|Year : 2020 | Volume
| Issue : 4 | Page : 399-404
Central venous occlusion in dialysis patients – Novel surgical management
Amitabha Chakrabarti, Manujesh Bandyopadhyay, Sathish Kumar
Department of Thoracic and Vascular Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India
|Date of Submission||18-Jun-2020|
|Date of Acceptance||06-Jul-2020|
|Date of Web Publication||24-Dec-2020|
Department of Thoracic and Vascular Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Introduction: The progress in the management of maintenance hemodialysis and renal transplant has led to longer survival and also increased incidence of delayed complications. One of its dreadful complications is central venous occlusion which needs a satisfactory management. Materials and Methods: Bilateral subclavian vein occlusion, innominate vein occlusion, or superior vena cava occlusion remains the most dreadful scenario for central venous stenosis and central venous obstruction (CVO) in dialysis patients. In these patients who are refractory to endovascular options, surgery must be considered. We hereby describe our experience of managing these complications by a novel surgery of draining the area proximal to CVO to the right atrium by reinforced Polytetrafluoroethylene graft. Results: Three of our patient's symptom relief, salvage of arteriovenous fistula, and primary graft patency (mean – 20 months) were achieved satisfactorily. No postoperative mortality or no severe morbidity noted. Anticoagulation orally used up to 3 months of operation. One patient had graft occlusion and mild symptom recurrence. Conclusions: All the current endovascular options for CVO in dialysis patients are prone to recur. Extra-anatomic central venous bypass grafting draining into right atrial appendage is a novel management to relieve the complications. A satisfactory conduit with long-term patency and minimum thrombotic complications is still not available. Randomized control trials with long-term follow-up are needed to develop appropriate treatment algorithms.
Keywords: Central venous occlusion, chronic kidney disease, extra-anatomic bypass, right atrial appendage bypass
|How to cite this article:|
Chakrabarti A, Bandyopadhyay M, Kumar S. Central venous occlusion in dialysis patients – Novel surgical management. Indian J Vasc Endovasc Surg 2020;7:399-404
|How to cite this URL:|
Chakrabarti A, Bandyopadhyay M, Kumar S. Central venous occlusion in dialysis patients – Novel surgical management. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2021 Jan 20];7:399-404. Available from: https://www.indjvascsurg.org/text.asp?2020/7/4/399/304644
| Introduction|| |
Central venous stenosis and centralvenous obstruction (CVO) commonly compromises the integrity of the hemodialysis access circuit by causing venous hypertension with debilitating symptoms. The incidence of CVO has been reported in the range of 30% among chronic kidney disease (CKD) patients in the literature.
Multiple central venous catheter placements, longer catheter dwell times, larger caliber of catheters, the location of the catheter in the central venous (for e.g., subclavian access more prone to CVO), the site of introduction (left-sided access more prone), and also pacemaker and defibrillator wires can lead to CVO.
A thorough knowledge of the anatomy of the central veins is critical to understand why CVO occurs in typical locations and the possible intervention or operation for its cure. The brachial and basilic veins join at the lower border of the teres major muscle to form the axillary vein. The axillary vein continues to the lateral border of the first rib where it becomes the subclavian vein, which enters the thoracic inlet posterior to the clavicle and anterior to the first rib and scalenus anticus muscle (costoclavicular space) and joins the internal jugular vein after (IJV) several centimeters to become the brachiocephalic vein. The right and left brachiocephalic veins join in the mediastinum to form the superior vena cava (SVC).
A suggested mechanism for the development of CVO includes central venous catheter-induced trauma to the venous endothelium and secondary inflammatory damage within the vessel wall at the time of insertion. Other proposed mechanisms include the presence of a foreign body in the vein, along with increased flow and turbulence from the creation of an arteriovenous access. Turbulent blood flow has been shown to incite an inflammatory response and stimulate intimal hyperplasia.,,,,
Bilateral subclavian vein occlusion, innominate vein occlusion, or SVC occlusion remains the most dreadful scenario for central venous occlusion. Narrowing or occlusion of the subclavian vein most commonly presents with edema and/or venous hypertension of the corresponding extremity and breast. Innominate vein stenosis or occlusion affects blood flow from the same side of the face as well as the upper extremity and breast.
The most common complaint is edema, which is much more common once a functional ipsilateral upper extremity arteriovenous access is created. SVC syndrome is the most feared complication. This can result in loss of the hemodialysis access site due to dysfunction or ligation for symptom relief.
Due to improved nephrological and dialysis management in patients without renal transplant or better medical management of postrenal transplant or even in posttransplant failure dialysis management, the patients nowadays have longer survival, which translates into a requirement for management of different delayed complications to salvage arterio venous fistula (AVF) and also problems arising out of central venous obstructive disease such as swelling of the face, neck, and breast and AVF dysfunction.
| Materials and Methods|| |
Endovascular intervention is the mainstay of treatment in patients with CVO. The kidney disease outcomes quality initiative guidelines recommend percutaneous transluminal angioplasty (PTA), with or without stent placement as the preferred treatment approach to CVO in hemodialysis patients. However, in patients refractory to endovascular options, surgical possibilities must be considered and before contemplating surgery CVO has to be confirmed. Digital subtraction central venography is the gold standard for the diagnosis of CVO and is more sensitive than duplex ultrasound. Magnetic resonance venography is an alternative to conventional venography.
If there is a functioning HD access in the ipsilateral extremity to the site of CVO, a simple reduction procedure may bring the volume down to something that can be accommodated by collateral circulation and continue to provide adequate flow for dialysis with a resolution of symptoms. However, salvaging the AVF is always the challenge with symptomatic relief of the patient being the priority.
Bilateral subclavian vein occlusion, innominate vein occlusion, or SVC occlusion in CVO patients can be addressed by extra-anatomic bypass, including jugular vein turndown procedures, subclavian vein to external or IJV bypass, or axillary to femoral vein bypass.,
However, the problem with extra-anatomic bypass grafting has the problem of finding a satisfactory conduit and a procedure with increased morbidity. As the venous system is low-pressure system, suitable venous conduit of autologous vein is preferred, but most of the time, the suitable length and diameter of venous conduit do not match (even after making a spiral venous graft). Therefore, surgeons are left with prosthetic grafts which have an increased chance of graft thrombosis.
A multidisciplinary team approach including the nephrologist, interventional radiologist, and vascular surgeon is always beneficial for planning of management of these patients.
We hereby present our experience of a novel extra-anatomic bypass graft surgery, bypassing the CVO by draining the venous return directly into the right atrial appendage (RAA) to handle CVO where subclavian (uni or bilateral) and innominate veins or jugular veins are obstructed and the challenge imposed by its varied presentation and challenges posed by the varying anatomy.
Case no 1
This 68-year-old gentleman suffering from CKD Stage V on hemodialysis with diabetes, hypertension, and ischemic heart disease was admitted with complaints of swelling and blisters in the right upper limb. He also had swelling of the right face and neck. He had a functioning AVF on the right upper limb. He was diagnosed to have a bilateral central venous disease with the right side being totally occluded and was not amenable to venoplasty. The left side was treated with venoplasty and was relieved of CVO symptoms. His great saphenous vein (GSV) was not of good caliber as assessed by Doppler study. He was taken up for central venous bypass surgery. After sternotomy right axillary vein to RA bypass was done with 8 mm ePTFE graft. Following the surgery, the patient had a significant reduction in right upper limb swelling.
Case no 2
This 59-year-old gentleman of CKD Stage V on maintenance hemodialysis with history of old cerebrovascular accident and epileptic disorder initially presented with complaints of right-side upper limb, neck, and facial swelling and pain. He had working AVF in the right upper limb. His GSV was assessed by Doppler and was found to be of narrow calibre. He was diagnosed to have right innominate vein stenosis for which angioplasty and stenting was done. Following intervention, the patient's swelling reduced, but later, the patient presented with recurrence of obstruction which was not amenable to venoplasty. He developed a venous occlusion distal to the stent. The patient was worked up for central venous bypass surgery. Right cephalic and IJV to RA bypass with 8 mm e-PTFE graft with external ring was done in a “U” manner as innominate vein was also blocked. Postoperatively, the patient's limb and facial swelling reduced. [Figure 1] right sided central venous obstruction preoperative angiogram showing central venous obstructionof case 2.
|Figure 1: Right-sided central venous obstruction. Preoperative angiogram showing central venous obstruction of Case 2|
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Case no 3
This 25-year-old female patient was admitted with complaints of pain and swelling in the right upper limb and face and pain and swelling of bilateral breasts. There was a history of renal transplant and graft rejection. The patient was taken up for extra-anatomic bypass graft surgery to RA. She had working right AVF. Both of her GSV were thrombosed hence not available for spiral venous grafting. Bilateral axillary and subclavian vein occlusion was noted on preoperative venogram and was not amenable to venoplasty. Bilateral axillary vein to RA bypass was done with 8 mm ePTFE graft sutured with continuous 5-0 polypropylene via sternotomy and two infraclavicular incisions. [Figure 2] clinical, operative photo and angiogram of case 3.
The graft was placed subcutaneously and entered into the thorax through the second intercostal space (ICS). Following the surgery, the patient had a significant reduction in limb, breast, and facial swelling. The graft was thrombosed after 2 years, but swelling and pain subsided significantly with development of collaterals via the chest wall.
We used oral anticoagulation in the initial 3 months for each of the patients in the form of Vitamin K antagonists, with a target international normalized ratio for prothrombin time in the range of 1.5–2.0. There was no bleeding episode during the period needing its stoppage or any other intervention for all the patients.
All the patients have been regularly followed up till the 2nd year. [Table 1] patient presentations, surgical indication and surgery performed.
|Table 1: Patient presentations, surgical indication, and surgery performed|
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Brief operative protocol
The patient is taken to the operation theater after proper preoperative evaluation and hemodialysis day before surgery. The patient is operated under general anesthesia preferably with a reinforced endotracheal tube. The patient is positioned in a supine position with hands by the side of the body and a shoulder roll placed under the shoulder blade so that neck-flexed head-extended position is achieved. For an exploration of IJV, the head is rotated to the other side.
Exposure of the axillary vein via an infraclavicular approach provides an excellent exposure. The incision begins inferior to the middle of the clavicle and is carried laterally to the deltopectoral groove. The exposure of the axillary vessels requires the separation of the pectoralis major muscle fibers and the retraction of the underlying pectoralis minor muscle. The pectoralis major is divided about 2 cm from its attachment to the humerus and retracted inferomedially. The underlying pectoralis minor then is divided near its insertion of the coracoid process and retracted inferiorly. The axillary vein is thus exposed fully. During dissection, all efforts should be made to preserve collateral branches and avoid iatrogenic nerve injury.
Incision was made anterior to the sternomastoid in the lower one-third of the neck and a subplatysmal flap was elevated. Thereafter, anterior border of the sternocleidomastoid muscle dissected and retracted laterally to expose IJV. Midline sternotomy pericardiotomy are done. The right atrium and other cardiac chambers are exposed by retracting margins of the pericardium.
A subcutaneous and subpectoral tunnel is created between the target regions (right atrial appendage and target veins) and graft is placed. In case of two sites to be bypassed, the nadir of the graft placed in U shape is kept near the RA appendage. The thorax is entered via puncturing the second ICS.
Heparinization (unfractionated Heparin) done at 1 mg/kg body weight intravenously.
Graft is usually chosen to be an external or internal ring 8 mm ePTFE graft to avoid kinking. End of the graft anastomosed to target vessel and nadir of side of graft or end of the graft anastomosed to the RA appendage with 5-0 continuous Prolene suture.
Hemostasis is secured and substernal pre-pericardial chest drain placed. Sternum is closed with stainless steel wire. Chest and other sites are closed in layer.
| Results|| |
All the patients were relieved of symptoms postoperatively. All three AVFs were salvaged. Case 3 developed recurrence of symptoms around the 2nd year but was less in severity. Venogram showed extensive collaterals and occluded graft. She was managed conservatively with working AVF.
There was early wound infection in one patient without any long-term consequences. Case 2 had functional limitation and limitation of limb movement due to his earlier cerebrovascular accident. Case 3 had limitation of limb movement and pain in the early postoperative days, but analgesic requirement was much less than before. [Table 2] patient outcome and follow up data.
No postoperative mortality was noted. Case 2 died of sepsis after 1 year and case 3 after 3 years due to cardiac failure. Two patients had functioning fistula up to 2-year follow up. The second patient had functioning graft till his death. The mean primary patency of graft was 20 months. [Figure 3] showing the incisions and postoperative outcome case 3.
| Discussion|| |
Percutaneous endovascular therapy is the first-line treatment for CVO but has its own failure rate and limitations. For PTA in CVO, technical failures are to be expected in the range of 10%–30%.
Bare metal stents (BMSs) came into the picture to get rid of the above-mentioned problems but are still not free from limitations. Covered stents provided a mechanical advantage of BMS and also reduced intimal hyperplastic response leading to restenosis following BMS insertion.
A study by Quinn et al. in 2003 placed six covered stents for CVD and 11 covered stents for venous outflow stenoses. There was a combined primary patency rate at 2, 6, and 12 months of 40%, 32%, and 32%, respectively. They utilized a Palmaz® stent (P308, Johnson and Johnson, Warren, NJ) with an ePTFE graft material manually sewn on.
There is clearly a subgroup of CVO patients with elastic lesions, unresponsive to PTA. Very frequently repeated interventions are required with PTA for CVO, in a group of patients. Another subgroup has tight occlusion or very long segment occlusion where PTA is not possible. Surgery remains the only option for all these spectra of diseases with varying anatomical challenges. Extra-anatomic right atrial venous bypass graft is one such novel technique to manage these challenges.
In one of the studies of nine patients with right atrial bypass grafting the result states that all patients except one had significant resolution of symptoms without operative mortality and bypass grafts remained patent, allowing the arteriovenous grafts to provide functional access for 1.5–52 months (mean, 15.4 months) after surgery.
In another study with 14 patients treated with extra-anatomic bypass grafting, the mean primary patency was 18.3 months. Primary patency rates at 6, 12, 18, and 24 months were 85, 78, 64, and 57%, respectively.
In another study, with three patients, venous decompression was performed with a bridge to the ipsilateral femoral vein using a 6 mm reinforced polytetrafluoroethylene graft tunnelled subcutaneously along the thoracoabdominal wall. The graft was found to be patent during an average follow-up of 16.3 months.
In our study, we chose to optimize our surgical management according to the anatomical variation of the CVO for each patient and bypassing the occluded veins in the affected area. Our result seems to be similar to the overall surgical result published so far in view of symptom relief, salvation of fistula, and primary graft patency. There was no mortality either. Our primary patency (mean – 20 months) is comparable with the published literature and also better than the endovascular interventions mentioned previously (only 32% at 12 months, whereas our all three grafts were patent at 12 months).
Only one of the above-mentioned publications takes bypass to right atrium as a choice to relief CVO surgically, and till date, we have not come across any study from India which shows the utility of this technique for surgical management of CVO. Another point worth mentioning that these patients are usually referred to the surgical team when deemed not amenable to any endovascular procedures or after recurrent failed interventional procedures, which makes them anatomically complicated to handle surgically. Still, this novel surgical option gives significant relief to these poorly suffering patients.
We also want to emphasize the use of oral anticoagulation for initial 3 months after the bypass procedure to increase the chance of graft patency, as these prosthetic grafts are placed in a low-pressure venous system and there is no increased risk of significant bleeding.
| Summary and Conclusions|| |
Central venous catheter placement is the most important risk factor for CVO. In patients at risk or with existing renal dysfunction, central venous catheter use should be avoided, particularly in the subclavian vein. The use of other peripheral lines should be minimized to preserve peripheral and central venous patency.
All the current endovascular options for CVO in dialysis patients are prone to recurrence requiring multiple repeat interventions. These patients suffer so badly that they need a palliative procedure for their relief.
Surgery is done to maintain patency in these patients as it offers long-term relief of symptoms and helps to salvage AVF. However, the problem of finding a satisfactory conduit and the innate problem of increased prosthetic graft thrombosis is yet to be solved. Oral anticoagulation may be used in the initial 3 months as an adjunct for increasing long-term graft patency.
Further randomized control trials with long-term follow-up for the currently available treatment options are mandatory to develop appropriate treatment algorithms. Further advancements in treatment technique, technology, and understanding the mechanisms of CVO will be required to improve the outcomes for this difficult problem.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]