This is a 60y man with a RIJ tunneled catheter for many months who was referred for facial and neck swelling for 1 week. He does not have any running accesses and had a recent pneumonia with cavitary lesions which responded to therapy. I noted on exam that there was a non healing wound along the tunnel tract with no drainage and pt did not have any fever or chills. I initially planned on using a femoral approach to study the central veins and if SVC stenosis is present then move the catheter to the femoral vein, remove the chest wall cath and treating the SVC stenosis.

Then I thought it would be easier to make a cutdown over the venotomy, transecting and wiring the catheter and then evaluating the centrals via a RIJ sheath. If there is a good response to PTA of the centrals then replacing the catheter, tunneling more lateral away from the nonhealing wound over the existing tunnel.

After removing the catheter I was able to manipulate the wire through a 8Fr sheath into the IVC. It was very difficult to manipulate the wire past the mid SVC level and based on the angle and looping of the tip of the wire it was suspicious for either a high grade stenosis or thrombus.  Tactile sensation suggested that it was bouncing off something and I did not think it was a stenotic lesion. I also injected through the catheter initially through a 12Fr dilator inserted into the transected catheter and there appeared to be SVC thrombus. Later injections through the 8Fr sheath revealed a massive SVC thrombus with most of the flow through the azygos vein.

I ended up putting in a femoral catheter and sending the patient to the hospital for a heparin gtt and lytic catheter by VIR.

Questions:

1) Should I have had a higher suspicion of SVC thrombus given the 1 week history of facial and neck swelling? I went into the case thinking it was a SVC stenosis with the catheter occupying the stenotic lumen.

2) If there is a suspicion of SVC thrombus would the therapy be removing the offending agent and placing the catheter elsewhere + anticoagulation +/- lytics or treating with the catheter in place.  There is literature in pts with malignancies and central thrombus of leaving the offending agent (infusion catheter) in place and treating with heparin + lytics so the thrombus doesn't migrate.

3) The CT scan (picture #4) showed a massive SVC thrombus extending into the right atrium; because the thrombus did not appear to be adherent to the wall the radiologist thought it was acute/subacute. Should surgery be considered; concern is that much of the massive thrombus appears to be free floating.

4) What's the likelihood of having thrombus adherent to the catheter or fibrin sheath? This makes me concerned when we just remove catheters without any imaging. That being said I've never had a complication associated with a catheter removal. But if you are scheduled to remove a catheter and the patient has facial and neck swelling are additional studies necessary before pulling the catheter?

Pic#1 is the initial injection after transecting the catheter and injecting through the catheter pulling the catheter back so the tip is in the innominate vein. There is a fibrin sheath present.

Pic#2-3 are both injections through the 8Fr sheath in the RIJ.

Pic#4 is the CT scan of the chest with contrast.

The patient presents to the ER with right arm and facial swelling. He has a right radiocephalic AVF.  A good thrill was palpated in the AVF body, which measured approximately 12 cm. This was the area where he was cannulated for hemodyalisis.

A fistulogram was performed. The findings are illustrated above.

Fistulogram shows a complete occlusion of the cephalic vein with collateral veins that drain into the basilic vein and an 80-90% stenosis in the right innominate vein, which is the culprit lesion.

I was not able to pass the wire to the basilic vein. Because of this I did a second ultrasound-guided cannulation in the upper arm and gained access to it.

After this, I did an angioplasty using a 10 x 4 mm balloon then a 12 x 4 mm.  Angiography post-dilation showed more than 30% restenosis. A 14 x 4 mm balloon was then used to dilate the vein further.  Post dilation angiography showed less than 30% restenosis.

The interesting point in this case is that despite a complete occlusion of the AVF at the body there was adequate function (good kt/v,) and drainage into the basilic vein through collateral veins. The second canulation and dilation of the right inomminate vein was performed in order to decrease the swelling in the arm and face, to avoid further complications, and to continue use of this AVF.  The patient has been using the AVF for 1 month following the angioplasty with no subsequent problem with the AVF and no swelling in the arm or face.

Points of interest:

1)   After the central lesion was dilated, the patient has no more swelling in the arm and face and the AVF has been working properly with no complications.

2)   There are physicians that could think that this AVF will not continue working adequately, but the physical exam and history of the patient suggested that the problem was not AVF, it was the central lesion, reason why I decided to do this.

3)   Physical exam and medical history will help us decide what is in the best interests of the patient. 

The following case is from the RENOVA  trial and illustrates some caveats of stent graft treatment for VA stenosis.

A  65 YO woman  with  ESRD,  DM, HTN, dyslipidemia, obesity  presented to the access center with a dysfunctional left upper arm Brachial Basilic bridge graft placed  4 months ago. She started hemodialysis one month after the graft was placed.  

Pertinent access history included  high venous pressures,   decreased access flows and prolonged bleeding at her cannulation sites.  On exam , the AVG was  pulsatile and there was a high pitched bruit at the VA.  Angiogram revealed a severe stenosis at the VA and absence of other inflow or outflow  stenoses. She was randomized in the RENOVA trial to the balloon PTA only arm.

Fig 1: shows redundant graft and  probably a  90 degree angle of anastomosis of graft with outflow basilic vein.  The VA is 100%  stenosed with retrograde flow to collaterals. 

Fig 2:  A wire would not cross the VA stenosis due to the acute angulation and lack of leverage using multiple guiding catheters.  Therefore, the basilic vein was cannulated using ultrasound guidance at the elbow and a glidewire was threaded  straight across the stenosis.

Fig 3 and 4: An 8 mm Conquest balloon was positioned across the VA occlusion and angioplastied to 30 atm. There was vascular rupture which was controlled and resolved easily  with prolonged balloon angioplasty. Note the absence of retrograde and collateral flow once the true outflow path was re-established.

Fig 5: Subsequently a  second glidewire  was  threaded across the VA from the graft access and angioplasty  with the 8 mm balloon over this second wire  was  repeated in the VA.   

Fig 6:  Post angioplasty angiogram.  Outflow basilic vein is approximately 8 mm in diameter and appears healthy. The graft was a straight 6 mm ePTFE.

Fig 7: Post angioplasty angiogram with graft wire and basilic wire removed from the VA.   Note the graft angulation with the VA returning.

The patient returned to the access center 2 months later with prolonged bleeding and high venous pressures.

Fig 8: The VA stenosis has reoccurred.

Fig 9: After balloon PTA with an 8 mm balloon, the VA stenosis was repaired with an  8 mm x 30 mm Flair stent graft.

This patient  completed her  2 year Renova follow up without any further interventions.  She continues to dialyze with  this graft and is approaching her 6 year anniversary of the graft placement.  Her VA has remained patent and never required further intervention since the Flair stent graft placement.  She has required 4 subsequent endovascular  interventions – all intragraft stenoses treated with balloon pta.

We now have 3 randomized controlled trials  published in peer-reviewed journals  demonstrating superior patency at the target lesion( VA) and in the access circuit  using  stent graft  treatment  vs balloon PTA  for VA stenosis;  the  Flair pivotal trial and the Renova trial  (Flair stent graft)  and  the Revise trial (Viabahn stent graft) .   Graft VA stenosis has been  recognized as a recurrent problem for 30 years and  yet we have been hypnotized by the immediate cosmetic success   of balloon angioplasty.   Bare metal stents were tried and  have never been proven any better than balloon angioplasty. These 3 stent graft trials  demonstrate that we have a better tool in our  tool box to treat graft VA stenosis.  I highly recommend dialysis access  interventionists read these published trials.   One does not need to be a statistician to recognize the superior results of stent grafting VA stenosis.  Much of the criticisms of this new treatment strategy has economic origins; and I agree that economics of stent graft use in the outpatient access centers are germaine.  However as we transition from a fee-for-service   to a  bundled , accountable care , pay-for- performance paradigm  of reimbursement ,  we need to  know which tool in the tool box is going to give us the best patency.  It behooves us to familiarize ourselves with how to deploy these stent graft devices ( read the IFU)  and the results they can provide our patients.  My experience is that  instent restenosis of a  stent graft  in  the VA is rare.

These are some caveats from the case presented. 

1.She  received a Flair stent graft  on her second visit in the trial and required no further interventions over the 2 year follow up. She was evaluated in the balloon only ( intention- to- treat) control cohort. Therefore her excellent results which i attribute to the Flair stent VA stenosis repair actually  contributed to  better target and access circuit patency as primary endpoints for the  balloon angioplasty  control  group.

2. It was fortuitous that she was randomized to the balloon only arm. A 90 degree angle of anastomosis was a contraindication to Flair stent deployment at randomization.  She ended up getting stent graft treatment and my experience is that the Flair stent stiffness is an excellent  "fix" for 90 degree angles at the VA.  Just as the wire helped straighten the redundant portion of graft and the acute angle,  i think the stent graft can  help  " straighten"  the angle and provides theoretically more laminar flow.   She had an obese upper arm and the graft has to go from superficial cannulation zone  to a very deep VA; i see this frequently in obese upper arm AVGs.

3. The retrograde and collateral flow is eliminated or "jailed off" with this covered stent treatment. This was a non-issue in the trial outcomes. My experience is also that this does not cause any clinical problems. i have never seen an arm swell after a VA stent graft treatment ( forearm or upper arm graft location). 

4. When does one stent graft the VA? The trials would indicate that primary treatment of VA stenosis  provides best patency. Even if one does not agree and wishes to try balloon angioplasty first, i would encourage interventionists to consider stent graft treatment for those VA stenoses that reoccur in under 3 months.  My dialysis patients with  av graft access do not have loss of their grafts  due to VA stenosis anymore ( with stent graft repair);  repetitive cannulation  injury  and pseudo-aneurysm degeneration in the graft body are now the leading causes of graft loss and abandonment for my patients.

Renal Tx in Jan 2016, Allograft working well with serum creat at 1.5 mg/dl. Now has a thrombosed HeRO. What would be an ideal treatment option to avoid risk of infective endocarditis/ bacteremia? 

A) Do nothing

B) Remove the catheter portion and leave the graft intact

C) Remove the entire HeRO device

Would having information on the presence or absence of underlying central venous stenosis alter the management? Unfortunately, I have no way to get that information.

38 year old Hispanic male with ESRD (presumed secondary to HTN and previous IV drug abuse) presented to our outpatient vascular center, 3 weeks post placement of right IJ tunneled catheter after initiation of dialysis. He was complaining of right sided neck swelling and tenderness for 1 week.

An ultrasound revealed a large right IJ thrombus.

Patient has no history of or predisposition to having a hypercoagulable state.

I proceeded, in our outpatient vascular center, to remove the right IJ tunneled catheter and placed a left IJ tunneled catheter. Then I directly admitted the patient to the hospital for initiation of Heparin/Coumadin.

Questions:

1) Anything wrong with my management?

2) How long would you anticoagulate with Coumadin?

3) If patient was found to have right IJ thrombus incidently and was asymptomatic, would you have done the same thing?

Enjoy the articles !!!!!!!!!!!!! 

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