Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients

OBJECTIVE: To evaluate the efficacy of stent placement for treating upper extremity central venous obstruction in chronic hemodialysis patients. METHODS AND MATERIAL: Between January 1999 and October 2001, we inserted metallic stents into the upper extremity central veins of 14 patients with shunt dysfunction and/or arm swelling. The indications for stent placement were stenosis or occlusion of the central vein in the upper extremity used for dialysis. Six of the individuals were diagnosed with subclavian vein stenosis, and 5 with brachiocephalic vein stenosis. Of the remaining 3 patients, 2 had subclavian vein occlusion, and 1 had left brachiocephalic vein occlusion. RESULTS: All the stent placement procedures were technically successful, and there were no major complications. Follow-up ranged from 2 weeks to 29 months. The 1-, 3-, 6- and 12-month primary stent patency rates were 92.8, 85.7, 50 and 14.3%, respectively. Repeat interventions, including percutaneous transluminal angioplasty and additional stent placement, were required in 9 patients. The 3-, 6-, 12-month, and 2-year assisted primary stent patency rates were 100, 88.8, 55.5 and 33.3%, respectively. CONCLUSION: Endovascular stent placement is an effective alternative to surgery in patients with shunt dysfunction due to obstruction of an upper extremity central vein. Repeated interventions are usually required to prolong stent patency.     

支架植入治疗血液透析动静脉瘘中心静脉阻塞的价值分析

目的 探讨经皮血管支架植入术(PTS)治疗自体动静脉内瘘(AVF)透析患者中心静脉阻塞(CVO)可行性及临床应用价值.方法 回顾性分析10例AVF伴CVO患者,临床均表现为手肿胀综合征.术前或术中均接受DSA检查明确阻塞部位,根据不同病情采用合适手术入路,伴有血栓形成患者先行导管接触溶栓(CDT),严重狭窄或闭塞患者先以小直径球囊预扩张遂行PTS,其余患者直接行PTS.结果 DSA显示5例有颈内静脉置管史患者为头臂静脉闭塞或/和锁骨下静脉、颈内静脉、上腔静脉闭塞或狭窄,5例无颈内静脉置管史患者均表现为内瘘侧锁骨下静脉内侧段局限性严重狭窄.10例PTS技术成功率为100％,植入支架19枚,1例(锁骨下静脉狭窄)术后7个月支架内再狭窄再行PTS术.一期通畅率在术后6个月为8/8,术后1年为3/4.结论 AVF透析患者CVO多为闭塞性或严重狭窄病变,PTS治疗成功率高、近中期效果满意、并发症轻微,安全有效、可行,可作为首选治疗方法.     

Asymptomatic central venous stenosis in hemodialysis patients

PURPOSE: To retrospectively evaluate the natural history of high-grade (>50%) asymptomatic central venous stenosis (CVS) in hemodialysis patients and the outcome of serial treatment of CVS with percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: The institutional review board granted exemption for this retrospective study, the need for informed consent was waived, and all data collection was in compliance with HIPAA. Patients with hemodialysis access requiring maintenance procedures between 1998 and 2004 and incidentally found to have ipsilateral (> or =50%) CVS were identified from a departmental database. Thirty-five patients (19 men, 16 women; mean age, 58.7 years) with 38 grafts met inclusion criteria, and 86 venograms were reviewed. CVS was measured by using venograms obtained before and after PTA, if performed. Patients with arm swelling, multiple CVS, indwelling catheters, and stents at the first encounter were excluded. CVS progression was calculated by dividing the change in the degree of stenosis by the time between venographic examinations. Wilcoxon rank sum test was used to evaluate differences in rate of CVS progression between treated and nontreated patients. RESULTS: Mean degree of CVS before intervention was 71% (range, 50%-100%). Sixty-two percent (53 of 86) of lesions had associated collateral vessels; 28% (24 of 86) of CVSs were not treated. Mean degree of stenosis in this group was 72% (range, 30%-100%); mean progression was -0.08 percentage point per day. No untreated CVS progressed to symptoms, stent placement, or additional CVS. Seventy-two percent (62 of 86) of CVSs were treated with PTA. Mean degree of stenosis in this group was 74% (range, 50%-100%) before and 40% (range, 0%-75%) after treatment; mean progression was 0.21 percentage point per day after treatment (P = .03). Six (8%) of 62 treatments were followed by CVS escalation; one patient developed arm swelling, four required stents, and four developed additional CVS. CONCLUSION: PTA of asymptomatic CVS greater than 50% in the setting of hemodialysis access maintenance procedures was associated with more rapid stenosis progression and escalation of lesions, compared with a nontreatment approach.     

Peripherally inserted central catheter placement in patients with unsuspected central venous obstruction

PURPOSE: To evaluate the feasibility and clinical usefulness of peripherally inserted central catheter (PICC) placement in patients with unsuspected central venous obstruction. MATERIALS AND METHODS: Of 3,272 PICC procedures performed from January 1999 to July 2006, 57 patients had central venous stenosis or obstruction during placement of the PICC. Sixty PICC placements were performed in 57 patients (30 male and 27 female patients; mean age, 59 years). The PICC placements in 57 patients were evaluated with regard to the location and severity of venous disease, underlying causes of venous stenosis or obstruction, catheter placement technique, technical success rate, catheter dwelling time, and complication rate. RESULTS: There were 48 complete obstructions and 12 stenoses. Ipsilateral lesion passage was attempted in 31 patients and was successful in 26 (84%) and unsuccessful in five (16%). Over-the-wire PICC placement was performed in 16 patients, and PICC placement after angioplasty was performed in 10. Contralateral PICC placement without a trial of traversing the lesion was done in 26 patients. The PICC dwell time ranged from 2 to 150 days (median, 25.5 days). Complications occurred in four of the 57 patients (7%) and included tube tip migration (n = 1), catheter occlusion (n = 1), and catheter infection (n = 2). CONCLUSIONS: PICCs can be safely placed across central venous lesions in patients with asymptomatic central venous stenosis or obstruction. Contralateral placement is favorable in cases of ipsilateral passage failure.     

Upper extremity venous Doppler ultrasound

Ultrasound is the initial imaging modality of choice when evaluating the upper extremity venous system. When sonographic findings are equivocal or nondiagnostic, particularly in evaluating the central deep veins, MR venography or catheter venography correlation may be helpful. Ultrasound provides an accurate, rapid, low-cost, portable, noninvasive method for screening, mapping, and surveillance of the upper extremity venous system.     

Upper extremity deep venous thrombosis: interventional management

Upper extremity deep venous thrombosis, previously thought to be a relatively innocuous disorder in comparison to lower extremity deep venous thrombosis, has recently begun to receive the attention it merits. Its optimal management remains controversial despite the development of several new techniques and devices which allow more rapid removal of thrombus and treatment of underlying venous stenotic disease. The following article provides a framework to discuss its treatment, with the emphasis on endovascular management.     

Digital subtraction venography in central venous obstruction

Thirty-five patients had central venous digital subtraction venography (DSV) to assess its value in detecting central line/shunt patency (13 patients) and central venous obstruction (22 patients). All examinations were easily performed and provided diagnostic images without conventional venographic supplementation. The disadvantages of DSV are outweighted by the advantages, which include saving time and money, superior contrast resolution, flexibility of image display, and reduced dosage of contrast agent.     

Diagnosis and treatment of concomitant venous obstruction in patients with secondary lymphedema

PURPOSE: It has been proposed that concomitant iatrogenic venous obstruction substantially contributes to the appearance and severity of the secondary lymphedema that follows cancer surgery, radiation, and other traumas. The purpose of this study was to investigate the frequency of venous obstruction in the clinical presentation of patients with secondary lymphedema and to analyze the efficacy of interventional therapy in this patient population. MATERIALS AND METHODS: The experience of the university center for lymphatic and venous disorders with combined lymphaticovenous edema was retrospectively examined. The records and clinical course were reviewed for all patients referred to a university lymphedema center for evaluation between January 1996 and March 1999. During this interval, in 365 patients with lymphedema, 35 radiocontrast venograms were obtained to evaluate the suspected presence of mixed lymphaticovenous edema. Venographic evidence of venous stenosis (>50%) or occlusion was analyzed, as were the technical success of the intervention, determined by ability to cross the affected segment of the vein and perform venoplasty and place the stent, and the clinical success of the intervention assessed by relief of clinical symptoms (edema, pain) within 24 hours. RESULTS: The diagnosis of venous obstruction was confirmed in 17 patients (4.6% of all patients with lymphedema; 49% of patients studied with venography). Venography disclosed clinically relevant venous stenosis in five of seven patients with edema of the upper extremity and in six of 10 patients with leg lymphedema. Venous occlusion was found in two of seven patients with upper extremity edema and in four of 10 patients with leg lymphedema. Percutaneous endovascular venoplasty was attempted in all 17 patients and was successful in 16. Subsequent venous stent placement was performed in three patients with upper extremity edema and in all patients with lower extremity lymphedema. Clinical amelioration of edema was observed in 15 of these 17 patients. Amelioration was assessed by relief of symptoms, improvement in function, and reduction in limb girth. CONCLUSIONS: This study supports the clinical importance of concomitant venous obstruction in some patients with chronic secondary lymphedema. Edema can often be ameliorated through percutaneous catheter-based interventions.     

血液透析病人中心静脉狭窄的介入治疗

中心静脉狭窄是血液透析病人常见的并发症,常引起上肢持续肿胀等典型临床症状,其发展受多种因素影响,其中中心静脉导管置入或留置是最主要的危险因素.血管造影是中心静脉狭窄诊断的金标准,可直接显示狭窄静脉的具体部位、程度.中心静脉狭窄的介入治疗主要包括血管球囊扩张成形术和血管支架植入术,且安全、有效,已逐渐成为治疗的首选.     

血液透析患者中心静脉狭窄的介入治疗

目的探讨血液透析患者中心静脉狭窄介入治疗的方法及疗效。方法 2010年5月至2011年11月共收治20例发生中心静脉狭窄的血液透析患者,所有患者均具有中心静脉狭窄的临床症状、体征,并行MRA或CTA明确诊断,经静脉造影明确病变长度、范围和程度,行血管球囊扩张成形术(PTA)对病变部位进行治疗,成形术失败时,行血管支架植入术。术后随访患者的临床症状、MRA、超声等影像学检查。结果所有患者均成功行静脉造影,成功处理了20例患者共17条狭窄静脉,其中成功进行PTA 15例,支架植入成功2例,术后狭窄静脉血管通畅,侧支循环消失。首次PTA后再狭窄发生率为11.8%,再次行P1A。所有手术成功病例随访至今未出现再狭窄。结论血液透析患者中心静脉狭窄的介入治疗安全、有效,静脉通畅率良好。     

Insertion of central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations

Introduction

Central venous catheter placement is an effective alternative vascular access for dialysis in patients with chronic renal failure. The purpose of this study was to evaluate the insertion of central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations in terms of efficacy of the procedure and early complications.

Materials and methods

Between 2008 and 2010, the vascular access team of our hospital placed 409 central venous catheters in patients with chronic renal failure. The procedure was performed using the Seldinger blind technique. In 18 (4.4%) cases it was impossible to advance the guidewire, and so the patients were transported to the angiography suite.

Results

Using the angiographic technique, the guidewire was advanced in order to position the central venous catheter. The latter was inserted into the subclavian vein in 12 (66.6%) cases, into the internal jugular vein in 4 (22.2%) and into the femoral vein in 2 (11.1%) cases. There was only one complicated case with severe arrhythmia in 1 (5.5%) patient.

Conclusion

Our results suggest that insertion of central venous catheters using angiographic techniques in hemodialysis patients with previous multiple catheterizations is a safe and effective procedure with few complications and high success rates.     

Treatment of venous outflow stenoses in thigh grafts with Wallstents.

OBJECTIVE: We studied the effectiveness of Wallstent deployment to treat elastic femoral and iliac vein stenoses in patients with lower extremity hemodialysis grafts. MATERIALS AND METHODS: Between August 31, 1992, and October 13, 1997, 44 metallic stents were deployed in 20 patients to treat stenoses exhibiting immediate, significant elastic recoil after angioplasty. Twenty-four stents were placed in the femoral and saphenous veins, and the remaining 20 stents were placed in the iliac veins. Follow-up was provided by the nephrology and surgical service at our institution and by electronic review of patients' charts. The follow-up period was from August 31, 1992, until October 1, 1998. RESULTS: Stents were successfully inserted and stenotic lesions dilated in 100% of procedures. Each patient successfully completed at least one session of dialysis after the procedure. The primary patency rate of stents was 87% 60 days after the procedure, 51% 180 days after, 39% 1 year after, and 20% 2 years after. The secondary patency rate was 95% 60 days after the procedure, 92% 180 days after, 81% 1 year after, and 62% 2 years after. Complications were limited to two graft infections that developed 5 and 7 days after stent placement. CONCLUSION: Treatment of elastic venous stenoses is effective in patients with lower extremity dialysis grafts using metallic stents. The patency rates of these devices placed in the iliac and femoral veins are comparable with those of metallic stents placed in upper extremity and central veins.     

中心静脉闭塞综合征血管腔内治疗的围手术期护理

目的 探讨介入治疗中心静脉闭塞综合征的围手术期临床护理方法.方法 40例采用介入腔内治疗的中心静脉闭塞综合征的血液透析患者通过评估-干预-效果评价的护理程序思维实施整体护理.其中包括:术前做好心理护理、护理访视,术中做好护理配合和并发症观察和预防,术后做好患肢护理、病情观察、抗凝治疗护理及出院指导.结果 术前患者情绪稳定,患者及家属接受及配合手术诊断治疗,通过术中、术后护理,急性心力衰竭、高血压危象、心包积液等危重并发症得到及时发现和有效处理.所有患者均康复出院.半年随访率为100％,症状复发患者得到及时发现和干预,保证了治疗整体疗效的提高.结论 规范、全面、系统的整体护理是保证中心静脉闭塞综合征介入治疗的重要组成要素.     

Percutaneous placement of central venous catheters: comparing the anatomical landmark method with the radiologically guided technique for central venous catheterization through the internal jugular vein in emergent hemodialysis patients

Purpose: To compare the success and immediate complication rates of the anatomical landmark method (group 1) and the radiologically (combined real-time ultrasound and fluoroscopy) guided technique (group 2) in the placement of central venous catheters in emergent hemodialysis patients.

Material and Methods: The study was performed prospectively in a randomized manner. The success and immediate complication rates of radiologically guided placement of central venous access catheters through the internal jugular vein (n = 40) were compared with those of the anatomical landmark method (n = 40). The success of placement, the complications, the number of passes required, and whether a single or double-wall puncture occurred were also noted and compared.

Results: The groups were comparable in age and sex. The indication for catheter placement was hemodialysis access in all patients. Catheter placement was successful in all patients in group 2 and unsuccessful in 1 (2.5%) patient in group 1. All catheters functioned adequately and immediately after the placement (0% initial failure rate) in group 2, but 3 catheters (7.5% initial failure rate) were non-functional just after placement in group 1. The total number of needle passes, double venous wall puncture, and complication rate were significantly lower in group 2.

Conclusion: Percutaneous central venous catheterization via the internal jugular vein can be performed by interventional radiologists with better technical success rates and lower immediate complications. In conclusion, central venous catheterization for emergent dialysis should be performed under both real-time ultrasound and fluoroscopic guidance.