We must always hurry up to place a fistula and get out the catheter!
The next step would be thrombosis of the SVC and it would be easier to place today a big balloon, than to face this thrombosis.

After long term tunneled catheter presence not infrequently there appears "stuff" in the SVC, a gemisch of fibrinous sheath, tethered thrombus, etc. This can respond very well to simple balloon angioplasty, and, if there is concern about embolization of material towards the lung, placement of large diameter non-covered stent. As an aside, even a 13mm covered stent looks too small at this point. - Lastly, the access flow could be reduced to 500-600 ml/min to aid in limiting edema symptoms.
So,
1. angioplasty now
2. follow in increasing intervals 3 months at first then 6 months...
3. If stenosis recurs place large non-covered stent
4. Follow
5. Once endothelium has grown densely enough through interstices use covered stent

Dirk,
In our practice, and from prior comments on this blog, the suitability of a covered stent for central venous stenosis seems to be better. Less stent fracture and much longer stent patency. So in that case, once you are at the point (#5 in your post), why not opt for a covered stent 1st instead of the non-covered?

No matter what you end up doing, the patency rate of the central venous system in this YOUNG woman is going to be quite limited.
If you have access to PD, the patient should be educated about that modality of dialysis in addition to expedited transplant evaluation and listing.

As for the matter at hand, the more conservative you can afford to be , the better .
Removing the catheter ( I suspect already done since I have hard time seeing it on the fluoroscopy image provided) and restricting flow as was mentioned are good first step followed by angioplasty if an indication arises.

Stenting the SVC should be a last resort and I would consider an unconverd stent for starters.

I agree with the general concept on covered versus non-covered stents in central venous circulation.
For this particular angiogram I would need to see how it looks after angioplasty with appropriately sized balloon. What we see is IMO not due to vessel narrowing but endoluminal addition of "tissue". Does it impair flow? - Yes. Is this an "active" disease process with progressive narrowing? I do not know. But there are enough instances where angioplasty alone provides years of patency. A non-covered stent similarly can add many years. I cannot tell from image. - But placing a 13mm x 10cm (or 5cm ???) mostly free floating tube in a 32-year old woman without symptoms seems a set-up for future issues. We do not see the right brachiocephalic vein, but if it still is patent any stent graft extending past the SVC will impair future options a well as occlude the current central collaterals that are sufficient for a fistula. [Advanta and iCast balloon expandable stent could be used but there is no long term experience]
The question in this case is really if to do anything at all. Multiple studies have documented that angioplasty accelerates the natural history of central venous stenosis. The cost of not intervening at this very time is the later risk of total occlusion with inability to pass a guidewire. To make that call many local factors have to be taken into account (e.g. loss to follow-up, enthusiasm to recannalize central venous occlusions, rate of kidney transplantation, etc.)

In this patient I would avoid a stent. If placing o covered stent one has to be very careful not to Jail off that large azygus vein, that is accommodating the high flow explaining the absence or minimal swelling described. I would only angioplasty and like Dr. Issa said educate on another modality of renal replacement therapy PD or preferably transplant.

Generally, I agree with the comments. Favor: gentle pta (don't over size the balloon per Dirks comment) and follow perhaps in 4-6 weeks to look at the trend in the lesion. 3 months might be ok but following central stenosis by signs and/or symptoms can lead to very late recognition of total and irreversible central vein occlusion. The hemiazygous vein can easily be recruited again if stenosis reoccurs. If the avf is running at 850, there is not much room to reduce flow so would leave this as later option if hemiazygous be comes only outflow and/or central edema becomes unmanageable. PD if other options don"t pan out.

Remember: Stents are "forever". So would not be quick to stent this young woman.

This is a case everyone will wrestle with. It is important to highlight some important points ; you dont know the time over which this lesion developed so its stability is unknown; clinically, there is adequate collateral flow; angioplasty alone is always an option when there is clinical indication; and if a stent is placed, take care to try and preserve the collaterals, they are helping.

I agree with other comments promoting conservative approach. at this point i would not intervene, but i would follow clinically. She should be followed either in the dialysis unit or in the access clinic for progressive swelling or change in dialysis adequacy/function. when there is progression, angioplasty may be indicated.

let us know what happens next.

Thank you Dr. Hyungseok Lee for providing this case for discussion.
General comments:
1) The patient is not in immediate trouble and likely not in near future trouble unless the AVF grows further and starts having more flow. This means there is time to think and follow up before an intervention is undertaken if any.
2) I did not see a TDC in place therefore I am assuming that it was removed. I am not sure how long ago it was removed. If recent removal, then at least one could say that there was a recent tract through the right sided central veins (from the TDC), to the RA, which may not be totally calcified and organized.
3) The azygous vein is very well developed and is providing good outflow.
4) It is not clear to me if the SVC is totally occluded. I usually don’t trust CT scans on the central veins and trust the angiogram more. However, since the image we are seeing is not an angiographic sequence run, I am not sure if the contrast trickling down to the RA is from collaterals or going through a tight narrowing of the upper SVC. Nevertheless, we know that TDC induce stenosis and induce transmural clots in the central veins. The shape of the SVC obstruction is interesting with a sharp transverse outline. But if I am not mistaken, there seems to be some tract going through the SVC to the RA. Thus the SVC is not totally occluded yet.
Specific recommendations:
1) Agree that simple observation and doing nothing is acceptable and the safest approach. She is draining well, thanks to a well developed azygous, with minimal arm edema.
2) Disagree with reducing the current AVF flow since it is not currently massive, and reducing an 800 ml/min flow to 600 ml/min is not entirely possible nor necessary at this time. Reducing AVF flow is not accurate science and what can be done may not always meet what is wished for. Besides, creating inflow banding on a low flow AVF could be a progressive lesion that may need future angioplasty. AVF reduction may be necessary if the AVF flow grows and she develops edema. Short answer for now No.
3) Why one would intervene at all? This is a good question, and I am not sure if there is one answer that satisfies all. I can argue both ways if I want to. If I want to argue in favor of doing nothing I would say: (a) patient not symptomatic enough (b) Azygous vein doing the Job and may grow further based on need, (c) Risk of intervention may not justify benefit, and (d) benefit if any is likely to be short term and repeat intervention may be necessary.
If I want to argue in favor of intervention, I would say: (a) patient is mildly symptomatic and that is why was referred in the first place, (b) Symptoms may worsen over time if the AVF grows with time, (c) Even though azygous is doing the job but there is risk of emergence of many surface collateral veins over the chest and abdomen that grow over time and become visually prominent and not desirable by the patient, (d) The SVC stenosis could progress with time and totally occlude (I am assuming it is not totally occluded now) and in that case, more symptoms would emerge in this relatively young patient who we should do every effort to keep her SVC patent.
4) I think in a case like this, it would not be a bad idea to have a multidisciplinary approach to it. I mean that we should engage vascular surgery or Interventional Radiology and not be heroic and try to work alone as Interventional Nephrologists. I am aware that local expertise vary and there may be some situations where no vascular surgeon or Radiologist is around, and at times they are around but don’t have the necessary experience, but should there be local expertise, one could consult with them to have a common consensus and then decide who is the best to handle this case. I have been lucky that in Houston there are good I.R. and good vascular surgeons who I can consult with.
5) But let us say there is no I.R. and no vascular surgery around, and there is concern about progressive stenosis/occlusion of the SVC, if she is my case and I see this lesion, two things cross my mind and these are (1) can I pass a guidewire through the SVC to the RA (from the left side where the AVF is) and (2) Are there clots in the SVC? The reason I am interested in knowing if there are clots is because it might increase the risk of any intervention by causing emboli if intervention is conducted (But I think the clot load is small in this case). I thus might consider 4 week of anticoagulation, and then stop anticoagulation in order to repeat the angiogram to see if anything improves. If improvement is seen, good (if some organized thrombus melts down with Coumadin or spontaneously). If no improvement, then I would attempt to cross a guidewire to the RA (may be also then to the IVC ) and conduct simple balloon angioplasty of the SVC using a 12 or 14 mm balloon (my guess based on the images, but be cautious not to oversize balloon in this location). Would not use larger balloon to avoid risk of rupture close to the pericardium, which would be disastrous. Then see result. If result good, great. If result not good, at least you gave it a chance, and despite not good result, you still have the azygous to rely upon.
6) I believe in stent grafts in many locations where there is active neointimal hyperplasia, but I would not advocate stent graft in this location. So my answer is no stent graft here as this location has not been studied well for stent grafts and most data and clinical experience with stent grafts in the central veins is not in this location. It is too close to the heart and any under sizing could risk migration and kill the patient.

Thanks everyone for all the kind comments.
In fact, I could hardly make a decision at that time, but one thing was clear. I had a time (or chance) for discussion. At least, the time to listen to other experts about this case.
I really appreciate for your advice and it will be a great help for me.

I made a contact with the hemodialysis center which referred the patient to me, and got more detail information.
The radiocephalic AV fistula was created at 29 February 2016.
The tunneled dialysis catheter was removed in early June 2016. ( The TDC was maintained in her right jugular vein for one year )
The angiography and CT scan was examined in late October 2016.

Hoping to be helpful, I uploaded the video of central venogram just now. ( You can access the video by the link below )

https://youtu.be/v3yjd8PxfI4

Having looked at the video (thanks) it seems the drainage is well established through both the Azygous and the SVC. I agree with others that less is more. If no issues with the AVF clinically, I'd consider doing nothing or, at most, an angioplasty of the SVC. I would not stent this. And if it becomes totally occluded in the future, but there is no "SVC Syndrome, arm swelling, or other issue, I'd still leave it alone.

JP

One important point to add and discuss, I usually make it a point to SVC gram and PTA when removing a longstanding catheter. A catheter that has been in place for more than a year is certain to have a thick sheath which can be ruptured, and perhaps this problem would never be much of a problem at all. Further, it can help with preservation of central veins.

Was there any angiogram and/or PTA done on catheter removal as far as you know? If so, recurrent central stenosis is not a surprise obviously. If not, that would be a consideration in future similar cases.