Kevin
I am glad you opened this discussion. The management of central venous stenosis is a pivotal issue second in importance only to the issue of prevention of central venous stenosis, namely by avoiding or limiting the use of central venous catheters in the first place (NKF-DOQI, '97).
We have found the use of stent grafts (specifically the Viabahn stent) in the central veins to be consistent with long term patency, and presented our results in poster and podium form at CIDA and VASA meetings in the past. A 90% five year secondary patency of stented central veins in 142 patients was documented. We now have over 200 patients in our little registry. I shake my head at meetings where participants have qualms about central venous stenting, and are apparently unaware that a large experience has already been presented several times. I must be a very poor speaker, or have lost my credibility somehow.
Bare wire stents are prone to fracturing, tissue ingrowth, and failure. We do not use them except the very biggest sizes in the innominant or SVC. If they are all we have at the moment, we resign ourselves to re-lining the barewire stent with a stent-graft. I reject the argument that barewire stents prevent "jailing out" side branches - if the channel goes down, everything is jailed out anyway.
Wall Stents and Wall Grafts have variable lengths when deployed and expanded - we don't use them any more. The Bard Fluency/Flair and Gore Viabahn stents do not have that problem (they have other problems). We use mostly Viabahn stents - I have placed several thousand since 2000.
I prefer to stent open the central veins rather than putting in a HeRO graft/catheter. Every time the patient moves their arm, the distance between the fixed end in the upper arm or shoulder and the free end in the atrium changes. The net effect is that a long stiff catheter component is bobbing up and down in the atrium. On occasion, the free end may get caught in the coronary sinus on the posterior wall of the atrium - and then your risk of death multiplies. The HeRO is a glitzy and cheap but dangerous solution that is most often more effectively and safely provided by a stent.
I could talk all night, but the men have come to lock me in my room for the evening again. Maybe tomorrow we can talk about the V-Wing, another dubious "advance".

Thanks for sharing this thoughtful response, I have a very similar practice experience here.

I generally try to maintain clinically significant central lesions by angioplasty only - but do proceed to stents/ stent-grafts with recurrent lesions (3 month recurrence), high-grade lesions, and total occlusions. Presence of significant arm edema also tends to push me towards stent-graft placement.

I initially placed bare metal (Lifestar) stents for aggressive central lesions, and with recurrent stenosis have re-lined these stents with a second bare metal stent. The overlapping mesh of multiple bare metal stents can give you some improved patency – but in-stent stenosis with bare metal is pretty much inevitable.

I too have proceeded more and more into using stent-grafts (Viabahns) for these lesions – and we have seen significant improvements in central patency.

While you may get more radial force out of the Flair and Fluency stent-grafts, I haven’t had an issue with radial force using the Viabahn. The advantages of the Viabahn are its conformability and the end-to-end PTFE coverage - which seems to give advantages in patency.

As previously mentioned, jailing off an IJ vein in this instance may not be such a big deal – especially if you are dealing with aggressive lesions that result in functional occlusion of the IJ veins anyway. Sometimes I’ll ultrasound the IJ veins before the case – and if your contralateral IJ is patent, you really have little downside.

I’ve heard of cases where jailing off the IJ vein did result in a symptomatic thrombosis of the IJ vein; however this is exceedingly rare and does not change my management – just something to keep in the back of your mind.

It goes back to the risk/reward of maintaining long-term central patency with a stent-graft, versus the need to preserve the IJ vein for a future catheter.

With good secondary AV access patency (often utilizing stent-grafts), we really can maintain many accesses for a lifetime now, and it’s relatively rare that we will completely abandon an access anymore. This somewhat diminishes the urgency of maintaining an IJ vein for a future catheter, in exchange for the ability to maintain an AV access indefinitely with a central stent-graft.
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A few caveats on central stent-graft placement - as I’ve mentioned in previous discussions, secure a stiff wire down the IVC for safety and go big (10-13mm for Viabahn – usually a 13). Also, do not jail off your contra-lateral brachiocephalic/innominate vein. While it’s not as big of a deal to jail off your IJ vein – you do not want to jail off your contralateral venous return.

Usually aggressive central lesions do not extend to the SVC, so you usually don’t have to advance that deeply into the central system – but be aware of your landing zones for your stent-grafts. Depending on the lesion location, you may need to anchor a fair amount of the stent-graft into the subclavian vein.
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We also have had a challenging long-term experience with the HeRO with the issues mentioned by Dr. Webb – but it does have a role is some cases. I think improved secondary access patency has limited our need of the HeRO locally - and we also have used stent-grafts to manage much of the central issues otherwise addressed by the HeRO.

I can infer some of your thoughts about V-wings – and we have minimized our use of them locally as well…