodialysis access, however multiple re-interventions are usually required to maintain stent patency. Further studies with large group of patients are needed to make correct decision.
References [1] Schwab S, Quarles D, Middleton J, Cohan R, Saeed M, Dennis V. Hemodialysis-associated subclavian vein stenosis. Kidney Int 1988;33:1156–9. [2] Surrat R, Picus D, Hicks M, et al. The importance of preoperative evaluation of the subclavian vein in dialysis access planning. Am J Roentgenol 1991;156:623–5. [3] Glanz S, Gordon D, Lipkowitz G, Butt K, Hong J, Sclafani S. Axillary and subclavian vein stenosis: percutaneous angioplasty. Radiology 1988;168:371–3. [4] McNally PG, Brown CB, Moorhead PJ, Raferty AT. Unmasking subclavian vein obstruction following creation of arteriovenous fistulae for hemodialysis: a problem following subclavian line dialysis? Nephrol Dial Transplant 1987;1:258–60. [5] Currier CB, Widder S, Ali A, Kuusisto E, Sidawy A. Surgical management of subclavian and axillary vein thrombosis in patients with a functioning arteriovenous fistula. Surgery 1986;100: 25–8. [6] Beathard G. Percutaneous transvenous angioplasty in the treatment of vascular access stenosis. Kidney Int 1992;42:1390–7.
C. Aytekin et al. / European Journal of Radiology 49 (2004) 81–85 [7] Kovalik EC, Newman GE, Suhocki P, Knelson M, Schwab SJ. Correction of central venous stenosis: use of angioplasty and vascular Wallstents. Kidney Int 1994;45:1177–81. [8] Davidson C, Newman G, Sheikh K, Kisslo K, Stack R, Schwab S. Mechanisms of angioplasty in hemodialysis fistula stenosis evaluated by intravascular ultrasound. Kidney Int 1991;40:91–5. [9] Vessely TM, Hovsepian DM, Pilgram TK, Coyne DW, Shenoy S. Upper extremity central venous obstruction in hemodialysis patients: treatment with Wallstents. Radiology 1997;204:343–8. [10] Haage P, Vorwerk D, Piroth W, Schuermann K, Guenther RW. Treatment of hemodialysis-related central venous stenosis or occlusion: results of primary Wallstent placement and follow-up in 50 patients. Radiology 1999;212:175–80.
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[11] Kalman PG, Lindsay TF, Clarke K, Sniderman KW, Vanderburgh L. Management of upper extremity central venous obstruction using interventional radiology. Ann Vasc Surg 1998;12:202–6. [12] Shoenfeld R, Hermans H, Novick A, et al. Stenting of proximal venous obstruction to maintain hemodialysis access. J Vasc Surg 1994;19:532–8. [13] Gray RJ, Horton KM, Dolmatch BL, et al. Use of Wallstents for hemodialysis access-related venous stenosis and occlusions untreatable with balloon angioplasty. Radiology 1995;195:479–84. [14] Jedwab M, Clerc C. A study of geometrical and mechanical properties of a self-expanding metallic stent: theory and experiment. J Appl Biomater 1993;4:77–85.
Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients Cüneyt Aytekin a,∗ , Fatih Boyvat a , Mahmut Can Ya˘gmurdur b , Gökhan Moray b , Mehmet Haberal b a
Department of Radiology, Ba¸s kent University Faculty of Medicine, 06490 Ankara, Turkey Department of Surgery, Ba¸s kent University Faculty of Medicine, 06490 Ankara, Turkey
b
Received 27 June 2002; received in revised form 25 November 2002; accepted 26 November 2002
Abstract Objective: To evaluate the efficacy of stent placement for treating upper extremity central venous obstruction in chronic hemodialysis patients. Methods and Material: Between January 1999 and October 2001, we inserted metallic stents into the upper extremity central veins of 14 patients with shunt dysfunction and/or arm swelling. The indications for stent placement were stenosis or occlusion of the central vein in the upper extremity used for dialysis. Six of the individuals were diagnosed with subclavian vein stenosis, and 5 with brachiocephalic vein stenosis. Of the remaining 3 patients, 2 had subclavian vein occlusion, and 1 had left brachiocephalic vein occlusion. Results: All the stent placement procedures were technically successful, and there were no major complications. Follow-up ranged from 2 weeks to 29 months. The 1-, 3-, 6- and 12-month primary stent patency rates were 92.8, 85.7, 50 and 14.3%, respectively. Repeat interventions, including percutaneous transluminal angioplasty and additional stent placement, were required in 9 patients. The 3-, 6-, 12-month, and 2-year assisted primary stent patency rates were 100, 88.8, 55.5 and 33.3%, respectively. Conclusion: Endovascular stent placement is an effective alternative to surgery in patients with shunt dysfunction due to obstruction of an upper extremity central vein. Repeated interventions are usually required to prolong stent patency. © 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Dialysis; Shunts; Veins; Grafts; Prostheses
1. Introduction Adequate venous outflow is important for proper function of hemodialysis access in chronic hemodialysis patients. Central venous obstruction in the upper extremity usually occurs secondary to previous subclavian catheter placement procedures, and may lead to dysfunction of the arteriovenous fistula and arm swelling in the affected limb. Angioplasty has been the treatment of choice for venous obstruction. However, a stent must be deployed when results with angioplasty are suboptimal, or when there is rapid restenosis or vessel perforation. The purpose of this study was to determine the effectiveness of metallic stents for treating subclavian or bra∗ Corresponding author. Present address: Ba¸skent Universitesi Tip Fakültesi, Radyoloji Bölümü, Fevzi Çakmak Cad. 10. Sok. No. 45, Bahçelievler, 06490 Ankara, Turkey. Tel.: +90-312-2126868/1015; fax: +90-312-2237333. E-mail address: [email protected] (C. Aytekin).
chiocephalic venous obstruction in chronic hemodialysis patients with shunt dysfunction.
2. Methods and material Between January 1999 and October 2001, 14 chronic hemodialysis patients (6 men and 8 women) with shunt dysfunction due to central venous obstruction were treated with stent placement. The average age in the group was 45 years (range, 16–75 years). Six patients had polytetrafluoroethylene grafts, and 8 had native arteriovenous fistulae. Based on the indications of arm swelling and/or insufficient hemodialysis, all 14 patients had undergone ipsilateral upper extremity venography. Six of the individuals were diagnosed with subclavian vein stenosis (right side in 5 cases, left side in 1 case), and 5 with brachiocephalic vein stenosis (right side in 1 case, left side in 4 cases). The degree of stenosis in these 11 cases ranged from 80 to 95%. Of the remaining 3 patients, 2 had subclavian vein occlusion (right
0720-048X/$ – see front matter © 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0720-048X(02)00370-4
82
C. Aytekin et al. / European Journal of Radiology 49 (2004) 81–85
Fig. 1. (a) Venogram obtained via transjugular route shows occlusion of left brachiocephalic vein in a 61-year-old chronic hemodialysis patient with shunt dysfunction. (b) After deployment of a 14×40-mm self-expandable stent (Memotherm stent), good filling of the vein is seen. (c) Six months after the procedure, the patient returned with left arm swelling. High-grade restenosis with collateral filling is demonstrated on a selective left brachiocephalic venogram. (d) Restenosis is managed by balloon dilation. There is another stenotic lesion (arrow) is seen at proximal end of cephalic vein. (e) This new stenosis is also treated with stenting in the same session.
C. Aytekin et al. / European Journal of Radiology 49 (2004) 81–85
side in 1 case, left side in 1 case), and 1 had left brachiocephalic vein occlusion. The indications for stent placement were suboptimal angioplasty (defined as >50% narrowing with persistent filling of the venous collaterals) and recurrent stenosis within 2 months after successful angioplasty. The venous access locations for stent placement were the cephalic vein in 8 cases, the basilic vein in 3 cases, and the left internal jugular vein in 3 cases. After insertion of a 7F or 8F vascular sheath (Terumo, Tokyo, Japan) at the venous access site, a hydrophilic guide wire (Terumo) was passed through the stenotic or occluded segment of the problem vein. Angioplasty was done initially in all cases. The required stent size was determined during this procedure, based on the balloon diameter and the diameter of the adjacent normal vein. The selected stent diameter was the same or 1 mm larger than the balloon diameter. The stent length required was determined based on the extent and location of the lesion. Fifteen stents, including self-expandable ones (10 Memotherm stents, Bard Angiomed, Karlsruhe, Germany (10–16 mm diameter, 4–6 cm length); 3 Wallstents, Boston Scientific, Watertown, MA (12 mm diameter, 50–89 mm length); and balloon-expandable stents (2 Palmaz stents, Cordis (12 mm diameter, 25–30 mm length)), were inserted in the 14 patients. One patient received two overlapping stents. In this case, the first stent (a 16-mm diameter, 60-mm long Wallstent) slipped backward after expansion so that it no longer completely covered the stenotic segment. As a result, a second stent (a 12-mm diameter, 25-mm long Palmaz stent) was deployed. After insertion, 3 of the 14 patients’ stents had to be redilated by balloon angioplasty in order to achieve full expansion. Our criterion for technically successful stent placement was less than 30% residual stenosis with no filling of the venous collaterals.
83
Follow-up screening for stent patency was done using routine upper extremity venography at 3-month intervals. This procedure was also performed when a patient had abnormal hemodialysis and/or arm swelling. When necessary, further interventions were carried out to prolong stent patency (Fig. 1). We evaluated both primary stent patency and assisted primary stent patency. Primary patency was defined as the interval between the day of stent placement and the day of first redilation, or the day the patient was lost to follow-up due to renal transplantation or death. Assisted primary stent patency is a term we applied to cases in which redilation or thrombolysis were needed, and was defined as the interval between stent placement and permanent stent occlusion or loss of the extremity for hemodialysis.
3. Results All the stent placement procedures were successful (procedural success rate 100%), and there were no major complications such as venous rupture or thrombosis. Early thrombosis (within 2 weeks) occurred in 1 case. In the other 13 patients, follow-up ranged from 4 to 29 months (Table 1). One patient died 5 months after stent placement due to aneurysmal rupture of the arteriovenous fistula. One individual underwent renal transplantation 25 months after the procedure. Four patients were lost to follow-up due to loss of the extremity for hemodialysis. The stents were patent from 14 days to 29 months. The 1-, 3-, 6- and 12-month primary patency rates were 92.8, 85.7, 50 and 14.3%, respectively. During follow-up, 9 patients underwent 22 repeat interventions (angioplasty (n=14) and additional stent placement (n=8)) to prolong stent patency. In these 9 cases, the 3-, 6-, 12-month, and 2-year assisted primary stent patency rates were 100, 88.8, 55.5 and 33.3%, respectively.
Table 1 Procedural data and follow-up Patient no.
Age (year)/sex
Location
Stent size (mm)a
Reintervention
Follow-up
1
31/M
Subclavian vein (L)
12 × 40
PTA (10, 21, 23 mo)
2 3 4
62/F 38/M 40/F
Brachiocephalic vein (L) Brachiocephalic vein (L) Brachiocephalic vein (R)
PTA (5, 11 mo) – –
5 6 7 8 9 10 11 12 13 14
64/F 16/F 58/M 36/F 24/F 50/M 53/F 61/M 75/M 28/F
Subclavian vein Subclavian vein Subclavian vein Subclavian vein Subclavian vein Subclavian vein Brachiocephalic Subclavian vein Brachiocephalic Brachiocephalic
14 × 40 12 × 50 16 × 60 12 × 25 14 × 60 10 × 60 10 × 40 12 × 30 12 × 89 14 × 50 16 × 60 12 × 40 14 × 40 14 × 60
Patient received renal transplant at 25 mo Patent stent, 17 mo Patent stent, 4 mo Patent stent, 6 mo
a
Listed as diameter × length.
(R) (R) (R) (R) (L) (R) vein (L) (R) vein (L) vein (L)
Additional Additional Additional Additional – Additional – Additional Additional –
stent stent stent stent
(3 mo) (7 mo), PTA (10 mo) (5, 9 mo), PTA (7 mo) (9 mo), PTA (11 mo)
stent (11 mo), PTA (3, 6, 19 mo) stent (4 mo) stent (4 mo), PTA (7, 16, 25 mo)
Patent died at 5 mo Loss of hemodialysis access after 11 mo Loss of hemodialysis access after 10 mo Stent occlusion after 17 mo Stent thrombosis after 2 weeks Patent stent, 29 mo Patent stent, 7 mo Loss of hemodialysis access after 7 mo Stent occlusion after 26 mo Patent stent, 7 mo
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The reasons for the end of primary patency were permanent stent thrombosis in 1 case, balloon angioplasty in 3 cases, and additional stent insertion in 6 cases. The reasons for the end of assisted primary stent patency included loss of hemodialysis access in 3 patients, stent occlusion in 2 patients, renal transplantation in 1 patient, and death in 1 case. At the time of writing, the stents in the remaining 6 patients were patent. In 1 case, venography at 3 months after the procedure revealed slight displacement of a stent located in the left brachiocephalic vein. However, since the device was still covering the lesion, there was no need for repeat intervention.
4. Discussions and conclusion Central venous obstruction is one of the most common reasons for shunt dysfunction in chronic hemodialysis patients. In most cases, this problem occurs as a chronic complication of subclavian dialysis catheters used for temporary hemodialysis access [1,2]. Subclavian or brachiocephalic vein stenosis may cause reduced vascular access flow, increased venous pressure, and subsequent graft thrombosis. These patients usually present with ipsilateral arm swelling and insufficient hemodialysis [3,4]. If the problem is not solved, it can make the extremity unusable for hemodialysis access. Surgical management of upper extremity central venous obstruction tends to be difficult because the vessels are deep in the thorax [5]. Percutaneous endovascular methods, including percutaneous transluminal angioplasty (PTA) and stent placement, are gaining popularity as therapeutic alternatives to open surgery. Endovascular approach can be done under local anesthesia, is well-tolerated by the patient, and is associated with shorter hospitalization time than surgery. Upper extremity central venous stenosis or occlusion can be treated with balloon angioplasty alone. However, because of the high frequency of elastic recoil, the recurrence rate for central venous lesions after PTA is higher than that for peripheral lesions. As a result, in patients with these lesions, it is very difficult to achieve long-term patency after PTA [6–8]. Patients with extensive stenosis, cases in which PTA fails, and lesions that recur after multiple PTA procedures are usually treated with stent placement [9–13]. Stenting of subclavian and brachiocephalic vein stenosis and occlusions extends the duration of hemodialysis access. However, after 1–2 years, restenosis is seen frequently. In their study of 20 hemodialysis patients who had stents placed in central veins, Vessely et al. [9] noted 1-, 3-, 6- and 12-month primary patency rates of 90, 67, 42 and 25%, respectively. In one of the largest series published to date (50 patients), Haage et al. reported 3-month, 6-month, 1-year, and 2-year primary patency rates of 92, 84, 56 and 28%, respectively. After stent placement, multiple re-interventions are often needed to prolong patency. Re-obstruction usually occurs
due to intimal hyperplasia at or near the stent site, or due to stenosis at a remote location. Restenosis can usually be treated with angioplasty alone in most cases, but additional stent placement is sometimes required. In several reports, the 1-year assisted primary patency rates have ranged from 33 to 97% [9–13]. Stent shortening and stent movement are rare causes of re-obstruction that are most often observed during the stent placement procedure. The rate of shortening increases with increasing nominal stent diameter [14]. As well, central venous contraction and expansion during respiration may facilitate both stent shortening and stent movement [9]. In a report on 52 patients who underwent stent placement, Gray et al. [13] observed stent shortening in 6 cases. Four of these individuals had an additional stent placed so that the original lesion was completely covered. In our study, although we noted stent shortening in 2 patients, the rate of shortening was not so much to uncover the lesion. In 1 patient with brachiocephalic vein stenosis, stent was minimally moved distally without shortening. None of our 3 cases of stent displacement required insertion of a second stent. Bridging of vascular side-branches during stent placement is controversial. In cases where the lesion is located at the junction between the central subclavian vein and the peripheral brachiocephalic vein it is usually not possible to avoid bridging the jugular venous junction. Under these circumstances, temporary catheterization of the ipsilateral patent jugular vein may carry some risk; however, it is possible to place the catheter through the meshwork of a stent. In conclusion, endovascular stent placement is a valuable means of ensuring hemodialysis access, however multiple re-interventions are usually required to maintain stent patency. Further studies with large group of patients are needed to make correct decision.
References [1] Schwab S, Quarles D, Middleton J, Cohan R, Saeed M, Dennis V. Hemodialysis-associated subclavian vein stenosis. Kidney Int 1988;33:1156–9. [2] Surrat R, Picus D, Hicks M, et al. The importance of preoperative evaluation of the subclavian vein in dialysis access planning. Am J Roentgenol 1991;156:623–5. [3] Glanz S, Gordon D, Lipkowitz G, Butt K, Hong J, Sclafani S. Axillary and subclavian vein stenosis: percutaneous angioplasty. Radiology 1988;168:371–3. [4] McNally PG, Brown CB, Moorhead PJ, Raferty AT. Unmasking subclavian vein obstruction following creation of arteriovenous fistulae for hemodialysis: a problem following subclavian line dialysis? Nephrol Dial Transplant 1987;1:258–60. [5] Currier CB, Widder S, Ali A, Kuusisto E, Sidawy A. Surgical management of subclavian and axillary vein thrombosis in patients with a functioning arteriovenous fistula. Surgery 1986;100: 25–8. [6] Beathard G. Percutaneous transvenous angioplasty in the treatment of vascular access stenosis. Kidney Int 1992;42:1390–7.
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