Multimodality therapy for management of acute on chronic central vein occlusion to maintain patency of upper arm arteriovenous fistula

Abstract

Central venous occlusive disease (CVOD) is a challenging problem that frequently leads to the abandonment of an otherwise functional hemodialysis access. Prior central venous access, including tunneled dialysis catheters, are a common predisposing factor. CVOD is typically preceded by an interval period of stenosis and often amenable to simple balloon angioplasty. Occasionally, the use of aggressive techniques, including sharp recanalization and percutaneous thrombectomy, is necessary to restore patency. We describe a case of acute CVOD involving the left axillary, subclavian, and brachiocephalic vein outflow of an upper extremity arteriovenous fistula that required a multimodality approach, including sharp recanalization of a chronic occlusion, large-bore percutaneous thrombectomy system, balloon angioplasty, and stenting to restore patency and salvage the access site.

Central venous occlusive disease (CVOD) is a common, yet intractable complication that affects up to 50% of end-stage renal disease (ESRD) patients and is associated with hemodialysis access dysfunction.^1,2 This condition results in a significant increase in venous pressures, which in turn manifests as pain, swelling, skin breakdown, prolonged bleeding after dialysis, access thrombosis, and disability of the affected extremity.³ CVOD is frequently attributed to turbulent flow, mechanical trauma with subsequent vessel wall fibrosis from central venous catheterization (CVC), and high-flow states from a pre-existing arteriovenous fistula (AVF).^4,5 Among these, the history or current presence of CVC represents a major predisposing factor for CVOD, accounting for 27% of cases with a particularly high incidence ranging between 20% and 40%.^6,7 CVC placement with resultant CVOD is also associated with venous thromboembolic events which threatens the survival of ESRD patients.⁸

Percutaneous transluminal angioplasty (PTA) with or without stenting is considered the first-line treatment for CVOD.¹ Guidewire passage through the occluded segment is a vital step for successful recanalization; however, some occlusions may prove difficult to traverse using traditional endovascular techniques. The high incidence of recurrent stenosis also leads to chronic occlusive lesions that are refractory to treatment with eventual abandonment of the extremity for hemodialysis access.⁹ This issue becomes more complex for patients who have exhausted all conventional access options, as well as those who are not eligible candidates for either renal transplantation or peritoneal dialysis.¹⁰

In the present case report, we highlight the therapeutic challenges of salvaging an upper extremity AVF in a patient with underlying CVOD who presented with acute thrombotic occlusion and required a multimodal endovascular approach to restore access patency. The patient provided consent for description of care provided and the use of deidentified images for publication.

Case report

A 57-year-old woman with history of ESRD on chronic hemodialysis for 17 years via left brachiocephalic AVF presented to her dialysis unit with a swollen arm and hyperpulsatile fistula consistent with venous hypertension. She previously underwent four balloon angioplasties of the left brachiocephalic vein (BCV over the last 2 years) origin for CVOD. Of note, she never required left-sided CVC during her access lifetime. The patient underwent temporary femoral dialysis catheter placement to achieve acute dialysis for hyperkalemia and mild volume overload owing to missed treatments owing to her dysfunctional left arm access.

Under local anesthesia with conscious moderate sedation, she underwent fistulogram which confirmed CVOD with acute axillary and BCV occlusion (Fig 1). The occlusion was unable to be crossed with simple retrograde guidewire. Using left femoral vein access, a long 7F steerable tip sheath (Oscor Destino, Integer Holdings LLC, Plano, TX) was placed into the superior vena cava then buried into the occlusion. A snare was placed at the tip of the sheath then deployed. A V18 Control wire (Boston Scientific Corporation, Marlborough, MA) was introduced through a second directional tip sheath placed from the AVF and buried into the occluded BCV immediately adjacent to the tip of the sheath from the femoral access (Fig 2, A). The stiff end of the wire was inserted through a 5F catheter into the AVF sheath and used to accomplish sharp recanalization by perforating through the occlusion and into the open snare in the superior vena cava sheath (Fig 2, B). Because the stiff end of the wire could not be safely pulled into the sheath, balloon angioplasty of the occlusion was performed with a 6 mm balloon to establish a usable lumen (Fig 3, A). The .018 wire was swapped out for an .035 wire which was then retrieved with the snare to establish through-and-through access.

Fig 1.

Fistulogram depicting central venous occlusive disease (CVOD) with complete axillary and brachiocephalic vein obstruction.

Fig 2.

Perioperative fistulogram demonstrating (A) introduction of V18 control wire through the second directional tip sheath placed from the arteriovenous fistula (AVF) and buried into the occlusion brachiocephalic vein immediately adjacent to the tip of the sheath from the femoral access, and (B) insertion of stiff end of the wire via 5F catheter through the sheath in the fistula to accomplish sharp recanalization by perforating through the occlusion into the open snare in the superior vena cava sheath.

Fig 3.

Perioperative fistulogram showing (A) results of balloon angioplasty of the occlusion with a 6-mm balloon to establish a useable lumen to withdraw the stiff end of the wire into the sheath, and (B) postangioplasty angiography confirming a large volume clot in the brachiocephalic vein.

Angiography confirmed a large volume clot in the BCV (Fig 3, B). From the femoral access, a 20F Dryseal Sheath (W. L. Gore and Associates, Flagstaff, AZ) was placed into the inferior vena cava. Over the .035 through-and-through wire, a 20F FlowTreiver percutaneous thrombectomy device (Inari Medical, Irvine, CA) was advanced across the stenosis (Fig 4, A) and used to aspirate the thrombus (Fig 4, B). The residual stenosis was treated with angioplasty and stenting using a 13 mm Viabahn stent graft (W. L. Gore and Associates, Flagstaff, AZ) post-dilated with a 14 mm ultra-high-pressure balloon (Fig 5, A) with excellent angiographic results although, owing to the length of the stent required for adequate purchase both proximal and distal to the stenosis, the left internal jugular vein was jailed by the stent (Fig 5, B). It should be noted that the use of the Viabahn stent graft and FlowTreiver are outside the instructions for use for these devices, therefore, consider off-label use.

Fig 4.

Perioperative fistulogram demonstrates the 0.035 through-and-through wire with advancement of the 20F FlowTreiver across the stenosis, and (B) results of FlowTreiver used to aspirate the thrombus.

Fig 5.

Post-thrombectomy fistulogram demonstrating treatment of residual stenosis with angioplasty (A) and stenting using a 13-mm Viabahn stent graft post-dilated with a 14-mm ultra-high-pressure balloon, with (B) the left internal jugular vein being jailed by the stent owing to the length required for adequate purchase both proximal and distal to the stenosis.

The postoperative course was unremarkable. She was observed overnight in the hospital then discharged home the following day with marked reduction of arm swelling and restoration of a palpable thrill in her AVF. Follow-up duplex obtained at 4 weeks demonstrated excellent flow volume without obvious recurrent or residual stenotic lesions in the visualized access circuit.

Discussion

With the ever-growing population of patients with ESRD, and the improving life expectancy of patients on hemodialysis, there is now an increasing emphasis on quality access creation, preservation, and long-term durability.¹¹ The current National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend creation of an autogenous AVF using a distal-to-proximal priority approach.^1,12 Nevertheless, it can be extremely difficult to maintain reliable vascular access among patients with recurrent CVOD as described in the present case. Presently, the literature offers variable results with endovascular intervention for CVOD, and there are no definitive KDOQI guidelines for managing recurrent disease.^1,8 The surgical approach should therefore be individualized to each patient according to their clinical characteristics, as well as the technical limitations of the performing institution.

Current KDOQI guidelines recommend PTA with or without stenting as the preferred therapeutic approach for symptomatic CVOD.⁸ Conventional PTA is capable of impressive immediate results, but the 6- and 12-month patency ranges widely between 41%-76% and 31%-45%, respectively.¹³ This approach is also known to offer only temporarily relief from symptomatic venous hypertension, with many patients often requiring multiple interventions to maintain patency.¹⁴ The high rate of restenosis is partially attributable to neointimal hyperplasia following endovascular intervention with PTA.¹⁵

With regards to bare metal stents and covered stents, previous studies have demonstrated primary patency rates of 92-97% at 3 months, 81-84% at 6 months, 56-67% at 12 months, and 28-45% at 24 months.^16,17 Covered stents, such as the one utilized in the present case, primarily function as an inert scaffold to prevent restenosis.¹⁶ For the treatment of CVOD in the setting of failing AV access, a number of studies have demonstrated superior patency of stent grafts compared with bare metal stents.^18,19 In their study, Lui et al. demonstrated superior patency of stent grafts compared to bare metal stents at 24 months of 83% vs 71% in hemodialysis patients with CVOD.¹⁸ It is worth noting that treatment efficacy with stenting is inherently reduced if the segment of intraluminal stenosis is located underneath the clavicle, an area prone to significant external mechanical compression of the central veins and resultant thrombosis.⁸ As such, the occluded brachiocephalic vein segment in the present case can be considered more amenable to stenting owning to lack of bony compression.

In many instances of endovascular management for CVOD, traversing an occluded venous segment may prove difficult when relying on traditional catheter and guidewire techniques. Sharp recanalization is becoming increasingly adopted for promising technical success, efficacy, and safety with acceptable 1-year primary and secondary patency rates upwards of 78% and 100%, respectively.²⁰ In the present case, sharp recanalization was utilized to ultimately achieve through-and-through wire access from the AVF to the left femoral vein sheath after conventional strategies had failed. Nevertheless, surgeons must be cognizant of potential complications including vessel dissection and perforation with injury to surrounding anatomical structures.²⁰

Within the past decade, several novel innovations have been made to address CVOD refractory to conventional endovascular strategies including percutaneous thrombectomy with the FlowTreiver and Inthrill (Inari Medical, Irvine, CA) devices. In the present case, the use of FlowTreiver® proved essential for extracting the significant clot burden obstructing the patient's BCV. This large-bore aspiration device has previously shown excellent capability in rapid removal of venous thromboembolism and salvaging hemodialysis access while also having lower risk of endothelial injury as compared to other mechanical thrombectomy devices.²¹ The novel Inthrill over-the-wire mechanical thrombectomy device has also demonstrated promising technical success of 100% with primary patency of 77% at 1 month, as well as assisted-primary and secondary patency of 100% at 1 and 3 months.²² These results are comparable with the average reported patency rates and suggested thresholds for arteriovenous thrombosis management with pharmacological thrombolysis as outlined by the Society of Interventional Radiology Standards of Practice Quality Improvement Guidelines.²² It is also worth noting that mechanical thrombectomy does not inherently require administration of thrombolytic agents and thus carries a lower risk of bleeding compared with pharmacological thrombolysis.²² Nevertheless, further investigation of mechanical thrombectomy approaches for CVOD management is warranted to evaluate long-term patency and durability.

For most patients, a mature AVF is still considered the most ideal vascular access for long-term hemodialysis. New strategies and innovations are continually being introduced in clinical practice to facilitate hemodialysis access creation and improve long-term patency of preexisting access sites. The addition of large-bore mechanical thrombectomy devices to the ever-expanding endovascular armamentarium possessed by vascular surgeons represents a safe and effective method for restoring hemodialysis access patency threatened by CVOD. Ultimately, our goal as vascular surgeons should be to enhance the overall quality of life for ESRD patients requiring hemodialysis who are now living longer than ever before.

Conclusions

In select cases, a multimodality approach to CVOD may prove vital to preserving AVF function, particularly among patients with few to no options available for hemodialysis.

Funding

None.

Disclosures

None.