Central Venous Occlusion Interventions: Angioplasty and Stenting

Central Venous Occlusion Interventions: Angioplasty and Stenting

There are a growing number of patients who survive end-stage renal disease for long periods because of improvement in patient care. The central veins are the sites of many complications that are unavoidable by these patients.

Endovascular management, including angioplasty and/or stent placement, is the treatment of choice, but the best strategy is still not clear.

The objective of a recent study was to further evaluate the efficacy of treatment in one institution. A retrospective chart review of patients, procedures, and outcomes was conducted and evaluated.

The study has shown that management of central occlusive disease in dialysis patients improves patency of venous access.

The Study
Of 600 dialysis patients seen in the authors’ institution over 40 months, 69 with central veno-occlusive disease were identified.

Methodology
Patients were treated with venography, then angioplasty, then stent placement if the angioplasty was not satisfactory. A stent was placed if residual stenosis was >30% and the collaterals filled, or if a stenosis recurred twice within 2 months.

Results
Of 69 patients, 40% presented with upper limb swelling, 43% had access dysfunction, and 17% had clotted access.

There was an average of 2.5 interventions per segment.

The initial technical success rate of angioplasty alone was 90%.

Of follow-up interventions, 96% were successful. The initial procedure produced an average of 6.8 months of patency, and follow-up procedures produced an additional 7.2 months of patency.

Mean length of patency of venous segments treated with percutaneous transluminal angioplasty alone versus the patency with stent placement was not statistically significant, being 12.5 months versus 15 months, respectively. There were 2 major complications.

Reviewer’s Comments
Management of central occlusive disease in dialysis patients improves patency of venous access.

The occlusion of central veins is caused by instrumentation, and by stenosis caused by the presumed damage of the intima by high arteriovenous blood flows.

Cannulation of subclavian veins may cause up to 50% of stenoses in these regions, and therefore should be avoided at all costs in dialysis patients.

Access via the right internal jugular vein seems to provide the least amount of central vein stenosis.

Primary stent placement in these areas has been advocated; however, the literature, and this study, does not show improved duration of patency.

These authors and the literature advocate use of stents when angioplasty fails to keep these central venous segments patent.

At least 55% of these patients remained catheter free for an additional 12 months with percutaneous management of their central veno-occlusive disease.

Of interest, this study showed an increase of stenosis in patients who have risk factors of hypertension, diabetes, and smoking. This study shows that maintaining patency of the central venous system increases survival of the dialysis access, thus increasing patient longevity even with end-stage renal disease.

Author: Sharon Gonzales, MD

Reference:
Nael K, Kee ST, et al. Endovascular Management of Central Thoracic Veno-Occlusive Diseases in Hemodialysis Patients: A Single Institutional Experience in 69 Consecutive Patients. J Vasc Interv Radiol; 2009;20 (January): 46-51