|Year : 2021 | Volume
| Issue : 1 | Page : 25-28
Role of central venography prior to vascular access surgery
Mustafa Razi, Chainulu V S R B Saripalli, Pradeep Burli, Prem Chand Gupta, Gnaneswar Atturu
Department of Vascular and Endovascular Surgery, Care Hospitals, Hyderabad, Telangana, India
|Date of Submission||15-Sep-2019|
|Date of Acceptance||21-Oct-2019|
|Date of Web Publication||20-Feb-2021|
Department of Vascular and Endovascular Surgery, Care Hospitals, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Purpose and Objective: Central vein stenosis is not uncommon in renal patients who are on dialysis. Performing new arterio-venous fistula (AVF) in patients with central vein stenosis can lead to significant problems, ultimately leading to loss of AVF. The aim of this study was to assess the role of central venogram before the creation of a new AVF. Materials and Methods: All patients who underwent central venogram before AVF surgery between September 2017 and June 2019 were included in the study. The medical records and central venogram images were reviewed. Data regarding demographics, indication, findings of venogram, arterio-venous access performed, were collected using an online database. Results: A total of 143 patients met the inclusion criteria. The mean age was 52.25 (range 23–86 years) and 85 were men (59.44%). One hundred and thirty-nine out of 143 (97.2%) patients were on dialysis and had a history of ipsilateral and/or contralateral central vein catheterization. However, only 18 of 143 (12.58%) had central vein symptoms. The most common indication was being a precious fistula or last access option (64 patients; 44.75%). Central venogram identified ipsilateral abnormality in 52 patients (36.36%) and contralateral abnormality in 46 patients. Preoperative plan was changed in 24 patients (16.78%) due to venogram findings. Conclusions: This study highlights that central vein stenosis/occlusion can exist in renal dialysis patients even without obvious clinical signs and symptoms. Routine use of diagnostic central venogram in such high-risk patients can identify central vein problems preoperatively and prevent postoperative complications.
Keywords: Arterio-venous fistula, arterio-venous fistula complications, central vein stenosis, central venogram
|How to cite this article:|
Razi M, Saripalli CV, Burli P, Gupta PC, Atturu G. Role of central venography prior to vascular access surgery. Indian J Vasc Endovasc Surg 2021;8:25-8
|How to cite this URL:|
Razi M, Saripalli CV, Burli P, Gupta PC, Atturu G. Role of central venography prior to vascular access surgery. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Feb 26];8:25-8. Available from: https://www.indjvascsurg.org/text.asp?2021/8/1/25/309719
| Introduction|| |
A working permanent vascular access, which can be regularly used to access the systemic circulation, is crucial for the survival of patients on maintenance hemodialysis. Due to repeated central vein access, central vein stenosis (CVS) can develop and should be suspected when there is unilateral edema of the extremity ipsilateral to an existing or previous tunneled dialysis catheter.
Previously unsuspected central venous stenosis (CVS) may become symptomatic after the placement of an ipsilateral vascular access. It is confirmed by angiography demonstrating >50% stenosis of the subclavian, brachiocephalic vein, and superior vena cava in the upper extremity or the iliac vein or inferior vena cava in the lower extremity.
CVS occurs commonly in hemodialysis patients., CVS can result in prolonged bleeding from the access puncture site after the removal of the dialysis needles, difficulty in access cannulation, elevated dialysis venous pressures, and vascular access thrombosis. High access recirculation in patients with CVS may produce a low Kt/V or hyperkalemia.
| Materials and Methods|| |
This was a retrospective study involving all adult patients (aged 18 and above) who underwent central venogram before having a new arterio-venous fistula (AVF) in our institute between September 2017 and June 2019. Patients with known central vein stenosis were excluded from the study. Venography of the central veins was performed by injecting 20 ml full strength nonionic radio-contrast agent followed by 20 ml saline flush through an intravenous cannula inserted into a superficial vein on the dorsum of the hand. Digital subtraction venography was performed using Ziehm Vision R machine with a frame rate of 12.5 frames/s. The images obtained were reviewed by two independent surgeons/interventional radiologists. Central vein abnormalities were classified as central vein stenosis, total central vein occlusion, and central vein thrombus. Central vein stenosis was then graded into four quartiles: <30 percent, 30%–50%, 50%–70%, and more than 70% compared to the distal vein [Figure 1]. Data regarding the demographics, indication, AV access performed, and outcomes (any change in site of AVF surgery compared to preprocedural plan) were collected using online database.
Statistical analysis was performed using the SPSS (Statistical Package for the Social Sciences) Statistics version 24 (IBM, International Business Machines Corporation) software. Descriptive statistics were used for continuous and categorical variables.
| Results|| |
A total of 143 patients met the inclusion criteria. The mean age was 52.25 (range 23–86 years) and 85 patients were men (59.44%). Descriptive statistics of demographics, clinical presentation, and indications for central venography are shown in [Table 1].
|Table 1: Demographics, clinical presentation, and indications for central venography|
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One hundred and thirty-nine of 143 (97.2%) patients were on dialysis and had a history of previous ipsilateral and/or contralateral central vein catheterization. However, only 18 patients (12.58%) had symptoms suggestive of central vein stenosis (swelling and/or pain) in the ipsilateral and/or contralateral side. Twenty-two patients (15.38%) had documented central line infection. In 64 patients (44.75%), additional indication for central venography was being a precious fistula or last access option.
Bilateral central venogram was performed in 112 patients, and in the remaining 31 patients, only ipsilateral venogram was performed. Abnormal findings were noted in 52 ipsilateral images (36.36%) and 46 contralateral images (41.07%, n = 112). Individual breakdown of the abnormalities is shown in [Table 2]. Based on the central venogram findings, the preoperative plan was changed to either contralateral AVF (16, 11.18%) to Permcath (6, 4.19%) or to lower limb vascular access (2, 1.39%) in a total of 24 patients (16.78%) [Table 3].
| Discussion|| |
Conformation of patency of central veins is essential before creating a native or graft arteriovenous fistula in at risk individuals. In this study, involving a selected group of patients, we found a prevalence of 36.36% (n = 143) and 41.07% (n = 112) in the ipsilateral and contralateral side of proposed surgery, respectively. To the best of our knowledge, this is the first published study from the Indian subcontinent showing the importance of central venography before planning vascular access surgery who are already on dialysis [Figure 2],[Figure 3],[Figure 4].
The results were similar to other studies which showed a high incidence of central vein stenosis ranging from 25% to 40%.
In other studies, the prevalence of central vein stenosis has been shown to be low ranging from 8.79% to 13%.,, The incidence was 13% in patients with a history of tunneled central lines. Majority of these patients were asymptomatic, and abnormalities were found incidentally during routine venography.
In a multicentric observational study on patients with central vein catheters, an overall prevalence of 8.79% of central vein stenosis has been noted by Wang et al. Subgroup analysis showed that the incidence of central vein stenosis was 15.28% with tunneled hemodialysis catheters and 3.86% with nontunneled catheters. However, the results of this study need to be interpreted carefully as only patients with signs and symptoms of central vein stenosis were investigated.
The incidence of central vein stenosis associated with central vein catheterization is high when the subclavian vein is used. As shown angiographically by Schillinger et al., the incidence of central vein stenosis was four times higher in patients who had subclavinan vein catheterization compared to internal jugular access.
In practice, as shown by MacRae et al. despite minimal usage of Subclavian Vein (SCV) for catheterization, the incidence of central vein stenosis associated with a previous history of catheterization and access problems can be as high as 41%.
Some studies have shown that central vein stenosis can occur even without a history of central vein catheterization. MacRae et al. showed that 13.6% did not have a history of an indwelling catheter but developed central vein stenosis. This is thought to be due to the direct endothelial injury caused by high blood flow rates through the fistulas.
There are several limitations with our study that limit the generalizability of the results. It is a single center, retrospective study, and the majority of the participants were on dialysis for more than 6 months at the time of presentation. A multicenter prospective study with a larger population group must be done to obtain a much better picture and strengthen the central venogram recommendations.
| Conclusions|| |
This study highlights that central vein stenosis/occlusion can exist in renal dialysis patients even without obvious clinical signs and symptoms. Routine use of diagnostic central venogram in such high-risk patients can identify central vein problems preoperatively and prevent postoperative complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tatapudi VS, Spinowitz N, Goldfarb DS. Symptomatic central venous stenosis in a hemodialysis patient leading to loss of arteriovenous access: A case report and literature review. Nephron Extra 2014;4:50-4.
Krishna VN, Eason JB, Allon M. Central venous occlusion in the hemodialysis patient. Am J Kidney Dis 2016;68:803-7.
Agarwal AK. Central vein stenosis. Am J Kidney Dis 2013;61:1001-15.
Osman OO, El-Magzoub AR, Elamin S. Prevalence and risk factors of central venous stenosis among prevalent hemodialysis patients, a single center experience. Arab J Nephrol Transplant 2014;7:45-7.
Gadallah MF, el-Shahawy MA, Campese VM. Unilateral breast enlargement secondary to hemodialysis arteriovenous fistula and subclavian vein occlusion. Nephron 1993;63:351-3.
Tedla FM, Clerger G, Distant D, Salifu M. Prevalence of central vein stenosis in patients referred for vein mapping. Clin J Am Soc Nephrol 2018;13:1063-8.
Hyland K, Cohen RM, Kwak A, Shlansky-Goldberg RD, Soulen MC, Patel AA, et al.
Preoperative mapping venography in patients who require hemodialysis access: Imaging findings and contribution to management. J Vasc Interv Radiol 2008;19:1027-33.
Wang K, Wang P, Liang X, Lu X, Liu Z. Epidemiology of haemodialysis catheter complications: A survey of 865 dialysis patients from 14 haemodialysis centres in Henan province in China. BMJ Open 2015;5:e007136.
Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterisation vein stenosis in haemodialysis: Comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant 1991;6:722-4.
MacRae JM, Ahmed A, Johnson N, Levin A, Kiaii M. Central vein stenosis: A common problem in patients on hemodialysis. ASAIO J 2005;51:77-81.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]