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Last-Ditch Access: Surgical Solutions for Central Venous
Occlusion
Lidie Lajoie MD, Dale Distant MD, Joon Hong MD PhD, Vinay Tak MD, Mark Song MD
SUNY Downstate Medical Center, Brooklyn, NY USA
www.downstatesurgery.org
Introduction
Definition: Venous occlusion of the subclavian veins, brachiocephalic vein, iliac veins, superior vena cava and/or inferior vena cava
Etiology: Trauma to the venous endothelium and resultant inflammatory response to prolonged or multiple placements of central venous catheters1
Incidence: Between 3% and 45% of patients receiving hemodialysis2
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Symptoms
• Aneurysmal dilation and tortuosity of arteriovenous access site
• Ipsilateral extremity edema, tenderness, pain, erythema • Ipsilateral pleural effusion • Superior Vena Cava syndrome: bilateral upper extremity,
face, and neck edema; collateral venous engorgement • tracheal edema and airway compromise • Downstream esophageal varices: hematemesis due to
downward venous flow through esophageal collaterals to the portal vein and inferior vena cava3
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Preoperative Patient Characteristics
Patient
Age (years) / Gender
Renal Failure
Etiology
Time on Dialysis (years)
Location of CVO Symptoms
Recent Usable Access
1 48 / male HTN 17 SVC
SVC syndrome requiring tracheostomy
Infected flank IVC catheter
2 31 / male congenital 8 SVC & IVC
Inadequate filtration on dialysis
Femoral catheter to lumbar collaterals
3 71 / male HTN 2 SVC
Bleeding downhill esophageal varices
Femoral catheter
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Patient/ Procedure Patency Complications/Interventions
1 Brachial – Atrial Graft
PRIMARY 1 month
ASSISTED
14 months
1mo: thrombectomy & stent placement for kink at chest wall entry site 7mo: revision for axillary wound infection
2 Brachial – Atrial Graft
PRIMARY 3 months
ASSISTED 8 months
3mo: thrombectomy for graft malfunction
3 Cross-Iliac Graft
PRIMARY 6 months
None
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Management Options for Central Venous Occlusion
• Arterial-Arterial Graft • Arterial-Atrial Graft • Infradiaphragmatic Arteriovenous Graft
• Extra-anatomic Arterio-venous Graft
• Intrathoracic venous reconstruction
• Infradiaphragmatic venous bypass
• Extra-anatomic venous bypass
• Infradiaphragmatic catheter • HeRO catheter
• Peritoneal dialysis • Renal transplantation
Alternatives to
Hemodialysis
Catheter-Based Hemodialysis
Central Fistula- Graft
Venous Bypass
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Study Number Of Patients
Procedure Patency at 6 months
30-day Mortality
Anaya-Ayala et al1 3 Brachial artery to Right Atrium Graft 33% 33%
Mickley4 1 Subclavian artery to Right Atrium Graft 100% 0
Salerno et al5 1 Subclavian artery to Right Atrium Graft 100% 0
Morsy et al6 18 Axillary artery to Vein Necklace Graft 94% 17%
Jean-Baptiste et al7 27 Axillary artery to Vein Loop Graft 75% 0
Hazinedaroglu et al8 26 Axillary artery to Internal Jugular or Axillary Vein Graft
64% 0
Hamish et al9 5 Axillary artery to Iliac Vein Graft 80% 0
Chemla et al10 11 Axillary, femoral, or popliteal artery to Femoral, popliteal or saphenous vein
55% 0
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Conclusions
• As patients are maintained longer on hemodialysis, access creation for patients with central venous occlusion who have exhausted autogenous access and in whom endovascular management has failed will undoubtedly become a more common problem for vascular surgeons. Centrally placed arteriovenous grafts provide a durable solution that can be performed with minimal morbidity in these patients
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References 1. Anaya-Ayala JE, Bellows PH, Ismail N, et al. Surgical Management of Hemodialysis-Related Central Venous
Occlusive Disease: A Treatment Algorithm. Ann Vasc Surg 2011; 25: 108-119. 2. Kundu S. Central Venous Obstruction Management. Semin Intervent Radiol 2009; 26: 115-121. 3. Hsu YH, Yang MT, Hsia CC, Tsai DM. Esophageal Varices as a Rare Complication of Central Venous Dialysis
Tunneled Cuffed Catheter. Am J Kidney Dis 2004; 43: e20-4. 4. Mickley V. Subclavian Artery to Right Atrium Haemodialysis Bridge Graft for Superior Vena Caval Occlusion.
Nephrol Dial Transplant 1996; 11: 1361-2. 5. Salerno AE, Green C, Zelikovsky N, et al. Creation of a Novel Hemodialysis Bridge Graft to Extend the Life of
an Adolescent. Pediatr Nephrol 2004; 19: 1297-9. 6. Morsy MA, Khan A, Chemla ES. Prosthetic Axillary-Axillary Arteriovenous Straight Access (Necklace Graft) for
Difficult Hemodialysis Patients: A Prospective Single-Center Experience. J Vasc Surg 2008; 48: 1251-4. 7. Jean-Baptiste E, Hassen-Khodja R, Haudebourg P, et al. Axillary Loop Grafts for Hemodialysis Access:
Midterm Results from a Single-Center Study. J Vasc Surg 2008; 47: 138-43. 8. Hazinedaroglu S, Karakayali A, Tuzuner D, et al. Exotic Arteriovenous Fistulas for Hemodialysis. Transplant
Proc 2004; 36: 59-64. 9. Hamish M, Shalhoub J, Rodd CD, Davies AH. Axillo-iliac Conduit for Haemodialysis Vascular Access. Eur J
Vasc Endovasc Surg 2006; 31: 530-4. 10. Chemla ES, Korrakuti L, Makanjuola D, Chang AR. Vascular Access in Hemodialysis Patients with Central
Venous Obstruction or Stenosis: one center’s experience. Ann Vasc Surg 2005; 19: 692-8
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