Last-Ditch Access: Surgical Solutions for Central … Access: Surgical Solutions for Central Venous Occlusion Lidie Lajoie MD, Dale Distant MD, Joon Hong MD PhD, Vinay Tak MD, Mark

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


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


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


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





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


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


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


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


Documents

Last-Ditch Access: Surgical Solutions for Central … Access: Surgical Solutions for Central Venous Occlusion Lidie Lajoie MD, Dale Distant MD, Joon Hong MD PhD, Vinay Tak MD, Mark