Endovascular management of central venous stenosis after proximal native arteriovenous fistula in hemodialysis patients

Endovascular  management of central venous stenosis after proximal native arteriovenous fistula in hemodialysis patients

Adel H Kamhawy,MD; Mohamed A,MD; El Heneidy,MD; Amr M Abo Rahma,MD

Vascular Surgery Unit, Faculty of Medicine, Tanta University, Egypt.

Abstract

Central  venous  stenosis  (CVS)  is a common  and significant problem in the long-term management of the hemodialysis access. The aim of this work was to study the efficacy and safety of endovascular management of central venous stenosis in relieving patient's symptoms and maintaining fUnctioning native shunt in end stage renal disease patients on hemodialysis. Balloon angioplasty (PTA) with or without stent were performed for 42 patients who had chronic renal failure and venous hypertension due to CVS. The studied group was 28 males and 14 females, mean age 45 years with 30 brachiocephalic and 12 basilic vein supeificialization. Our patients  had 3 SVC, 5 innominate, 34 subclavian vein stenosis.  PTA alone was technically successfUl in 27 (64.3%) of 42 cases. Primary stents were placed in the remaining 15 (35.7%). All procedures were technically successfUl with no major complications. Primary patency rate were 85%, 67% and 44% at 3, 6 and 12 months respectively. 28 patients needed reintervention within the 1st year of follow-up.All patients with repeated dilatation had no major complications. In conclusion, Endovascular management of central venous stenosis is an effective and safe alternative to surgery. Follow-up  and repeated  dilatations are indicated  to relieve  patient symptoms and extend  the life  of the proximal  native  A-V shunt  in hemodialysis patients.

Introduction:

The growing population of patients with

end-stage  renal  disease  (ESRD)  and their increased survival has substantially increased the burden associated  with dialysis access related complications.!More than 86 % of patients with   ESRD  are  dependent on hemodialysis (HD).2  Management of  the complications ofHD access is now integral to vascular practice.3

Central venous stenosis (CVS) is a common and significant problem  in  the long-term management of the HD access.4 The placement of catheters in the subclavian veins have led to the development of stenosis in patients up to 40- 50%,5,6 whereas catheterization of the right internal jugular vein is associated with the lowest frequency of CVS.1 Most patients who develop a subclavian vein stenosis remain asymptomatic. Only 1 % to 5 % of these will develop clinically significant stenosis, manifested  as venous  hypertension in the affected extremity.7 CVS can also occur in the venous outflow of an AVF without previous

catheterization.8

The pathophysiology of CVS is not well known but it is thought to be due to thrombus formation from direct intimal trauma at the catheter site, in turn leading to neointimal fibroplasia.9  Formation  of subclavian  vein thrombosis does not produce  a clinically significant syndrome in most patients because of the rapid development of collaterals bypass the occluded venous segment. But when an AVF is created ipsilateral to the stenosis, the increase in blood flow becomes greater than the capacity of the collaterals,  and venous hypertension results.2 Patients with venous hypertension present with pain, massive edema with or without skin breakdown, and disability of the affected extremity. In addition, the increased venous pressure produces inefficient dialysis. This scenario represents challenging problem  to   the   treating  physician.2

Historically, the only  treatment  option available was ligation of the arteriovenous shunt.lO This is a simple surgical solution and resolves the symptoms of venous hypertension.

But  ligation eliminates a precious site  of vascular access for life-sustaining dialysis and precludes future access sites from being created in the affected extremity.2

Nowadays, the  optimal therapy for symptomatic central venous obstruction is not clearly defined. Both endovascular and open procedures have been used for the treatment of CVS and occlusions.8 Several years ago, angioplasty was the treatment of choice for CVS. Several  investigators, however,  have reported reduced long  term  patency after angioplasty of central  lesions; as compared with peripheral venous stenosis.ll-13 Surgical options are limited due to the morbidity associated with  the exposure and  repair  of these deep thoracic veins.14

Despite the adoption of"Dialysis Outcomes Quality  Initiative Clinical Guidelines" and early description of percutaneous interventions in hemodialysis fistulas, there  is a relative paucity of information on percutaneous management of dysfunctional arteriovenous fistulas and  outcomes after  percutaneous interventions.1s

The aim of this work was to study the efficacy  and safety of percutaneous balloon angioplasty with or without primary stenting of CVS in relieving  patient's  symptoms and maintaining functioning  native shunt in end stage renal disease patients on hemodialysis.

Materials and  methods:

Between 1st January 2007 and 31 December

2010, 42 chronic hemodialysis patients with proximal native AVF with CVS were included in this study. The clinical presentations of our patients were one or more of the following: significant  arm edema Figure(l), prominent chest  wall venous collaterals, prolonged bleeding after needle removal and inefficient dialysis (increased recirculation and  high venous pressure) Figure(2).

For each patient, medical and demographic

variables, including smoking, diabetes mellitus, and hypertension and risk factors such as central line   catheter placement were recorded.

Exclusion criteria in this study were: patients

undergoing secondary  stenting  for failed  or suboptimal angioplasty, patients with complete occlusion with inability to cross the lesion with guidewire, recent thrombosis, allergy from the

radiocontrast material, congestive heart failure, uncorrectable coagulopathy, presence of acute infection, synthetic  AVF and distal AVF in the forearm.

Diagnosis of CVS was  confirmed in all cases  by  venogram through the  AVF  that revealed significant stenosis in the central veins,  which  was defined as 50%  or more narrowing of the vein. Intervention was done in the same setting of diagnostic venography. Ultrasound is also important to exclude acute venous thrombosis.

Technique:

The  procedure was  done   under local anesthesia. The arterialized vein is cannulated

3cm  or more  distal  to the anastomosis and

away  from the sites of dialysis  puncture. A small subcutaneous tunnel is made between the skin and vein entry point to facilitate compression and placement of a suture. Intravenous Heparin (5000 units) was given IV at start of the procedure. Pass the guide wire via needle into vein then advance the sheath.

Venography using nonionic  contrast

{Ultravist 370) was done to defme the site, length  and degree  of the  stenosis. Manual compression on the site of anastomosis  was done to enhance the contrast in large sized central veins. An angled-tip hydrophilic guide wire 0.035  was used to navigate through the stenosis. After crossing the lesion, dilatation was done. The diameter of the balloon was chosen to allow for 10%-20% oversize, which usually resulted in a balloon diameter  1 or 2 mm larger than  the diameter of reference segment. The  maximum pressure applied ranged from 18 to 20 atm. Inflation time for 3 minutes was performed. If there was resistant stenosis or elastic recoil repeated inflations could be done till disappearance of the balloon waist. After dilatation a completion venogram was done. If there was 30-500/o residual stenosis redilatation using a 1-mm larger balloon was done. If there is a residual stenosis  >50 % a stent should be considered.

After the procedure is complete, withdrawal

of the introducer sheath and purse-string suture was taken around the entry point and manual compression to stop bleeding Figure(3). The suture was  removed 24  hours after the

procedure.16 The used balloon was Ultra-thin TM, Diamond TM, (Boston). The used stent was Wallstent,  Venous Endoprosthesis with Unistep' Plus   Delivery System (Boston Scientific Scimed Inc.).

In the present study, 42 chronic hemodialysis patients with proximal native AVF with CVS were  included. Patients' demographics are shown in Table(l). All of them had a native proximal AVF, 30  (71.4%) were brachiocephalic while 12(28.6%) were basilic vein superficialization. There were 27 lesions (64.2%} in the right side while 15 (35.8 %} in the left side. Our patients had 34 subclavian (81%), 5 innominate (11.9%) and  3 SVC (7.1%) venous stenosis and were subjected to PTA with or without primary stent. All patients had a history  of ipsilateral subclavian vein catheter. Most of them (28/34) had a history of repeated or prolonged catheterization of the subclavian vein  for  hemodialysis access.

All procedures were performed percutaneously through  the  fistula. Initial percutaneous angioplasty was  technically successful in  27(64.3%} of  42  cases. Suboptimal results  from  PTA  led  to stent placement in the remaining 15 (35.7%). Self­ expanding stents were used to successfully treat these 15 residual lesions. One challenging case of subclavian vein  obstruction was successfully recanalised through  combined approach by passage of two guide wires, one through  the AVF  and the other  through  the femoral vein. By using the stiff end of the back of the guidewire the occlusion was passed and

Table (1): Patients demographics

PTA with  primary stent  was performed successfully Figures(4-6).

The overall technical success rate of PTA with or without primary stent was 100 %. The size of the balloon for fmal  dilatation was lOmm and 12nun according to adjacent normal venous segment. Balloon length was 4cm with maximum inflation pressures of 18 to 20 ATM.

No  post-operative complications were

encountered except access complications in the form  of hematoma in  one  patient.  All patients were discharged the day or the day after the procedure. It is to be mentioned that the patency  of the vein in the present  study was not assessed by objective methods in all patients. The success of the  procedure for providing symptomatic relief is the goal of the procedure and ultimately determines procedural success.

The overall one year patency rate of the 42 patients could be successfully followed in 33 patients, for the remaining 9 patients; one died and 5 patients showed loss of the vascular access for haemodialysis due to thrombosis by which they reached the end point of the study and were excluded from the late follow up and

3 patients were missed in the follow up period The mean of follow-up period was 17.4 months (range, 6-39 months). Primary patency rates were 100%, 85%, 67% and 44% at one, 3, 6 and 12 months respectively. 28 patients needed reintervention within the 1st year of follow­ up. All patients with repeated dilatation  had no major complications.

Figure (1): A case of right upper limb edema due to CVS.

Figure (2): Dilated co/laterals and AVF malfUnction.

Figure (3): Purse-string suture in the skin tied after extraction of the introducer.

(A)

(B)

(C)

(D)

(E)

Figure (4): A case of complete subclavian vein occlusion successfUlly recanalised through combined approach and PTA with primary stent.

(A): Subclavian vein occlusion with two guidewiresfrom above (trans AVF) and below (trans femoral),  (B): Successful  crossing  of the lesion,  (C): Balloon  dilatation with waisting, (D):  Complete Balloon  dilatation, (E):  Stent  placed  through  the  occluded  segment.

(A)

(C)

(E)

(B)

(D)

(F)

Figure (5): A case of subclavian vein stenosis treated by stent.

(A): Stenosis  of Rt subclavian vein, (B): Stent  before  deployment positioned  in  place, (C): Stent after deployment with waisting, (D): Balloondilatation inside the stent, (E): Complete dilatation  of   the   stent,  (F):  Complete dilatation  without residual  stenosis.

-&iiihl!fiii!ffNtiiDfil!%'

(A)

(C)

(E)

(B)

(D)

(F)

Figure(6):A case of superior vena cava syndrome.

(A): A patient with SVC syndrome with congestion of face and dilated veins over chest wall, (B): Clinical improvement  few days after the procedure,(C): Severe stenosis of SVC, (D):  Balloon  dilatation with  waisting, (E):  Complete dilatation  of  the  balloon, (F):   Venography  after   complete  dilatation  with   accepted residual stenosis.

Discussion:

Percutaneous endovascular methods, including PTA and stent placement, are gaining popularity as therapeutic alternatives to open surgery in treatment of CVS. Endovascular approach can be done under local anesthesia, is well-tolerated by the patient, and is associated with shorter hospitalization time than surgery.14

Because of the steady growth of the HD population and the persistently high percentage of late referrals requiring emergency renal replacement therapy, increasing  numbers of HD catheters are being implanted. In Europe between 15% (Germany) and 50% (UK) and in the US even 60% of end-stage renal disease had a history of HD catheters.17

All patients in this study had a history of prior catheterization which was used in initial dialysis.Inaccordance to other studies, a history of central vein catheter was reported in 40%

& 90%  in  HD  patients with   CVS_l8,19

In our study results analysis clarified that stenosis occurred in areas with no valves like SVC  and innominate vein;  on  contrary to opinion  that says stenosis started at the sites of valves by thrombosis then recanalization.20

Concerning the site of entry, in the present study  we  used  catheterization through the fistula. On contrary, Oderich et al.21 preferred catheterization from  the femoral venous approach for patients with  small-caliber, tortuous, or  angulated peripheral upper­ extremity veins, which could not be accessed through the AVF.

In the  current study, the  vein  most commonly treated was the subclavian vein (34 case-81%), followed  by the innominate (5 cases-11.9%) vein and SVC in 3 cases (7.1%). The most prevalent lesion type was stenosis rather  than occlusion; however  most of the stenosis was of the severe type.

In the study of Haage et al.,22 there were

an obstruction situated in the subclavian vein in 35 patients  out of 50 patients  included  in his study and in the brachiocephalic vein in 15 patients. Of the 35 patients with obstruction in the subclavian vein, 25 (71%) had a high­ grade stricture, and 10 (29%) had an occlusion. Of the 15  patients with  obstruction in the brachiocephalic vein, 13 (87%) had a severe stenosis, and two (13%) had an occlusion. In

another  study  by Sprouse  et al.8 the lesions were most commonly located in the subclavian vein.  It was  involved in  17  (53%)  cases followed by the innominate vein in 11 (34%), axillary vein in 3 (9%), and superior vena cava in 1 (3%).

In the current  work,  the type of balloon used for all patients were illtra-thin Diamond TM,  (Boston Scientific). The  maximum pressure  applied  ranged from 18 to 20 atm. Inflation time was 3 min. Trerotola et al.23 stated that in his long standing  practice has been to treat hemodialysis-related venous stenosis  in an escalating  fashion,  beginning with  moderately high-pressure angioplasty balloons (Ultra-thin; Boston Scientific, Natick, Mass [rated burst pressure, 12 atm], which was succeeded by  the  Ultrathin SDS;  Boston Scientific [rated burst pressure, 12 atm]) inflated to  atmospheric pressures above the manufacturer recommendation  (off-label use,

18 atm for the Ultra-thin balloon, 21 atm for the Ultrathin SDS balloon). When a resistant stenosis was encountered  at these pressures, they used another  high-pressure angioplasty balloon (Blue Max; Boston Scientific  [rated burst pressure, 20 atm]) inflated to pressures above the manufacturer recommendation (off­ label use, 27 atm). Also in the study ofBakken et al.3 the angioplasty balloons used were Bard (Murray Hill,  NJ) and Boston Scientific (Natick, Mass), with burst pressures of 8 to 15 atm and operational pressures of 10 to 20 atm.

As regards to proper inflation time, Forauer et al.24 demonstrated that technical  success was 4.7 times more likely in the 3 versus the

1 minute inflation group.The 1, 3, and 6 month

post intervention patencies were not significantly different between the two groups.

The stents used in our study was Wallstent in all cases. Most studies in the same domain reported the use ofWallstent effectively.3,25

It is preffered  because  of its flexibility and self-expanding nature. The flared ends promote stability in intravascular placement, preventing not only stent migration but also providing a relatively smooth transition at both ends of the stent  conduit. It also  can  be  collapsed for removal ifit migrates to the heart or pulmonary bed.25

Davidson12 stated that Wallstents are the treatment of choice for PTA failures and early recurrences in central veins. Verstandig et al.26 showed the disadvantages of Wallstent which include foreshortening at the time of placement.

In the present study, the overall technical success rate of PTA with or without primary stent was 100 %. PTA was technically successful in 27(64.3%) of 42 cases. In the remaining 15 lesions (35.7%) stents were used successfully. Reintervention was needed in 28 patients (66.6%) within the 1st year of follow­ up. This was in agreement with the results of other studies. Sprouse et al.8 found that initial PTA was technically successful in 26 (81%) of32 cases. Suboptimal results from PTA led to stent placement in the remaining six (19%) cases. The overall technical success rate of PTA and PTA combined with stent placement was 100% and needed reintervention in 63% of cases. Similarly, Bakken et al.3 reported that the initial treatment of CVS was technically successful in 82% of the PTA group and 96% ofthe PTS group. However, residual stenosis was   significantly  more   common with angioplasty (53%) than with stenting (7%).

It is to be mentioned that the patency of the vein in the present study was not assessed by objective methods in all patients. Regardless of the patency, however, the success of the procedure for providing symptomatic relief is the goal of the procedure and ultimately determines procedural success. Sprouse et al.8 rarely perform duplex ultrasound scanning to document patency or occlusion in this setting, because it does not alter the   plans for venography to assess for recurrent lesions.

No  post-operative complications were encountered in the current study except access complications in the form of hematoma in one patient. All patients were discharged the day or the day after the procedure. Similarly, Sprouse  et al.8  reported that patients  were typically discharged on the day of the procedure after clinical assessment.

On the basis of the results of the present

work, it could be concluded that endovascular management of central venous stenosis is an effective  and  safe  alternative to surgery. Follow-up and repeated dilatations are indicated to relieve patient symptoms and extend the life

of  the proximal  native  A-V  shunt  in HD

patients.

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10-Kahn D, Pontin A R, Jacobson J E, et al: Arteriovenous  fistula in the presence of subclavian  vein thrombosis: A serious