Endovascular management of brachiocephalic vein stenosis and occlusion in hemodialysis patients: Technical outcomes and 6-month dialysis access patency

Abstract

Objective

Central venous stenosis involving the brachiocephalic vein (BCV) is an important cause of upper limb swelling and hemodialysis access dysfunction. In Sri Lanka, central venous disease is increasingly encountered because many patients present late with end-stage kidney disease and require crash dialysis with multiple central venous catheter insertions before definitive arteriovenous fistula creation. Endovascular therapy is the first-line treatment. This study evaluates the technical outcomes and short-term clinical results of endovascular management of BCV lesions in a tertiary vascular unit.

Methods

A retrospective analysis was performed of consecutive patients who underwent attempted endovascular treatment for BCV stenosis or occlusion over a 1-year period at a single tertiary care center. Demographic characteristics, clinical indications, lesion morphology, access routes, procedural details, and technical outcomes were analyzed.

Results

Fifteen patients underwent attempted intervention. Mean age was 49 years (range, 21-76), with male predominance (80%). Left-sided disease was more frequent (66.7%). Stenosis accounted for 60% of lesions and occlusions for 40%. Balloon venoplasty alone was performed in eight patients (53.3%), whereas five patients (33.3%) required adjunctive stent placement using bare metal stents (diameter, 12-14 mm; length, 4-6 cm). Technical success was achieved in 13/15 cases (86.7%). Two procedures were abandoned due to chronic total occlusions that could not be crossed. During the follow-up, two patients developed early recoil after venoplasty within 6 months, one of whom required subsequent stent placement. At the mean follow-up of 6 months, symptom improvement was observed in all patients who had successful venoplasty or stenting. Except for one patient, all arteriovenous fistulas remained functional for hemodialysis.

Conclusions

Endovascular management of BCV stenosis and occlusion is safe and effective, with high technical success and favorable short-term clinical outcomes. Balloon venoplasty remains the primary treatment, with selective stent placement providing durable results in cases of recoil or persistent stenosis. Chronic total occlusions remain the principal technical limitation.

In the hemodialysis (HD) population, central venous occlusive disease (CVOD) is a prevalent issue that greatly increases morbidity because it can impair the effectiveness of dialysis by causing venous hypertension, prolonged postdialysis bleeding and incapacitating symptoms such as headaches, arm swelling, and facial swelling.¹ The central veins of the upper body—including the superior vena cava, brachiocephalic vein (BCV), and subclavian vein—are an essential aspect of HD because, on the one hand, they are the vessels used to place dialysis catheters, and on the other hand, they represent the final segment of the vascular access circuit before the heart. In addition, they are the primary causes of their stenosis.² According to a single-center cohort study, the incidence of central venous stenosis (CVS) among patients undergoing HD was 4.3%, increasing to 41% when patients undergoing HD with access issues were assessed using venography.^3,4 According to the analysis of 655 individuals treated for different CVOD, the incidence of BCV stenosis was as high as 42%.⁵ Prolonged central venous catheterization and high flow conditions in arteriovenous fistula (AVF) or grafts are the primary causes of CVS in patients undergoing HD, which leads to venous intimal hyperplasia and stenosis.

The main goal of the treatment is to relieve patients' symptoms while maintaining AVF's functionality.⁶ The management options for CVOD include open surgery, endovascular therapies such as percutaneous transluminal angioplasty and implantation of bare metal stent (BMS), and covered stent (CS), the latter of which are associated with reduced restenosis.⁷ This study evaluates the technical outcomes and short-term clinical results of endovascular management of BCV lesions at a tertiary vascular unit.

Methods

This retrospective observational study was conducted at a single center and included consecutive patients undergoing HD who underwent attempted endovascular management for BCV stenosis or occlusion over 1-year period. Institutional approval was obtained before data collection, and the requirement for individual informed consent was waived due to the retrospective design of the study.

Fifteen adult patients aged 18 years and above with end-stage renal disease on maintenance HD who were referred for evaluation and treatment of suspected central venous outflow obstruction involving the BCV were considered for inclusion. Patients were included if they had clinically significant BCV stenosis or occlusion confirmed on imaging and had a functioning or previously functioning upper limb AVF or arteriovenous graft, and if an endovascular intervention was attempted. Patients with isolated stenosis not involving the BCV, those managed conservatively or surgically without endovascular intervention, and those with incomplete procedural or follow-up data were excluded from the study.

Baseline demographics and clinical data were collected from medical records, including age, sex, comorbidities such as diabetes mellitus and hypertension, duration of HD, and previous history of central venous catheter placement. Clinical indications for intervention included ipsilateral upper limb swelling, facial or neck swelling, and prolonged bleeding following dialysis.

All patients underwent preprocedural imaging evaluation using duplex ultrasound guidance and computed tomography venogram to determine lesion location, severity, and extent. Lesions were classified as stenosis when there was a luminal narrowing of 50% or greater, and as occlusion when there was complete absence of luminal continuity. Additional lesion characteristics, including lesion length, degree of stenosis, and the presence of collateral venous circulation were also documented.

All endovascular procedures were performed in an angiography suite under local anesthesia, with or without conscious sedation. Vascular access was obtained through one or more routes depending on the lesion characteristics, including peripheral venous access via the AVF, femoral venous access, or internal jugular venous access. A combination of hydrophilic guidewires and diagnostic catheters were used to traverse the stenotic or occluded segments. In cases of chronic total occlusion, advanced techniques using stiff guidewires and support catheters were used to achieve lesion crossing.

Following successful traversal of the lesion, balloon angioplasty was performed using appropriately sized balloons. Balloon diameter was selected according to the estimated native vein diameter, typically ranging from 10 to 14 mm. Balloon angioplasty was initially performed using a high-pressure Mustang balloon catheter (Boston Scientific Corporation). In cases where adequate luminal expansion was not achieved, an ultra-high-pressure balloon was subsequently used. The ultra-high-pressure balloon was inflated to a maximum pressure of 24 atm and maintained at this pressure until the angiographic waist produced by the stenotic lesion was released. Following complete release of the waist, the balloon was maintained at the manufacturer-recommended nominal pressure for the remainder of the inflation. Stent placement with BMSs was performed in selected cases where there was significant elastic recoil, residual stenosis greater than 30%. Procedural details, including balloon size, inflation pressure, stent type, and stent length, were recorded.

Technical success was defined as successful recanalization of the target lesion with restoration of inline flow and less than 30% residual stenosis on final angiography. Clinical success was defined as resolution or significant improvement of presenting symptoms along with restoration of adequate dialysis function. Procedural complications were recorded and classified as minor or major according to standard interventional radiology reporting guidelines.

Patients were followed up for a period of 6 months after the procedure. Primary patency was defined as the interval from the initial successful intervention to the first occurrence of access dysfunction requiring repeat intervention or access thrombosis. Secondary patency was defined as the interval from the initial intervention to eventual access abandonment, including cases requiring repeat interventions to maintain access function.

Results

A total of 15 patients underwent attempted endovascular intervention for BCV stenosis or occlusion during the study period. The mean age of the study population was 49 years, with a range of 21 to 76 years. There was a clear male predominance, with 12 patients (80%) being male and three patients (20%) female. The majority of patients had a previous history of central venous catheter placement for HD access (Table I).

Table I.

Baseline demographic and clinical characteristics

Characteristics	Value
Mean age, years (range)	49 (21-76)
Sex
Male	12 (80)
Female	3 (20)
Previous central venous catheterization	15 (100)
Sides of BCV lesion
Left	10 (66.7)
Right	5 (33.3)
Lesion types
Stenosis	9 (60)
Occlusion	6 (40)

BCV, Brachiocephalic vein.

Categorical data are shown as number (%).

Left-sided BCV involvement was more common, observed in 10 patients (66.7%). Based on initial venogram, nine patients (60%) were found to have significant stenosis, whereas six patients (40%) had complete occlusion of the BCV.

Endovascular intervention was technically successful in 13 out of 15 patients, yielding a technical success rate of 86.7%. In the remaining two patients (13.3%), the procedures were unsuccessful because of failure to cross chronic total occlusions (CTOs) despite the use of advanced guidewire techniques, and attempts to cross the lesions both antegrade and retrograde from femoral access; however, these interventions were subsequently abandoned. Both patients ultimately required ligation of the fistula.

Among the successfully treated patients, balloon venoplasty alone was performed in eight patients (53.3%). The remaining five patients (33.3%) required adjunctive stent placement due to significant residual stenosis or elastic recoil following balloon angioplasty (Fig 1). All stents used were BMSs, with diameters ranging from 12 to 14 mm and lengths between 4 and 6 cm (Table II).

Fig 1.

A and B, Preprocedure images of two patients. C and D, Postprocedure images of same patients respectively.

Table II.

Procedural outcomes and 6-month clinical results

Parameters	Value
Technical success rate	13 (86.7)
Failed procedures (CTO not crossed)	2 (13.3)
Intervention type
Balloon venoplasty alone	8 (53.3)
Balloon + stent	5 (33.3)
Stent type: Bare metal stents
Diameter, mm	12-14
Length, cm	4-6
Procedural complications	None major
Early restenosis (<6 months)	2 (balloon-only cases)
Reintervention for recoil	1 patient (stent placement after restenosis)
Symptom improvement at 6 months	13/13 (100) of technically successful cases
AVF/AVG patency at 6 months	12/13 (92.3)
Access abandonment	0

AVF, Arteriovenous fistula; AVG, arteriovenous graft; CTO, chronic total occlusion.

Categorical data are shown as number (%).

No major procedure-related complications were observed in this cohort.

During the follow-up period, two patients who initially underwent balloon venoplasty developed early restenosis due to elastic recoil within 6 months. One of these patients subsequently underwent successful reintervention with stent placement, resulting in improved vessel patency and clinical outcome.

At a mean follow-up duration of 6 months, all patients who had successful endovascular treatment demonstrated clinical improvement, including resolution or significant reduction of upper limb swelling and improved dialysis efficiency (Figs 2 and 3). Except for one patient, all arteriovenous fistulas (AVFs) remained patent and functional for HD. No cases of access abandonment were observed among patients with technically successful initial intervention during the follow-up period.

Fig 2.

A, Preprocedure image of a patient presenting with left upper limb edema. B, Postprocedure image of the same patient with resolution of left upper limb edema.

Fig 3.

A, Preprocedure image of another patient presenting with right upper limb edema. B, Postprocedure image of the same patient with resolution of right upper limb edema.

Discussion

This study demonstrates that endovascular management of BCV stenosis and occlusion in patients undergoing HD is both feasible and effective in a resource-limited setting, with a high technical success rate of 86.7% and favorable short-term clinical outcomes. These findings are consistent with existing literature, where technical success rates for central venous interventions typically range from 70% to 90%, supporting endovascular therapy as the first-line treatment for CVOD.⁸

The actual incidence of CVS remains unknown. Patients are typically referred for evaluation when they present with symptoms such as swelling of the upper limb, pectoral, and breast regions, as well as increased bleeding at the puncture site following needling.

In our series, we encountered 15 patients within 1 year at a regional center serving a population of approximately 1.2 million. This incidence is comparatively higher than that reported in other series.^9,10 A possible explanation is the higher proportion of patients in our setting who initiate vascular access through central venous catheters before the creation of an AVF. In our region, approximately 15% of patients undergoing maintenance HD use central venous access for dialysis.¹¹

In our cohort, 66.7% of patients had left-sided central vein lesions. This finding is consistent with existing evidence that left-sided vascular access has a greater predisposition to developing CVS or occlusion.¹² All of our patients had a history of central venous catheterization, which is known to induce an inflammatory response, leading to the formation of a fibrin sheath around the catheter and subsequent development of neointimal hyperplasia.

Balloon venoplasty alone was sufficient in the majority of patients (53.3%), highlighting its role as the primary therapeutic modality. However, one-third of patients required adjunctive stenting due to residual stenosis or elastic recoil. This is in keeping with current practice, where stent placement is reserved for suboptimal angioplasty results.¹³ We reserved stent placement for the lesions with significant elastic recoil and persistent residual stenosis of >30%. Although CSs have been shown to provide superior patency compared with BMSs in recent literature, the exclusive use of BMSs in this cohort likely reflects cost and availability constraints in low- and middle-income settings. CSs have inert covering and provide a stable scaffold for endothelialization while reducing neointimal hyperplasia, thereby lowering restenosis rates.¹⁴ In our setting, the availability of CSs, drug-coated balloons, and stents, re-entry devices, intravascular ultrasound guidance, and dedicated CTO crossing systems was limited because of financial constraints and procurement challenges. Therefore, treatment strategies had to be adapted using the available endovascular inventory while prioritizing preservation of dialysis access.

Despite this, short-term outcomes remained favorable in our series with BMSs, suggesting that selective stenting remains a pragmatic and effective strategy.

CTOs represented the main technical challenge, accounting for all procedural failures in this study. Failure to cross CTOs despite advanced guidewire techniques is well recognized and continues to limit procedural success. This highlights the need for improved technical expertise and dedicated devices. Early identification and treatment of stenotic lesions before progression to occlusion may improve overall success rates.

The clinical outcomes observed in this study are encouraging, with all successfully treated patients demonstrating symptomatic improvement and preservation of dialysis access in nearly all cases at 6 months. The high rate of access patency underscores the importance of timely intervention in maintaining functional AVFs, which remain the preferred modality for HD access. The occurrence of early restenosis in two patients following balloon venoplasty is consistent with the known limitation of angioplasty due to elastic recoil and neointimal hyperplasia, further supporting the role of stenting in the selected cases.

This study also highlights important contextual factors relevant to Sri Lanka and similar health care settings. Late presentation of end-stage renal disease and reliance on temporary central venous catheters contribute significantly to the burden of CVOD. These findings emphasize the need for early referral, timely creation of AVFs, and strategies to minimize catheter dependence in order to reduce the incidence of central venous complications.

The study has several limitations. Its retrospective design and small sample size limit the generalizability of the findings. The single-center nature of the study may also introduce selection bias. Information regarding the laterality of previous central venous catheter insertion in relation to the affected side was not consistently available in the retrospective clinical records. Therefore, the potential association between the side of previous catheterization and the development of ipsilateral CVS or occlusion could not be reliably assessed. In addition, the follow-up duration was limited to 6 months, precluding the assessment of long-term patency and reintervention rates. The absence of a comparison group, particularly between balloon angioplasty alone and stenting, limits the ability to draw definitive conclusions regarding optimal treatment strategies.

Despite these limitations, this study provides valuable real-world data on the management of BCV lesions in patients undergoing HD in a low-resource setting. It adds to the limited body of evidence from South Asia and supports the continued use of endovascular techniques as the cornerstone of treatment.

Conclusions

Endovascular management of BCV stenosis and occlusion in patients undergoing HD is safe, feasible, and associated with high technical success and good short-term clinical outcomes in a resource limiting set-up. Balloon venoplasty remains the primary treatment modality, whereas selective stent placement provides effective management in cases of residual stenosis or elastic recoil. CTOs continue to pose the main technical challenge and may limit procedural success. Early detection of central venous disease and strategies to reduce prolonged catheter use are essential to improve long-term dialysis access outcomes. Further larger, prospective studies with longer follow-up are required to validate these findings and optimize treatment strategies.

Funding

None.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the authors used ChatGPT (Open AI) for language editing, drafting, paraphrasing, and improving the clarity and structure of the manuscript. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Disclosures

None.