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The First Case Using Synthetic Vein for Jugular to Iliac Vein Bypass to Treat Superior Vena Cava Obstruction: Clinical Dilemma and Literature Review
C A S E
R E P O R T
The First Case Using Synthetic Vein for Jugular to Iliac Vein Bypass to Treat Superior Vena Cava Obstruction: Clinical Dilemma and Literature Review Mohamed Zaki, MB, MSc, MRCS, BCh Department of Vascular and Endovascular Surgery, Western Vascular Institute, and Department of Vascular Surgery, Ain Shams University, Cairo, Egypt Niamh Hynes, MD, MBBCh, MRCS, MMSc Department of Vascular and Endovascular Surgery, Western Vascular Institute, and University Hospital Galway, Galway, Ireland Mahmoud Alawy, MD, MB, MSc, MRCS, BCh Mohamed El Kassaby, MB, MSc, MRCS, BCh Wael Tawfick, MBBCh, MSc, MRCS Department of Vascular and Endovascular Surgery, Western Vascular Institute, Sherif Sultan, MD, MB, MCh, BCh, FRCS (Vasc), EBSQ-VASC, FAARM, FACS Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, Galway, Ireland
Galway, Ireland;
Galway, Ireland;
Galway, Ireland Galway, Ireland; and
Abstract Chronic refractory venous hypertension is a common complication following repeated central venous cannulation performed as a temporary vascular access for dialysis in patients with chronic renal failure. The symptoms of venous hypertension may diverge from being asymptomatic to severe edema, ulceration, headaches, bloating, and blackouts, especially if the patient has a surgical arteriovenous fistula for dialysis in any of his upper limbs. Treatment options for such patients are mainly directed toward endovascular management via balloon angioplasty and possibly stenting of the stenosed vein. Resistant lesions or cases with total venous occlusion coerce surgeons to consider surgical bypass. We present a case of a 43-year-old patient with history of renal impairment and repeated bilateral central venous cannulation for dialysis. The patient experienced superior vena cava syndrome with bilateral total occlusion of the internal jugular veins and both subclavian veins (with an occluded previously inserted stent) along with the superior vena cava. An extra-anatomical bypass was done from the left internal jugular vein to the left external iliac vein using a synthetic silver Dacron ringed graft. The procedure was successful and resulted in relief of the patient’s symptoms and a dramatic improvement of the patient’s quality of life. Superior vena cava syndrome represents 1 of the most challenging complications for patients with chronic renal impairment and repeated central venous cannulation. The endovascular approach is currently gaining popularity as the first line of treatment for such patients. However, surgical management is sometimes the only available option when the endovascular approach is not technically feasible. Our case, along with others, shows that an extra-anatomical synthetic graft bypass can be a reliable, less invasive option for the management of superior vena cava syndrome once surgical intervention is inevitable. Keywords: superior vena cava syndrome, venous hypertension, complications of central venous cannulation, jugular to iliac vein bypass
Correspondence concerning this article should be addressed to [email protected] http://dx.doi.org/10.1016/j.java.2015.01.004 Copyright © 2015, ASSOCIATION FOR VASCULAR ACCESS. Published by Elsevier Inc. All rights reserved.
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Introduction atients with chronic renal failure undergo repeated attempts for central venous access for dialysis on a temporary basis. Unfortunately these attempts lead to the inevitable fibrosis and thrombosis of the central veins, and subsequently, venous hypertension. Thrombosis is a well recognized complication of central venous catheterization and its overall incidence is up to 13%.1 The symptoms of venous hypertension include severe edema, ulceration, headaches, bloating, and blackouts. This mainly depends on the abundance and development of a collateral venous circulation to bypass the stenosis and occlusion. Moreover, the symptoms are markedly exacerbated with the presence of a surgical arteriovenous fistula in either of the upper limbs causing an increase in blood velocity, volume, and pressure loads flowing through the venous system. Five percent of patients with surgical arteriovenous fistulae present with symptoms of venous hypertension.2 Diagnosis is mainly suspected by the clinical picture and confirmed by examination, which may show puffiness of the eyelids, facial plethora, dilated neck veins, and the presence of engorged collaterals along the neck and anterior chest wall. On examination, patients may also exhibit a positive Pemberton sign, which is marked facial plethora and some cyanosis within 30 seconds after a patient raises both arms simultaneously (Pemberton maneuver).3 Investigations include duplex ultrasound and computed tomography venography to accurately delineate the exact site of stenosis or occlusion. It is reported that duplex ultrasound scanning finding of a peak vein velocity ratio of > 2.5 across the stenosis is the best criterion to use for the presence of a pressure gradient of 3 mm Hg.4 Treatment options for such cases are mainly directed toward endovascular management via balloon angioplasty and possibly stenting of the stenosed vein. Resistant lesions or cases with total venous occlusion coerce surgeons to consider surgical bypass.
P
Patient Course and Management A 43-year-old male renal transplantation patient with past history of hypertension, meningitis, and chronic renal failure presented to our clinic with disabling pain, bilateral upper limb swelling, and fullness in his head and neck along with plethora and congestion, which increased on leaning forward to the extent that “he can no longer tie his own shoes.” The patient had received regular hemodialysis through a left brachiocephalic arteriovenous fistula, had a history of several bilateral central venous cannulation with double lumen catheters for dialysis, underwent renal transplantation 5 years ago, and had the fistula defunctioned after the transplant. Venography showed a right subclavian vein stenosis and a left subclavian and internal jugular vein total occlusion. Subsequently, the patient underwent balloon angioplasty and a stent was placed from the left subclavian vein to the superior vena cava 4 years ago. Two years later, the patient’s symptoms started to reappear and another venogram showed total occlusion of the left internal jugular vein from the midneck, along with occlusion
Figure 1. Conventional venography showing bilateral total occlusion of both internal jugular veins proximally and subclavian veins along with collateral flow through the internal thoracic vein (B) and the occluded left subclavian vein stent (A). of the previously placed stent (Figures 1, 2, 3, and 4). Attempts of redo endovascular management failed due to inability to pass the guide wire through the occluded stent. An original surgical plan was devised to bypass the occluded segments
Figure 2. Computed tomography venography showing bilateral total occlusion of both internal jugular veins and subclavian veins along with the occluded stent.
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Figure 4. Conventional venogram through a collateral from the left internal jugular vein (A) showing the totally occluded proximal part of the left internal jugular vein (B) as well as the occluded left subclavian stent (C). Figure 3. Three-dimensional reconstruction for the computed tomography venogram showing total occlusion of both internal jugular veins, subclavian veins, as well as superior vena cava with formation of a huge right sided anterior chest wall collateral. by performing a bilateral juguloatrial bypass using a synthetic polytetrafluoroethylene graft, through a thoracotomy. However, because of the markedly congested anterior chest wall collaterals, the cardiothoracic surgery team recommended avoiding thoracotomy for this patient because of the very high risk of bleeding, morbidity, and unfavorable outcome, taking into consideration the patient’s young age. Alternately, we were compelled to concoct another management plan. On thorough examination of the venogram, we found that the patient had developed a reliable collateral outflow for drainage of the right internal jugular and subclavian veins to the right internal mammary vein (Figure 1), and therefore our problem was confined to the total occlusion of the left internal jugular and left subclavian veins as well as the superior vena cava. Consequently, a left internal jugular to a left external iliac vein bypass was performed using an 8 mm 85 cm ringed silver polyethelene synthetic graft (Intervascular, La Ciotat, France) (Figure 5). Postoperatively, the patient experienced acute kidney injury, and underwent temporary hemodialysis for 3 weeks after which he recovered completely from both the renal impairment and the symptoms of superior vena cava obstruction (Figure 6). Follow-up of the patient in our clinic was uneventful.
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Discussion Superior vena cava syndrome refers to a constellation of signs and symptoms resulting from obstruction of the superior vena cava. Symptoms of superior vena cava syndrome may be both exceedingly disabling and life threatening. Whereas a majority of cases are caused by malignant lesions of the mediastinum, about 5% to 10% are related to nonmalignant causes, including fibrosing mediastinitis, postradiation sequelae, and are secondary to central venous catheter placement.1 The choice of the treatment modality varies widely depending on the timing, presentation, etiology, severity of the condition,
Figure 5. Operating room view of the subcutaneous tunnel created for passage of the synthetic vein from the left internal jugular vein to the left external iliac vein.
2015
has been used as a conduit for bypassing superior vena cava occlusion.8 The most common bypass done is conducted between the internal jugular vein and the right atrium. There are also few reports of extra-anatomic subcutaneous bypass between the jugular vein and the femoral vein,7 and between the axillary vein and the great saphenous vein.8 However, most of the extra-anatomic bypass grafts are usually done to salvage a precious patent vascular access for dialysis in the upper limb such as an arteriovenous fistula or graft.9,10 When done in the absence of an arteriovenous connection, the challenge remains in preserving the patency of the graft, especially if it is a synthetic graft, due to the lack of the high flow velocity and pressure created through shunting of the blood from the arterial side to the venous side. In our case, the option of endovascular redo was tried and failed, and the option of surgical bypass of the occluded superior vena cava to the right atrium was considered; however, it was not possible because of the massive network of congested collateral venous channels on the anterior chest wall that rendered the surgery extremely perilous, especially in young patients. Patency has been maintained in our patient through 4 months of postoperative follow-up without the need to create any arteriovenous anastomosis. The postoperative morbidity was minimal, and although the patient had to undergo a few hemodialysis sessions as a result of his renal history, he totally recovered.
Figure 6. Postoperative picture of the patient with resolution of the symptoms. and the availability of necessary resources. Thrombolytic therapy may be used when superior vena cava syndrome is caused by catheter-induced intraluminal thrombosis. Thrombolytic therapy or tissue plasminogen activators are used to treat catheterinduced thrombosis and can effectively lyse clots. It should be noted that treatment with thrombolytic agents should be initiated within 5 to 7 days of the onset of symptoms for maximal effectiveness.5 Another treatment option is the endovascular approach, which is currently gaining popularity as a first-line management modality because it conveys less patient morbidity and has favorable outcomes. There are, however, technical limitations to such an option, the most prominent of which is the presence of total venous occlusion with the inability to pass the guide wire across the lesion safely. Recently, sharp recanalization has been introduced; however, its use is strictly off-label in most manufactured catheters and it always carries the risk of detrimental complications such as venous perforation and hemorrhage.6 The final option for management is the surgical bypass route. Several techniques for bypass of the superior vena cava to relieve severe symptoms have been described. These techniques have used spiraled saphenous vein grafts, femoral vein grafts, and polytetrafluoroethylene grafts as conduits.7 More recently, a cryopreserved ascending aortic allograft
Conclusions Venous hypertension is 1 of the most common complications of repeated central venous cannulation for patients undergoing hemodialysis. Its symptoms can cause severe impairment of normal daily activity and drastic lifestyle mutilation. The choice of management must be judged individually according to each patient’s general condition, type and extent of lesion, history of previous interventions, and comorbidities. The selection of the procedure should adequately balance the risks of the procedure itself with the expected lifestyle improvement. In our case, an internal jugular to external iliac vein extra-anatomic bypass using a silver polyethelene synthetic graft was done successfully and improved the patient’s symptoms dramatically. Before embarking on such a route, questions should be raised about the extent of patient benefit, expectations for patency, and the need for arteriovenous connection. To our knowledge, no case has been reported in the literature describing a bypass from the internal jugular vein to the external iliac vein. Although our patient had bilateral jugular and subclavian occlusion along with the superior vena cava, we could only operate on the left side to not jeopardize his transplanted kidney because his right renal vein was implanted to the right external iliac vein. However, his symptoms improved bilaterally. Our case, along with others, shows that an extra-anatomic synthetic graft bypass can be a reliable, less invasive option for the management of superior vena cava syndrome once surgical intervention is inevitable.
2015
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Disclosures The authors have no conflicts of interest to disclose. References 1. Sriramnaveen P, Siva KV, Krishna KC, et al. Delayed presentation of superior vena cava syndrome after hemodialysis catheter removal. Saudi J Kidney Dis Transpl. 2011;22(3):554-556. 2. Acri I, Carmignani A, Vazzana G, et al. Ipsilateral jugular to distal subclavian vein transposition to relieve central venous hypertension in rescue vascular access surgery: a surgical report of 3 cases. Ann Thorac Cardiovasc Sur. 2013;19(1):55-59. 3. Basaria S, Salvatori R. Images in clinical medicine. Pemberton’s sign. N Engl J Med. 2004;350(13): 1338. 4. Labropoulos N, Borge M, Pierce K, Pappas PJ. Criteria for defining significant central vein stenosis with duplex ultrasound. J Vasc Surg. 2007;46:101-107.
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5. Molhem A, Sabry A, Bawadekji H, Al Sarhan K. Superior vena cava syndrome in hemodialysis patients. Saudi J Kidney Dis Transpl. 2011;22(2):381-386. 6. Anil G, Taneja M. Revascularization of an occluded brachiocephalic vein using Outback-LTD re-entry catheter. J Vasc Surg. 2010;52(4):1038-1040. 7. Dhaliwal R, Luthra S, Singh J, Mehta S, Singh H. Management of superior vena cava syndrome by internal jugular to femoral vein bypass. Ann Thorac Surg. 2006;82:310-312. 8. Firstenberg MS, Blais D, Abdel E, Go MR. Superior vena cava bypass with cryopreserved ascending aorta allograft. Ann Thorac Surg. 2011;91(3):905-907. 9. Kavallieratos N, Kokkinos A, Kalocheretis P. Axillary to saphenous vein bypass for treatment of central venous obstruction in patients requiring dialysis. J Vasc Surg. 2004;40:640-643. 10. Asciutto G, Mumme A, Asciutto K, Geier B. Salvage of a dialysis angioaccess by bypassing a central venous obstruction to the common femoral vein. Vasa. 2009;38(3):245-248.
2015
R E P O R T
The First Case Using Synthetic Vein for Jugular to Iliac Vein Bypass to Treat Superior Vena Cava Obstruction: Clinical Dilemma and Literature Review Mohamed Zaki, MB, MSc, MRCS, BCh Department of Vascular and Endovascular Surgery, Western Vascular Institute, and Department of Vascular Surgery, Ain Shams University, Cairo, Egypt Niamh Hynes, MD, MBBCh, MRCS, MMSc Department of Vascular and Endovascular Surgery, Western Vascular Institute, and University Hospital Galway, Galway, Ireland Mahmoud Alawy, MD, MB, MSc, MRCS, BCh Mohamed El Kassaby, MB, MSc, MRCS, BCh Wael Tawfick, MBBCh, MSc, MRCS Department of Vascular and Endovascular Surgery, Western Vascular Institute, Sherif Sultan, MD, MB, MCh, BCh, FRCS (Vasc), EBSQ-VASC, FAARM, FACS Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, Galway, Ireland
Galway, Ireland;
Galway, Ireland;
Galway, Ireland Galway, Ireland; and
Abstract Chronic refractory venous hypertension is a common complication following repeated central venous cannulation performed as a temporary vascular access for dialysis in patients with chronic renal failure. The symptoms of venous hypertension may diverge from being asymptomatic to severe edema, ulceration, headaches, bloating, and blackouts, especially if the patient has a surgical arteriovenous fistula for dialysis in any of his upper limbs. Treatment options for such patients are mainly directed toward endovascular management via balloon angioplasty and possibly stenting of the stenosed vein. Resistant lesions or cases with total venous occlusion coerce surgeons to consider surgical bypass. We present a case of a 43-year-old patient with history of renal impairment and repeated bilateral central venous cannulation for dialysis. The patient experienced superior vena cava syndrome with bilateral total occlusion of the internal jugular veins and both subclavian veins (with an occluded previously inserted stent) along with the superior vena cava. An extra-anatomical bypass was done from the left internal jugular vein to the left external iliac vein using a synthetic silver Dacron ringed graft. The procedure was successful and resulted in relief of the patient’s symptoms and a dramatic improvement of the patient’s quality of life. Superior vena cava syndrome represents 1 of the most challenging complications for patients with chronic renal impairment and repeated central venous cannulation. The endovascular approach is currently gaining popularity as the first line of treatment for such patients. However, surgical management is sometimes the only available option when the endovascular approach is not technically feasible. Our case, along with others, shows that an extra-anatomical synthetic graft bypass can be a reliable, less invasive option for the management of superior vena cava syndrome once surgical intervention is inevitable. Keywords: superior vena cava syndrome, venous hypertension, complications of central venous cannulation, jugular to iliac vein bypass
Correspondence concerning this article should be addressed to [email protected] http://dx.doi.org/10.1016/j.java.2015.01.004 Copyright © 2015, ASSOCIATION FOR VASCULAR ACCESS. Published by Elsevier Inc. All rights reserved.
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Introduction atients with chronic renal failure undergo repeated attempts for central venous access for dialysis on a temporary basis. Unfortunately these attempts lead to the inevitable fibrosis and thrombosis of the central veins, and subsequently, venous hypertension. Thrombosis is a well recognized complication of central venous catheterization and its overall incidence is up to 13%.1 The symptoms of venous hypertension include severe edema, ulceration, headaches, bloating, and blackouts. This mainly depends on the abundance and development of a collateral venous circulation to bypass the stenosis and occlusion. Moreover, the symptoms are markedly exacerbated with the presence of a surgical arteriovenous fistula in either of the upper limbs causing an increase in blood velocity, volume, and pressure loads flowing through the venous system. Five percent of patients with surgical arteriovenous fistulae present with symptoms of venous hypertension.2 Diagnosis is mainly suspected by the clinical picture and confirmed by examination, which may show puffiness of the eyelids, facial plethora, dilated neck veins, and the presence of engorged collaterals along the neck and anterior chest wall. On examination, patients may also exhibit a positive Pemberton sign, which is marked facial plethora and some cyanosis within 30 seconds after a patient raises both arms simultaneously (Pemberton maneuver).3 Investigations include duplex ultrasound and computed tomography venography to accurately delineate the exact site of stenosis or occlusion. It is reported that duplex ultrasound scanning finding of a peak vein velocity ratio of > 2.5 across the stenosis is the best criterion to use for the presence of a pressure gradient of 3 mm Hg.4 Treatment options for such cases are mainly directed toward endovascular management via balloon angioplasty and possibly stenting of the stenosed vein. Resistant lesions or cases with total venous occlusion coerce surgeons to consider surgical bypass.
P
Patient Course and Management A 43-year-old male renal transplantation patient with past history of hypertension, meningitis, and chronic renal failure presented to our clinic with disabling pain, bilateral upper limb swelling, and fullness in his head and neck along with plethora and congestion, which increased on leaning forward to the extent that “he can no longer tie his own shoes.” The patient had received regular hemodialysis through a left brachiocephalic arteriovenous fistula, had a history of several bilateral central venous cannulation with double lumen catheters for dialysis, underwent renal transplantation 5 years ago, and had the fistula defunctioned after the transplant. Venography showed a right subclavian vein stenosis and a left subclavian and internal jugular vein total occlusion. Subsequently, the patient underwent balloon angioplasty and a stent was placed from the left subclavian vein to the superior vena cava 4 years ago. Two years later, the patient’s symptoms started to reappear and another venogram showed total occlusion of the left internal jugular vein from the midneck, along with occlusion
Figure 1. Conventional venography showing bilateral total occlusion of both internal jugular veins proximally and subclavian veins along with collateral flow through the internal thoracic vein (B) and the occluded left subclavian vein stent (A). of the previously placed stent (Figures 1, 2, 3, and 4). Attempts of redo endovascular management failed due to inability to pass the guide wire through the occluded stent. An original surgical plan was devised to bypass the occluded segments
Figure 2. Computed tomography venography showing bilateral total occlusion of both internal jugular veins and subclavian veins along with the occluded stent.
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Figure 4. Conventional venogram through a collateral from the left internal jugular vein (A) showing the totally occluded proximal part of the left internal jugular vein (B) as well as the occluded left subclavian stent (C). Figure 3. Three-dimensional reconstruction for the computed tomography venogram showing total occlusion of both internal jugular veins, subclavian veins, as well as superior vena cava with formation of a huge right sided anterior chest wall collateral. by performing a bilateral juguloatrial bypass using a synthetic polytetrafluoroethylene graft, through a thoracotomy. However, because of the markedly congested anterior chest wall collaterals, the cardiothoracic surgery team recommended avoiding thoracotomy for this patient because of the very high risk of bleeding, morbidity, and unfavorable outcome, taking into consideration the patient’s young age. Alternately, we were compelled to concoct another management plan. On thorough examination of the venogram, we found that the patient had developed a reliable collateral outflow for drainage of the right internal jugular and subclavian veins to the right internal mammary vein (Figure 1), and therefore our problem was confined to the total occlusion of the left internal jugular and left subclavian veins as well as the superior vena cava. Consequently, a left internal jugular to a left external iliac vein bypass was performed using an 8 mm 85 cm ringed silver polyethelene synthetic graft (Intervascular, La Ciotat, France) (Figure 5). Postoperatively, the patient experienced acute kidney injury, and underwent temporary hemodialysis for 3 weeks after which he recovered completely from both the renal impairment and the symptoms of superior vena cava obstruction (Figure 6). Follow-up of the patient in our clinic was uneventful.
94
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Vol 20 No 2
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Discussion Superior vena cava syndrome refers to a constellation of signs and symptoms resulting from obstruction of the superior vena cava. Symptoms of superior vena cava syndrome may be both exceedingly disabling and life threatening. Whereas a majority of cases are caused by malignant lesions of the mediastinum, about 5% to 10% are related to nonmalignant causes, including fibrosing mediastinitis, postradiation sequelae, and are secondary to central venous catheter placement.1 The choice of the treatment modality varies widely depending on the timing, presentation, etiology, severity of the condition,
Figure 5. Operating room view of the subcutaneous tunnel created for passage of the synthetic vein from the left internal jugular vein to the left external iliac vein.
2015
has been used as a conduit for bypassing superior vena cava occlusion.8 The most common bypass done is conducted between the internal jugular vein and the right atrium. There are also few reports of extra-anatomic subcutaneous bypass between the jugular vein and the femoral vein,7 and between the axillary vein and the great saphenous vein.8 However, most of the extra-anatomic bypass grafts are usually done to salvage a precious patent vascular access for dialysis in the upper limb such as an arteriovenous fistula or graft.9,10 When done in the absence of an arteriovenous connection, the challenge remains in preserving the patency of the graft, especially if it is a synthetic graft, due to the lack of the high flow velocity and pressure created through shunting of the blood from the arterial side to the venous side. In our case, the option of endovascular redo was tried and failed, and the option of surgical bypass of the occluded superior vena cava to the right atrium was considered; however, it was not possible because of the massive network of congested collateral venous channels on the anterior chest wall that rendered the surgery extremely perilous, especially in young patients. Patency has been maintained in our patient through 4 months of postoperative follow-up without the need to create any arteriovenous anastomosis. The postoperative morbidity was minimal, and although the patient had to undergo a few hemodialysis sessions as a result of his renal history, he totally recovered.
Figure 6. Postoperative picture of the patient with resolution of the symptoms. and the availability of necessary resources. Thrombolytic therapy may be used when superior vena cava syndrome is caused by catheter-induced intraluminal thrombosis. Thrombolytic therapy or tissue plasminogen activators are used to treat catheterinduced thrombosis and can effectively lyse clots. It should be noted that treatment with thrombolytic agents should be initiated within 5 to 7 days of the onset of symptoms for maximal effectiveness.5 Another treatment option is the endovascular approach, which is currently gaining popularity as a first-line management modality because it conveys less patient morbidity and has favorable outcomes. There are, however, technical limitations to such an option, the most prominent of which is the presence of total venous occlusion with the inability to pass the guide wire across the lesion safely. Recently, sharp recanalization has been introduced; however, its use is strictly off-label in most manufactured catheters and it always carries the risk of detrimental complications such as venous perforation and hemorrhage.6 The final option for management is the surgical bypass route. Several techniques for bypass of the superior vena cava to relieve severe symptoms have been described. These techniques have used spiraled saphenous vein grafts, femoral vein grafts, and polytetrafluoroethylene grafts as conduits.7 More recently, a cryopreserved ascending aortic allograft
Conclusions Venous hypertension is 1 of the most common complications of repeated central venous cannulation for patients undergoing hemodialysis. Its symptoms can cause severe impairment of normal daily activity and drastic lifestyle mutilation. The choice of management must be judged individually according to each patient’s general condition, type and extent of lesion, history of previous interventions, and comorbidities. The selection of the procedure should adequately balance the risks of the procedure itself with the expected lifestyle improvement. In our case, an internal jugular to external iliac vein extra-anatomic bypass using a silver polyethelene synthetic graft was done successfully and improved the patient’s symptoms dramatically. Before embarking on such a route, questions should be raised about the extent of patient benefit, expectations for patency, and the need for arteriovenous connection. To our knowledge, no case has been reported in the literature describing a bypass from the internal jugular vein to the external iliac vein. Although our patient had bilateral jugular and subclavian occlusion along with the superior vena cava, we could only operate on the left side to not jeopardize his transplanted kidney because his right renal vein was implanted to the right external iliac vein. However, his symptoms improved bilaterally. Our case, along with others, shows that an extra-anatomic synthetic graft bypass can be a reliable, less invasive option for the management of superior vena cava syndrome once surgical intervention is inevitable.
2015
j
Vol 20 No 2
j
JAVA
j
95
Disclosures The authors have no conflicts of interest to disclose. References 1. Sriramnaveen P, Siva KV, Krishna KC, et al. Delayed presentation of superior vena cava syndrome after hemodialysis catheter removal. Saudi J Kidney Dis Transpl. 2011;22(3):554-556. 2. Acri I, Carmignani A, Vazzana G, et al. Ipsilateral jugular to distal subclavian vein transposition to relieve central venous hypertension in rescue vascular access surgery: a surgical report of 3 cases. Ann Thorac Cardiovasc Sur. 2013;19(1):55-59. 3. Basaria S, Salvatori R. Images in clinical medicine. Pemberton’s sign. N Engl J Med. 2004;350(13): 1338. 4. Labropoulos N, Borge M, Pierce K, Pappas PJ. Criteria for defining significant central vein stenosis with duplex ultrasound. J Vasc Surg. 2007;46:101-107.
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5. Molhem A, Sabry A, Bawadekji H, Al Sarhan K. Superior vena cava syndrome in hemodialysis patients. Saudi J Kidney Dis Transpl. 2011;22(2):381-386. 6. Anil G, Taneja M. Revascularization of an occluded brachiocephalic vein using Outback-LTD re-entry catheter. J Vasc Surg. 2010;52(4):1038-1040. 7. Dhaliwal R, Luthra S, Singh J, Mehta S, Singh H. Management of superior vena cava syndrome by internal jugular to femoral vein bypass. Ann Thorac Surg. 2006;82:310-312. 8. Firstenberg MS, Blais D, Abdel E, Go MR. Superior vena cava bypass with cryopreserved ascending aorta allograft. Ann Thorac Surg. 2011;91(3):905-907. 9. Kavallieratos N, Kokkinos A, Kalocheretis P. Axillary to saphenous vein bypass for treatment of central venous obstruction in patients requiring dialysis. J Vasc Surg. 2004;40:640-643. 10. Asciutto G, Mumme A, Asciutto K, Geier B. Salvage of a dialysis angioaccess by bypassing a central venous obstruction to the common femoral vein. Vasa. 2009;38(3):245-248.
2015