Retrograde Veno-Cutaneous Recanalization in Chronic Central Venous Occlusions
Hyein Kim, MD, Edward Y. Woo, MD and Tareq M. Massimi, MD
MedStar Heart and Vascular Institute, MedStar Georgetown University Hospital/Washington Hospital Center, Washington, DC.
Objective(s): Central venous occlusion (CVO) is a major cause of hemodialysis (HD) access failure resulting in significant morbidity and potential mortality in patients with End-Stage Renal Disease (ESRD). Using Hemodialysis Reliable Outflow (HeRO) graft offers a reliable long term solution that can avoid femoral access and its inherited risk of infection. However, CVO can prevent the technical success of this procedure. We report successful neovascularization of the superior vena cava (SVC) via minimally-invasive, hybrid caval-cutaneous recanalization approach as a salvage, bridging technique to establish central venous access and eventual placement of HeRO graft.
Methods: Patients with CVO and lower extremity prosthetic arteriovenous hemodialysis access who presented with failed access due to occlusion and/or infection participated in our novel approach. After excision of the graft and clearance of infection were achieved, venography demonstrated chronic total occlusion of superior vena cava and standard antegrade access was unsuccessful. Retrograde, sub-adventitial neovascularization of SVC was successfully performed via percutaneous femoral venous access. Guide wire/catheter techniques were used to navigate the wire to the subcutaneous plane and the wire was then retrieved through a small cut-down on the right side of the neck. This established central venous access and standard placement of tunneled dialysis catheter followed by HeRO graft insertion.
Results: All patients underwent successful SVC recanalization and placement of tunneled dialysis catheter without complication. HD was immediately resumed in all patients. Tunneled dialysis catheters were eventually exchanged to HeRO grafts to achieve more durable, long term HD access in all patients. All grafts were patent at follow up.
Conclusions: Neovascularization of superior vena cava via hybrid retrograde caval-cutaneous recanalization in central venous occlusion offers a safe alternative for patients who have exhausted standard HD access options.
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