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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 494-498

Endovascular management of central venous stenosis in hemodialysis patients


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Vascular Surgery Resident at Ministry of Health, Matarieah, Egypt

Date of Submission23-Sep-2017
Date of Acceptance29-Oct-2017
Date of Web Publication25-Jun-2019

Correspondence Address:
Emad M El-Areef
Matarieah Teaching Hospital, Matarieah Square, Matarieah 32653, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_656_17

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  Abstract 

Objectives
The aim of this study was to assess the effectiveness of percutaneous transluminal angioplasty (PTA) with or without stent deployment for treatment of venous hypertension resulting from central venous stenosis (CVS) in hemodialysis (HD) patients and to determine the relationship between the temporary dialysis catheters and the type of the fistula from one side and development of CVS on the other side.
Background
The quality of life of HD patients depends mainly on the patency and proper function of their arteriovenous shunts. Vascular surgeons should have many surgical and endovascular plans to keep the hemodialysis access working properly, endovascular management of CVS is one of these plans.
Patients and methods
A prospective study in which 30 recruited patients with end-stage kidney disease on regular hemodialysis (HD) complaining of venous hypertension owing to CVS with functioning arteriovenous fistulas or arteriovenous grafts was carried out during the period from October 2015 to February 2017.
Results
Endovascular management through percutaneous transluminal angioplasty and/or stent deployment resulted in a significant higher fistula flow rate at 3 months (593.18 vs. 1964.54 ml/min; P = 0.05), and there was a significant improvement of patient symptoms and angiographic findings. Additionally, there was a higher incidence of CVS with past history of central veins cannulation and proximal arteriovenous fistulas.
Conclusion
Endovascular treatment of the CVS and venous hypertension whether by balloons and/or stents has a significant positive effect on the fistula flow and relief of venous hypertension symptoms in HD patients.

Keywords: central venous stenosis, hemodialysis, venous hypertension


How to cite this article:
Abugruidah HS, Abdelhalim MS, El-Areef EM. Endovascular management of central venous stenosis in hemodialysis patients. Menoufia Med J 2019;32:494-8

How to cite this URL:
Abugruidah HS, Abdelhalim MS, El-Areef EM. Endovascular management of central venous stenosis in hemodialysis patients. Menoufia Med J [serial online] 2019 [cited 2019 Sep 17];32:494-8. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/494/260908




  Introduction Top


A variety of complications are reported with arteriovenous fistulas (AVFs). These are either systemic or local complications. Systemic complications include high cardiac output and heart failure, and local complications of AVF include venous hypertension, steal syndrome, and huge dilatation of the output vein and may be aneurysmal dilatation of the outflow vein at the anastomosis[1]. Central venous occlusive disease (CVOD) includes central venous stenosis (CVS) or obstruction (CVO) and is a prevalent and clinically significant problem for hemodialysis (HD) patients affecting the HD access circuit by causing symptomatic venous hypertension and access flow dysfunction[2]. CVS and CVO classically present with arm edema, dilated collateral neck and chest wall veins, and bleeding for prolonged time at the needle site after dialysis sessions. Asymptomatic CVS may be revealed when elevated static venous pressures or elevated pump pressures during dialysis sessions are detected with surveillance and monitoring. If severe, losing arteriovenous access can occur because of thrombosis so ligation was necessary for severe persistent symptoms[3]. Avoiding CVOD in HD patients is of the outmost importance. Central venous dialysis catheters placement or central venous lines are the commonest factors causing CVOD. In patients with renal impairment, central and peripheral venous access placement must be avoided as much as possible. The insertion of peripheral venous lines should be reduced to preserve future peripheral potential access sites[4]. The aim of this study was to assess the effectiveness of percutaneous transluminal angioplasty (PTA) with or without stent deployment for treatment of venous hypertension resulting from CVS in HD patients with functioning AVFs or arteriovenous grafts (AVGs) as a primary outcome. In addition to that, we aimed to determine the relationship between the central venous temporary dialysis catheters and the type of the AVF from one side and development of CVS on the other side.


  Patients and Methods Top


Study design

This prospective study was performed at Menoufia University and Military armed Forces hospitals on 30 HD patients who were recruited from the outpatient clinics and the dialysis units with functioning AVFs or AVGs complaining of venous hypertension caused by CVS or obstruction. All patients gave consent for participating in this study and publishing their photographs during the procedure and photographs indicating clinical improvement. The study was granted an ethical approval from the Institutional Review Board at Faculty of Medicine, Menoufia University, Egypt.

Participants

The study was conducted for any patients with end-stage kidney disease (ESKD) older than 18 years of both sexes who were on regular HD by functioning AVFs or AVG affected by symptomatic CVS in form of venous hypertension; ipsilateral arm, chest, or facial edema; ipsilateral arm pain; color changes; cyanosis; ulceration; distended collateral veins over the access limb or chest wall; and bleeding from access puncture at the end of dialysis sessions for prolonged time. The number of available patients with those criteria was 30 during the period from October 2015 to February 2017. Patients who had any contraindications for endovascular intervention were excluded from this study. These contraindications included previous surgical treatment, active access site infection, aneurysmal dilatation and thrombophlebitis of the vein, known allergy to intravascular contrast agents, and contraindications to anticoagulation or antiplatelets therapy. A written informed consent was signed by all patients who agreed to participate in this study.

Interventions

Thirty HD patients were recruited from the outpatient clinics and the dialysis units with functioning AVFs or AVGs complaining of venous hypertension because of CVS or obstruction.

All patients have been subjected to conservative measures in form of elastic compression and limb elevation without significant improvement or relief of their symptoms that forced using endovascular option for dealing with CVS.

For each patient, we recorded (i) full written medical history; (ii) full clinical examination, including detailed vascular examination focusing on pain at rest or during dialysis, swelling or edema of the limb with AVF, and skin changes like change in color, cyanosis, ulceration, and movements of the wrist and small joints of the hand; and (iii) laboratory investigations or radiological ones such as duplex ultrasonography and multislice computed tomography.

For all of patients, we performed duplex ultrasonography to measure the preoperative fistula flow. All cases were operated in an angioplasty suite with peripheral vascular capabilities under complete aseptic conditions using nonionic contrast medium (Ultravist Bayer Health Care Pharmaceuticals; Berlin, Germany).

Every case was studied individually according to the previously mentioned criteria and subjected to percutaneous angioplasty using either balloons or venous stents as primary choice. A normal coagulation profile was considered, and the procedure was performed under local anesthesia with sedation only during severe pain.

Each case was documented individually regarding anesthesia (local, regional, or general), site of puncture, procedure duration, and equipment used (sheath Fr size, guide wire, balloon, or stent type, guiding catheter if used and pressure used).

Our patients received the following medications: (i) before the procedure, patients not taking aspirin or clopidogrel before received a loading dose of 300 mg of clopidogrel 12 h before the procedure and (ii) during the procedure, patients received 5000 IU of heparin (70: 100 U/kg) after sheath insertion.

All of the cases were subjected to postoperative evaluation and follow-up in the form of immediate postoperative results; outpatient clinic follow-up after 3, 6, and 12 months; feasibility of the shunt for dialysis; duplex to detect any increase in blood flow through the AVF; and postoperative complications.

We considered failing of guide wire to cross the stenotic or occluded segment of the vein as primary failure of the procedure.

Statistical analysis

Results were statistically analyzed by SPSS, version 22 (SPSS Inc., Chicago, Illinois, USA) and the following statistics were performed: (i) descriptive analysis for quantitative data, for example, %, mean, and SD, (ii) analytical statistics such as paired t-test for parametric data. P value was considered significant if it was less than or equal to 0.05.


  Results Top


This study included 30 patients with ESKD on RHD. All patients had venous hypertension resulting from CVS. There were 25 (83.3%) males and five (16.7%) females. The age of the patients ranged from 35 to 65 years, with a mean age of 52.5 years. Most of them were in the fifth and sixth decades of their life, comprising approximately 80% of the studied group [Table 1]. Endovascular interventions were the primary line of treatment. All (100%) patients had used conservative methods before, without significant improvement or relief of their symptoms. In all of our 30 (100%) patients, we used local anesthesia in the puncture site whereas only one (3.3%) case needed sedation for severe pain during the ballooning of subclavian vein. Regarding our primary outcome, endovascular interventions whether by PTA or venous stents showed a significant improvement of fistula flow after the endovascular intervention with mean of preoperative fistula flow rate of 593 ml/min and the mean postveinoplasty fistula flow rate of 1964 ml/min (P = 0.001) [Table 2]. Regarding our secondary outcome, arteriovenous fistula types in this study were brachiocephalic fistula in 18 (60%) patients, brachiobasilic fistula in eight (26.7%) patients, and femoral arteriovenous synthetic grafts in four (13.3%) patients, with no cases with radiocephalic fistula. This indicates higher incidence of symptomatic CVS and venous hypertension in the proximal AVFs than distal ones. Moreover, all (100%) patients had a past history of central venous cannulation at the same side of the limb complicated with venous hypertension. Twenty (66.7%) patients had subclavian vein catheters, six (20%) patients had internal jugular vein catheters, and four (13.3%) patients had femoral vein dialysis catheters [Table 3]. This indicates the role of temporary dialysis catheters as a very potent precipitating factor for development of CVS. In this study, it is apparent that venous hypertension is not linked to particular sex or age group. In seven (23.3%) patients, the guide wire failed completely to cross the stenotic or the occluded lesion, whereas in 23 (76.7%) patients, endovascular interventions were successful. Twenty-three (76.7%) patients were treated by PTA of the stenosed segment whereas only six (20%) patients needed primary stenting for tight recoiling venous stenosis [Table 4]. Total results were satisfactory [Figure 1] and [Figure 2].
Table 1: General characteristics of the studied group

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Table 2: Distribution of the studied group regarding the flow rate (ml/min) before and after intervention

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Table 3: Medical characteristics of the studied groups

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Table 4: Follow-up of the studied group (n=23)

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Figure 1: Example of endovascular management of central venous stenosis (CVS) (a), showing right subclavian vein stenosis at the site of star; arrows indicating collateral veins because of subclavian stenosis (b), showing subclavian stent deployed, improvement of flow, and disappearance of collateral veins.

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Figure 2: Example of clinical improvement of upper limb swelling (a) and preoperative right upper limb edema (b); 1-year postoperative result indicating relieving of edema, which was following subclavian stent deployment as indicated in [Figure 1].

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  Discussion Top


Venous hypertension is a significant problem for the patient on chronic HD that results in disabling upper extremity edema and impairment of arteriovenous access function[5]. The effect of central venous catheterization as a risk factor for venous hypertension has been studied by many authors. Kundu et al.[6] have reported that CVS is a common problem for hemodialysis patients in the USA[6]. It is estimated that 25–40% of patients with ESKD receiving HD have central venous stenosis, and this estimated incidence has changed little since before the widespread transition from subclavian to jugular vein for dialysis catheters[6]. Chandler et al.[7] have reported that only 1–5% of patients who develop stenosis of subclavian vein secondary to central venous catheterization will develop clinically significant stenosis manifested as venous hypertension in the affected extremity. Hossny[8] reported in his study that venous hypertension was mostly because of a preoperative undiagnosed subclavian vein outflow problem caused by an ipsilateral subclavian catheter. Stenosis of subclavian vein is a significant venous hypertension development risk factor[8]. It is obvious that our results go in line with all the aforementioned studies or trials. Using subclavian vein catheters as temporary access in patient with ESKD must be avoided[9]. A retrospective review was performed of 500 consecutive discrete patients by Trerotola et al.[10], half with AVFs and half with AVGs, who had performed fistulograms over a 4-year period and evaluated them for CVS. Statistical analysis was done to assess the association between fistula type, degree and site of stenosis, and symptoms[10], and results showed that CVS is more commonly to be symptomatic in patients with AVGs versus AVFs, and patients with upper arm access are more commonly to be symptomatic than patients with forearm access regardless of the access type. Trerotola et al.[10], in their recent study, revealed increased liability of symptomatic CVS in patients with AVGs, which was 52%, when compared with AVFs, which was 29%, possibly related to greater capacitance of AVFs than grafts[10]. Lok et al.[11] have reported in their trial that across all studies in the literature, brachiobasilic AVFs are at higher risk for venous hypertension, hemorrhage, and poor maturation. Regarding AVF type in our study, brachiocephalic fistula was present in 18 (60%) patients, brachiobasilic fistula in eight (26.7%) patients, and femoral arteriovenous synthetic grafts in four (13.3%) patients, with no patients with radiocephalic fistula. The commonest duration of fistula usage before presentation of venous hypertension ranged between 6 and 14 months in 24 (80%) patients of study group. In this study, 22 (73.3%) patients had functioning fistula for over 1 year. Prasad and colleagues reported that there are several ways that a CVS may manifest. Patients commonly present with ipsilateral upper-limb or lower-limb edema, tenderness, pain, and pigmentation. Physical examination reveals a dilated tortuous access with aneurysms. Severe CVS may also present with facial edema, dilated congested neck veins, ipsilateral breast swelling, and dilated congested collateral veins over the chest wall depending on the site of stenosis or occlusion. Rarely, patients develop ipsilateral pleural effusion[12]. In our study, clinical features of the studied patients were swelling in 30 (100%) patients; pain and hyperesthesia in nine (30%) patients; ulcers in two (6.7%) patients; hyperpigmentation in one (3.3%) patient; impaired finger function, weak hand grip, and decreased motor power in two (6.7%) patients; cyanosis in six (20%) patients; and dilated veins over chest wall and neck veins in comparison with the other side in 26 (86.7%) patients. Pain was increasing by dropping of upper limb, with dialysis, in the evening, with movement and palpation and was relieved by bandage, limb elevation above the heart, elastic sleeve, and in the morning. One of the most important studies to date on PTA for CVOD by Bakken and colleagues comprising 47 patients showed a success rate of 77%. There was a primary patency rate at 3 months of 58%, 6 months of 45%, and 12 months of 29%. There was a cumulative patency rate at 3 months of 76%, 6 months of 62%, and 12 months of 53%[13]. Jones and colleagues reported that many series of retrospective studies showed 70–90% success rate of angioplasty for CVS. However, the 6-month primary success rates are poor, ranging from 23 to 63%. Bare metal stent provides higher patency rates (55–100%) in 6 months. Stent grafts prevent in-stent stenosis from intimal hyperplasia and provide an 81% primary patency at 6 months after placement[14].


  Conclusion Top


Endovascular lines of treatment of the CVS and venous hypertension whether by balloons and/or stents showed a significant positive effect on the fistula flow and dialysis sessions for HD patients. It is obvious that central venous temporary dialysis catheters are the main precipitating factor for CVS and venous hypertension. Moreover, they are more common with proximal fistulas than distal ones.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Michael ML, Murphy GJ, Conlon PJ, Schwab SJ, Nicholson ML. Surgical considerations in vascular access. Hemodialysis vascular access: practice and problems. 1st ed. Oxford: University Press Inc.; 2000. 101–119.  Back to cited text no. 1
    
2.
Lumsden AB, MacDonald MJ, Isiklar H, Martin LG, Kikeri D, Harket LA, et al. Central venous stenosis in the hemodialysis patient: incidence and efficacy of endovascular treatment. Cardiovasc Surg 1997; 5:504–509.  Back to cited text no. 2
    
3.
Jennings WC, Miller GA, Coburn MZ, Howard CA, Lawless MA. Vascular access flow reduction for arteriovenous fistula salvage in symptomatic patients with central venous occlusion. J Vasc Access 2012; 13:157–162.  Back to cited text no. 3
    
4.
Sanjoy K, Milad M. Treatment of central venous obstruction in the dialysis patient: patient considerations and treatment options. J Radiol Nurs 2011; 30:55–61.  Back to cited text no. 4
    
5.
Neville RF, Abularrage CJ, White PW, Sidway AN. Venous hypertension associated with arteriovenoushemodialysis access. Semin Vasc Surg 2004; 17:50–60.  Back to cited text no. 5
    
6.
Kundu S. Review of central venous disease in hemodialysis patients, J Vasc Interv Radiol 2010; 21:963–968.  Back to cited text no. 6
    
7.
Chandler NM, Mistry BM, Garvin PJ. Surgical bypass for subclavian vein occlusion in hemodialysis patients. J Am Coll Surg 2002; 194:416–421.  Back to cited text no. 7
    
8.
Hossny A. Brachiobasilic arteriovenous fistula: different surgical techniques and their effects on fistula patency and dialysis-related complications. J Vasc Surg 2002; 37:821–826.  Back to cited text no. 8
    
9.
National Kidney Foundation: NKF-DOQI. Clinical practice guidelines for vascular access guidelines. I Patient preparation for permanent hemodialysis access. Am J Kidney Dis 2006; 48(suppl 1):176–247.  Back to cited text no. 9
    
10.
Trerotola SO, Kothari S, Sammarco TE, Chittams JL. Central venous stenosis is more often symptomatic in hemodialysis patients with grafts compared with fistulas. J Vasc Interv Radiol 2015; 26:240–246.  Back to cited text no. 10
    
11.
Lok CE, Oliver MJ. Overcoming barriers to arteriovenous fistula creation and use. Semin Dial 2003; 16:189–196.  Back to cited text no. 11
    
12.
Prasad V, Baghai S, Gandhi D, Moeslein F, Jindal G. Cerebral infarction due to central vein occlusion in a hemodialysis patient. J Neuro Imaging 2015; 25:494–496.  Back to cited text no. 12
    
13.
Bakken AM, Protack CD, Saad WE, Lee DE, Waldman DL, Davies MG. Long-term out-comes of primary angioplasty and primary stenting of central venous stenosis in hemodialysis patients. J Vasc Surg 2007; 45:776–783.  Back to cited text no. 13
    
14.
Jones RG, Willis AP, Jones C, Mccafferty IJ, Riley PL. Long-term results of stent-graft placement to treat central venous stenosis and occlusion in hemodialysis patients with arteriovenous fistulas, J Vasc Interv Radiol 2011; 22:1240–1245.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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