Chirurgia Vascolare Alma Mater Studiorum – Università di Bologna

Efficacy of Endovascular Treatment of Central Vein Stenosis to

Improve Vascular Access Performance in Hemodialysis Patients

Raffaella Mauro

Arteriovenous fistula (AVF) remains the method of choice in long term

haemodialysis (HD)

Dysfunction of AVF and grafts (AVG) occurs frequently in HD patients and

increases morbidity and hospitalization in the dialysis population

Vascular access durability is often compromised by venous stenosis due to

• intimal hyperplasia at the outflow vein

• central venous stenosis or occlusion for long-standing CVC

Endovascular interventions by PTA or PTA/stenting are increasingly utilized for

access salvage and maintenance

Introduction

Central vein stenosis: reduction of vessel diameter >50%

Reduction in access flow (< 300 ml/min)

Increased dynamic venous pressure > 150 mmHg

Prolonged bleeding after cannulation

Arm edema and cellulitis

Central Vein Obstructive Disease (CVOD)

Early diagnosis and treatment of CVOD

are vital to achieve long term access function

KDOQUI guidelines, 2006

Severe venous dilatation

Arm edema

Ulceration

Vascular access

disfunction/ thrombosis

CVOD: symptoms

Outflow

cephalic vein

Severely dilated

cephalic vein

Juxta

anastomotic

region

Epidemiology and Risk Factors

Long term (> 6 weeks) subclavian catheterism is at high risk (25-50%)

Compression of the innominate vein between arch vessels and sternum

Occasionally idiopathic

Cardiac-Rhythm Device-Associated CVOD in (50-64%)

Schwab et al, Kidney Int. 1988

Sticherling C et al, Am Heart J. 2001

De Costa S et al, Pacing Clin Elettrophysiol. 2002

True incidence and prevalence of CVOD in ESRD population is unknown because

most studies are limited to symptomatic patients

CVOD becomes symptomatic after AVF or AVG creation in the ipsilateral extremity

Conservative approach

Surgical treatment

Endovascular treatment

Strategy of treatment

Conservative approach

Surgical treatment

Endovascular treatment

Strategy of treatment

Close follow-up of patients with obstruction.

A good collateral pathway may be sufficient

Conservative approach

Surgical treatment

Endovascular treatment

Strategy of treatment

Access ligation

• Direct repair with saphenous vein or

PTFE

• Jugular vein turn-down to bypass a

stenosed subclavian vein

• End to end vein anastomosis

Conservative approach

Surgical treatment

Endovascular treatment

Strategy of treatment

Access ligation

• Direct repair with saphenous vein or

PTFE

• Jugular vein turn-down to bypass a

stenosed subclavian vein

• End to end vein anastomosis

Difficult option: often requires

claviculectomy or median

sternotomy

surgical bypass between axillary

and jugular vein using

greater saphenous vein

Jugular vein exposure

Saphenous vein

tunnelled over the

clavicula

Surgical treatment

Strategy of treatment

Conservative approach

Surgical treatment

Endovascular treatment

Authors N. PTA

(%)

PTA/Stent

(%)

Primary Patency PTA

(12-24 months)

Primary Patency PTS

(12-24 months)

Assisted Primary patency

PTA

(12-24 months)

Assisted Primary

patency PTS

(12-24 months)

Glanz et al.

(Ann Surg,

1987)

30 100% - 35% (12 months)

10% (24 months)

- - -

Wisselink et

al.

(Am J Surg,

1993)

15 100% - 36% (12 months)

0% (24 months)

- - -

Vorwek et al.

(Radiol,

1995)

27 - 100% - 60% (12 months)

60% (12 months)

- -

Bakken et al.

(J Vasc Surg,

2007)

75 35% 65% 29% (12 months) 21% (12 months) 73% (12 months) 46% (12 months)

Ozyer et al.

(AJR, 2009)

147 69% 31% 78%(12 months)

58% (24 months)

34% (12 months)

24% (24 months)

70% (12 months)

22% (24 months)

57% (12 months)

13% (24 months)

P=.48 P=.08

P=.0001 P=.28

Endovascular treatment

Surgical AVF exposure

• 6 F Introducer

• The stenotic site crossed with a

0.035-inch hydrophilic guidewire

(Terumo, NJ, USA)

• In case of obstructing lesions, the

stiff end of the guidewire can be

used

Strategy of treatment:PTA

Pre-dilatation Armada 6X40

Progressive dilatation: Armada 9X20

Last dilatation: Armada 12X20 Final Result

Collaterals

Symptomatic Re-stenosis after-PTA

3 months

Strategy of treatment:PTA/Stent

Final Result

Pre-dilatation

Armada 6X40;8X40

Post-dilatation PTA balloon Atlas-

Bard 12X20

Residual stenosis

Stent Venovo-Bard 16x40mm

Introducer: flexor 10F in subclavian vein

AngioRx:

innominate vein

stenosis

Post-stenosis

collaterals

Our experience

2014-2016: 529 procedures

90%

2%7% 1%

Avf

AvgRev Evt

From 2009 to 2016: 15 (1%) CV cases: 12(80%) stenosis and 3 (20%) obstruction

2 (13%) had a prosthetic fistula and 13 (87%) a proximal AVF

Mean F-UP: 16 months

26

1

3 1

2

brachiocephalicvein

axillary vein subclavian vein

PTA STENT COVERED STENT

Our experience

Endpoints

Primary Patency, AVF Patency and Dialytic Performance were

evaluated

Dialitic Performance: pre and post-operative comparison of

dialytic venous pressure (DVP) and dialytic flow (DF)

Results

Technical

Success

Perioperative

Complications

100% 0%

DVP

(mmHg)

DF

(mL/min)

Pre procedure 191±15 282±19

Post procedure 149±14 313±22

P 0.001 0.001

Technical Success: residual stenosis

with less than 30% diameter reduction

Results

PTA

STENT

Time (months)

Pate

ncy

Conclusions

EVT is safe and effective treatment for CV obstruction and

stenosis and allows to ameliorate AVF early dialytic

performance in terms of DVP and DF

The midterm results in terms of patency and dialytic

performance seems to take advantage from the placement

of a stent

Conclusions

EVT with or without stenting is our first choice for CV

obstructive disease treatment