Dear Colleagues,

This post is in relation to the fascinating discussion regarding stents in the central Veins. I wanted to share my experience with you all. I abandoned bare metal stents in the central veins approximately 2.5 years ago due to the early recurrence of in stent stenosis and fracture, or collapse of these stents in the subclavian vein. I have moved on to using only stent grafts (Viabahn), when deploying a stent in the central veins.

I try to manage with angioplasty alone andI only reach for a stent when the lesion is refractory to routine angioplasty (Elastic Recoil or early recurrence) with persistent manifestations of venous hypertension. I have a small series of 25 patients with good long term potency results. A couple of the first patients have returned with 'candy rap' stenosis on repeat angiogram, but no in stent stenosis. I am not sure if the development of stenosis adjacent to the stent was due to oversizing of the stent?

When deploying a stent Graft my preference is to use two access sites. One to deploy the stent and the other to selectively catheterize the opposite Brachiocephalic vein. This to characterize the angiographic  anatomy of the central veins with the outmost detail to avoid Jailing off the opposite brachiocephalic vein.  If the access is a graft, I access the  graft to selectively catheterize the opposite Brachiocephalic vein and I access the ipsilateral Femoral vein to place the 11F or 12 F sheath to deploy the stent graft. If it is a large caliber AV fistula I perform both sticks through the fistula. I am sharing images from today to illustrate the technique. The images were posted in sequence. The discussion regarding central stenting has been fascinating  and enlightening! Thank you. 

This is a 75 y.oPatient with a right upper arm AV graft who present a week ago with right upper extremity edema and prolonged bleeding following removal of the access needles after dialysis. Treated with angioplasty of the high grade stenosis in the right Brachiocephalic Vein with > 30 % residual stenosis. Came back today with mild improvement of his right upper extremity edema, and persistent prolonged bleeding for placement of a right Brachiocephalic vein Stent graft.

Prior to Angioplasty within the stent, I remove the catheter.

Thank YOU!

Alejandro C Alvarez, St Louis Missori.