Long-term results and patient survival after first rib resection and endovascular treatment in hemodialysis patients with subclavian vein stenosis at the thoracic outlet.

OBJECTIVE: Hemodialysis patients with upper extremity vascular access and subclavian vein stenosis at the thoracic outlet can present with significant arm edema and threatened dialysis access that is frequently refractory to endovascular therapy without bone decompression. We have presented our long-term results of first rib resection, followed by endovascular therapy. METHODS: We performed a retrospective review of 15 consecutive hemodialysis patients with subclavian vein stenosis treated with first rib resection and endovascular therapy from 2013 to January 2021. The diagnosis was confirmed by ultrasound and venography. Bone decompression was performed with transaxillary or infraclavicular rib resection. RESULTS: During the study period, we treated 1440 unique dialysis patients. Of these 1440 patients, 346 had undergone subclavian vein angioplasty. Of the 346 patients, 15 had undergone first rib resection and were the subject of the present report. Of the 15 patients, 10 were women and 5 were men. Their mean age was 56.4 years (range, 30-82 years). The most commonly associated medical conditions were hypertension and diabetes. The mean previous hemodialysis duration was 5.4 years (range, 1-13 years). Fourteen patients had preexisting functioning access and severe arm edema. Nine patients (60%) with subclavian vein occlusion had undergone vein recanalization before the bone decompression procedure. Of the 15 patients, 5 had undergone transaxillary and 10 had undergone infraclavicular first rib resection. In addition, nine patients had undergone simultaneous vein stenting, six had undergone vein stenting within 4 weeks, and one had undergone stenting at 13 months. A stent-graft was used in eight patients and a bare metal stent was used in seven. All preexisting dialysis access sites were used the day after the procedure. The average postoperative stay was 2.6 days (range, 1-8 days). No complications developed. The average follow-up was 35.13 months (range, 4-86 months). The freedom from any subsequent intervention was 50% at 10.5 months. The average number of endovascular procedures per patient during follow-up was 4.6. Ten patients had required access surgery during follow-up. Secondary patency was 100%. The median patient survival was 69.3 months. CONCLUSIONS: Symptomatic hemodialysis patients with threatened vascular access caused by subclavian vein stenosis at the thoracic outlet were safely and successfully treated with first rib resection, followed by endovascular techniques. The procedure resulted in no morbidity and preserved dialysis access function in all patients during follow-up. Our experience has confirmed that excellent secondary patency and long-term clinical success can be obtained with regular follow-up, although with multiple secondary interventions. The median survival of 69 months after the procedure suggests it is worthwhile to expend this effort to maintain the hemodialysis access function of these patients.

Long Term Results of Bypass Graft to the Right Atrium in the Management of Superior Vena Cava Syndrome in Dialysis Patients.

BACKGROUND: Superior vena cava (SVC) occlusion in dialysis patients is a serious complication that can cause SVC syndrome and vascular access dysfunction. While endovascular therapy has advanced to become the first line of treatment, open surgical treatment may still be needed occasionally. However, no long term outcome data has been previously reported. METHODS: We performed a retrospective review of 5 dialysis patients treated with bypass graft to the right atrium from 2012 to 2014. Four patients had severe dysfunction of their upper arm dialysis access as well as superior vena cava syndrome, and one patient with a femoral tunneled dialysis catheter (TDC) had SVC occlusion. None of the patients were candidates for lower extremity access creation or peritoneal dialysis (PD). Three patients underwent a left brachiocephalic-right atrial bypass and 2 underwent a bypass from the cephalic fistula to the right atrium. RESULTS: All procedures were technically successful and maintained function of the arteriovenous fistulas or allowed creation of a new upper extremity dialysis graft. One-year secondary patency rate of the bypass was 100%. Longer follow up revealed that one patient died of leg sepsis and another one of a stroke within 14 months after the procedure. Another patient did well for 16 months when recurrent graft thrombosis occurred; and ultimately the graft failed after 31 months despite multiple interventions. Two patients maintained bypass graft patency during a follow up of 78 months; however, they underwent multiple endovascular interventions (23) and open vascular access procedures (4) to maintain hemodialysis function. CONCLUSION: Bypass grafts to the right atrium in dialysis patients with SVC occlusion are successful in maintaining function of already existing vascular access or new ones. Long term secondary patency can be achieved but requires strict follow up and a proactive endovascular strategy to treat lesions in the access and or the bypass graft.

Management of Superior Vena Cava Occlusion Causing Bleeding "Downhill" Esophageal Varices.

The health care system in Peru treats 15,000 dialysis patients annually. Approximately 45% of patients receive therapy using catheters. The incidence of catheter-induced superior vena cava (SVC) occlusion is increasing along with its associated significant morbidity and vascular access dysfunction. One of the unusual manifestations of this complication is bleeding "downhill" esophageal varices caused by reversal of blood flow through esophageal veins around the obstruction to the right atrium. Herein is presented the case of an 18-year-old woman on hemodialysis complicated by SVC occlusion and bleeding esophageal varices who underwent successful endovascular recanalization of the SVC. Bleeding from "downhill" esophageal varices should be considered in the differential diagnosis of dialysis patients exposed to central venous catheters. Aggressive endovascular treatment of SVC occlusion is recommended to preserve upper extremity access function and prevent bleeding from this complication.

Endovascular treatment of type 3 and 4 thoracic central vein obstruction in hemodialysis patients.

OBJECTIVE: Thoracic central vein (TCV) obstruction (TCVO) in the presence of upper extremity (UE) hemodialysis access can present as superior vena cava syndrome (SVCS) and cause vascular access dysfunction and failure. We report the techniques and results of endorevascularization of TCVO in hemodialysis patients, which allowed for long-term functioning vascular access in the UE. METHODS: From June 2009 to February 2020, 45 hemodialysis patients underwent TCV endorevascularization. The indications for surgery were TCVO or SVCS that threatened the function of a preexisting upper arm access or contraindicated placement of a new upper arm access. Conventional endovascular techniques were used when feasible. Patients with unfavorable anatomy were treated using a transseptal needle to cross difficult intrathoracic stenosis and occlusions or to facilitate an inside-out central venous access technique. The reestablishment of venous outflow was accomplished with angioplasty, stenting, and/or placement of HeRO conduits. Successful revascularization was followed by hemodialysis access revision or a new UE access placement. We recorded the risk factors and procedural outcomes, patency rates, complications, and mortality. RESULTS: The mean age was 53 ± 16.3 years, and 51% were women. The most common risk factors were diabetes mellitus (64.2%) and hypertension (56%). Twenty-five patients (55.5%) had symptoms of SVCS. These symptoms resolved after the TCV procedure in all cases. Crossing of the TCV lesion was successful using a conventional catheter and wire in 26 cases (57.8%) and transseptal needle in 17 cases (37.8%), including 12 using an inside-out central venous access technique. Treatment of the TCV lesion included a HeRO conduit in 20 cases (44.4%), stenting in 17 (37.7%), and transluminal balloon angioplasty alone in 7 (15.5%). Other veins were treated in 33 cases (73.3%). The overall technical success rate was 95.5%. Two intraoperative complications occurred, including one case of severe hypotension and one of fatal cardiac tamponade. Of the 16 patients with preexisting UE access, its function was preserved in all 16 (100%). In 24 of 27 patients (85.7%), new arm access was successfully created after the TCV procedure. The overall clinical success rate was 88.9%. The average follow-up was 663.4 days (median, 507 days; range, 0-2679 days). During follow-up, 26 patients had undergone 90 procedures to maintain access function, 21 had undergone repeat endovascular interventions, and 17 had undergone open procedures. Eight patients (17.8%) had developed infection, five involving HeRO conduits that required excision with loss of access. During the follow-up period, 14 patients (31%) had died of unrelated causes, and 34 patients (75.5%) maintained functional access. CONCLUSIONS: The results of the present study have shown that endorevascularization of TCVO reconstruction is effective in maintaining function or allowing the creation of UE hemodialysis access, with acceptable complication rates.

Novel Reconstruction of Complex Central Venous Occlusion Using Supraclavicular Stent Graft in Hemodialysis Patients.

BACKGROUND: Subclavian vein and brachiocephalic vein occlusions are challenging problems in dialysis patients with ipsilateral upper extremity (UE) vascular access or in need of one. HeRO grafts (Hemodialysis Reliable Outflow, Merit Medical Systems, Inc, South Jordan, UT) have been used to manage such occlusions but patients with chronic hypotension treated with HeRO graft may have threatened patency. We describe an alternative technique using a supraclavicular stent graft to reconstruct the venous outflow, evaluate outcomes of this procedure, and discuss its role in complex hemodialysis patients. METHODS: From January 2019 to January 2020, we performed open surgical and endovascular dialysis access procedures in 297 patients. Eight patients (2.7%) with failing or failed access and subclavian and or brachiocephalic vein occlusion were treated with supraclavicular stent graft placement. Mean age was 52 years, ranging from 32 to 70. Five patients had failed access and were dialyzed using catheters (two femoral). Three patients with failing fistulas had severe arm edema. Two patients had recurrent HeRO graft thrombosis. We performed a retrospective review of these 8 patients and evaluated access patency and complications. RESULTS: Technical success and access function were 100% in all patients. One patient developed ischemic neuropathy and underwent proximalization of the arterial inflow with improvement. Already-existing fistulas were used for dialysis the day after the procedure and new grafts within 2-4 weeks. Arm edema resolved within one week after the procedure. Median follow-up was 254.5 days, range 24-408 days, with primary patency rate of 87.5% and secondary patency rate of 100%. Only one patient has required reintervention. Postoperative evaluation with ultrasound has revealed patent stent graft in the area of the subcutaneous cervical tunnel over the clavicle. CONCLUSIONS: Supraclavicular stent graft placement to a central vein can be used successfully to reconstruct venous outflow in hemodialysis patients with complex central vein occlusions. A supraclavicular extra-anatomic path can be used safely and effectively to place new UE vascular access or salvage threatened access in this challenging patient population.

Safety and Efficacy of Arterial Closure Devices in an Office-Based Angiosuite.

INTRODUCTION: We aimed to compare the safety and efficacy of 5 arterial closure devices in an outpatient endovascular surgery center. METHODS: We retrospectively reviewed all cases using femoral arterial access performed between January 2012 and December 2013. Five different arterial closure devices (AngioSeal, Perclose, StarClose, ExoSeal, and Mynx) were used by 7 endovascular surgeons. All femoral arteries were accessed with 6F sheaths under ultrasound guidance. All patients received systemic anticoagulation with sodium heparin (70 IU/kg). Sheath-shot angiograms of all arterial punctures were taken before deploying closure devices. Device failure was defined as any partial or complete failure requiring additional closure assistance. Minor complication was defined as any event that occurred because of incomplete hemostasis but did not result in hospitalization, including hematoma, hypotension, bleeding, arterial dissection, or extended recovery. Major complication was defined as any event that occurred because of incomplete hemostasis requiring inpatient management. Any device failure was identified per device and per surgeon. Device safety, efficacy, and relationships between other variables were analyzed using a binomial logistic regression. Results with P values < 0.05 were considered to be statistically significant. RESULTS: During the study period, there were a total of 3142 endovascular procedures, including 1976 arterial cases (62.9%). Out of 1898 femoral artery punctures, closure devices were used in 1810 (95.4%), which forms the basis of this report. Device failure occurred in 151 cases (8.34%), and minor complications occurred in 53 cases (2.93%). There were 11 hospitalizations (0.61%). AngioSeal had both the lowest device failure rate (3.5%) and minor complication rate (1.3%). Our data showed a significant difference between the respective arterial closure devices for device failure rate (P = 0.007) and minor complication rate (P = 0.049), but not for major complication rate (P = 0.199). No significant difference was observed between surgeons for device failure (P = 0.798), minor complication (P = 0.218), or major complication rate (P = 0.899). CONCLUSIONS: With the lowest device failure and minor complication rate, AngioSeal is a consistently well-performing arterial closure device in the office surgical suite setting.

New Vein Compression Entities in Patients with Unexplained Leg Swelling.

BACKGROUND: This retrospective study identifies often overlooked anatomical sites for nonthrombotic venous outflow obstruction (NTVO) in patients with unexplained lower extremity edema and pain. METHODS: We reviewed the charts of 75 consecutive patients experiencing symptoms of unexplained lower extremity edema with pain that were unexplained by ultrasound, computed tomography angiography (CTA), and magnetic resonance imaging (MRI), who subsequently underwent venography in an outpatient medical office from 2010 to 2014. We categorized venograms based on the presence or absence of NTVO lesions and calculated prevalence of each at specific sites. The patients with NTVO lesions showing >50% stenosis on venography were then treated with angioplasty and/or stenting. After intervention, we documented subjective levels of pain and edema. RESULTS: Of the 75 venograms reviewed, physicians classified 52 as normal and 23 as showing evidence of compression, including 9 with May-Thurner syndrome and 14 with anatomical compressions at previously underreported sites. These 14 compression sites occurred at the following: iliofemoral vein at the inguinal ligament region (n = 7, 50%), external iliac vein at the iliac artery bifurcation (n = 1, 7.1%), both inguinal ligament region and iliac artery bifurcation (n = 4, 28.6%), and popliteal vein at the popliteal fossa (n = 2, 14.3%). Nine of the 14 patients (64.3%) reported total or near total resolution of lower extremity pain and edema at follow-up between 1 and 7 months (mean = 5.3 ± 2 months, median = 6 months) after balloon angioplasty and/or stent. Five with failed primary interventions underwent subsequent stenting and/or angioplasty and reported total or near total resolution of pain and clinical resolution of edema. CONCLUSIONS: This study provides evidence to broaden the disease profile of venous compression syndromes to other sites such as the hypogastric artery, inguinal ligament, and popliteal fossa. The results support previous research that suggests increased incidence of NTVO exists among patients with unexplained lower extremity edema and pain. In an effort to encourage further exploration, we developed a diagnostic algorithm to support a critical and systematic review of patients with lower extremity edema and pain that may go unexplained using traditional diagnostic measures, including ultrasound, CTA, and MRI alone.

Radial artery access for peripheral endovascular procedures.

OBJECTIVE: The radial artery is often used for coronary angiography, with a demonstrated decrease in local complications and an increase in postoperative mobility of the patient. Data on radial artery access for peripheral endovascular procedures, however, are limited. We describe our experience with radial artery access for diagnostic and endovascular interventions. METHODS: Between February 2012 and March 2015, there were 95 endovascular procedures performed using radial artery access in 80 unique patients. Demographic and clinical data were recorded. Perioperative, postoperative, and 30-day follow-up data were evaluated retrospectively for major and minor complications. Major adverse events included any immediate hospitalization admission, stroke, hand amputation, bleeding requiring transfusion, hematoma requiring surgery, and death. Minor complications included superficial bleeding and hematoma. RESULTS: The patients (52.6% male, 47.4% female) had a mean age of 72.1 ± 9.4 years. Radial artery access was used for diagnostic purposes in 15.8% of all procedures and for therapeutic intervention, including angioplasty and stenting, in 84.2%. The radial artery was the only access point in 80% of patients and was accessed in conjunction with other sites in 20%. Percutaneous access was achieved in 100% of patients with a 100% technical success rate. Hemostasis after catheterization was achieved by manual compression (22.1%) and TR band (Terumo Medical, Tokyo, Japan; 77.9%). Major adverse events occurred in three cases (3.2%) and were unrelated to radial artery access. Radial artery access site-related complications occurred in three cases (3.2%), all of which were minor hematomas that required no treatment. The risk of radial artery complication was not associated with procedure type, vessels treated, or use of heparin. The incidence of stroke, hand ischemia, and upper extremity limb or finger loss was 0%. CONCLUSIONS: Radial artery access for peripheral endovascular procedures appears to be safe and effective and should be considered more often. Complication rates are lower than those reported for femoral artery access.

Treatment outcomes and lessons learned from 5134 cases of outpatient office-based endovascular procedures in a vascular surgical practice.

Introduction The office-based endovascular facility has increased in number recently due in part to expedient patient experience. This study analyzed treatment outcomes of procedures performed in our office-based endovascular suite. Methods Treatment outcomes of 5134 consecutive procedures performed in our office-based endovascular suites from 2006 to 2013 were analyzed. Five sequential groups (group I-V) of 1000 consecutive interventions were compared with regard to technical success and treatment outcomes. Results Our patients included 2856 (56%) females and 2267 (44%) males. Procedures performed included diagnostic arteriogram, arterial interventions, venous interventions, dialysis access interventions, and venous catheter management, which were 1024 (19.9%), 1568 (30.6%), and 3073 (60.0%), 621(12.1%), and 354 (6.9%), respectively. The complication rates for group I, II, III, IV, and V were 3%, 1.5%, 1%, 1.1%, and 0.7%, respectively. The complication rate was higher in group I when compared to each of the remaining four groups ( p < 0.05). Nine patients (0.18%) died within the 30-day period following their procedures, and none were procedure related. Conclusions Endovascular procedure can be performed safely in an office-based facility with excellent outcomes. Lessons learned in establishing office-based endovascular suites with efforts to reduce procedural complications and optimize quality patient care are discussed.

Thoracic aorta aneurysm repair using the right axillary approach.

We present a 66-year-old man with a 5.7-cm saccular descending thoracic aortic aneurysm and a smaller 4.6-cm aneurysm just proximal to the celiac artery. The patient was judged to be too risky for open surgical repair because of poor anatomy and health. Previous stenting of the iliac arteries for a kinked aortoiliac open graft precluded conventional endovascular aneurysm repair. The descending thoracic aorta was successfully repaired using endovascular methods with a standard Talent (Medtronic, Los Angeles, Calif) thoracic proximal main stent graft, which was reverse-loaded onto the delivery device and delivered antegrade through the right axillary artery.

Intravascular lead extraction using the excimer laser: pitfalls and tips for success.

Removal of retained pacemaker and defibrillator leads is often indicated in the face of infection, venous obstruction, or lead malfunction with the need to upgrade to a newer lead. While simple traction is often successful in newly placed or infected leads, chronic leads can be problematic in their removal. The laser extraction sheath offers a method for removal by "cutting" through scar tissue. This device can be potentially hazardous, so the laser lead extraction procedures should be performed in a properly equipped operating room for immediate cardiothoracic surgical intervention should massive bleeding occur. This article outlines a few suggestions for avoiding severe complications with this useful procedure.

How I do it: cervical access for carotid artery stenting.

Atypical aortic arch anatomy, vessel tortuosity, and extensive atherosclerotic disease in the aortic arch and great vessels represent significant risks for embolization during angioplasty and stenting of carotid occlusive lesions. The technique of cervical access to the proximal common carotid artery is demonstrated as a safer means for dealing with these problems. Combining endovascular and open surgical techniques can simplify and help ensure the safety of carotid stent procedures.