| Abstract|| |
Central venous stenosis is usually due to previous catheter insertion in the subclavian vein or internal jugular vein. These patients usually present with swelling of the arm bearing the arterio-venous fistula and adequate hemodialysis is not feasible. Endovascular treatment includes balloon angioplasty and stenting, but there is early recurrence of stenosis. Balloon angioplasty is the first treatment of choice. Stent may be used if there is elastic recoil after angioplasty or there is recurrence of stenosis within three months after angioplasty. Endovascular irradiation and stent graft do not prolong the patency. The results of newer technique, like drug eluting stent and cutting balloon, have to be evaluated.
Keywords: Dialysis, Central vein, Stenosis, Stents and prosthesis.
|How to cite this article:|
Kwok PC. Endovascular Treatment for Central Venous Stenosis due to Central Vein Catheterization for Hemodialysis. Saudi J Kidney Dis Transpl 2004;15:338-45
|How to cite this URL:|
Kwok PC. Endovascular Treatment for Central Venous Stenosis due to Central Vein Catheterization for Hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2020 Sep 19];15:338-45. Available from: http://www.sjkdt.org/text.asp?2004/15/3/338/33707
| Introduction|| |
The term "central venous stenosis" (CVS) usually refers to a significant stenosis in a big intrathoracic vein, including the subclavian vein, the brachiocephalic vein and the superior vena cava. Stenosis is considered significant if it causes flow disturbance or obstruction to forward flow, this usually occurs if the diameter of the stenotic portion is less than 50% of the adjacent normal portion. The effect of the stenosis also depends on the flow rate and CVS may be silent until an arteriovenous fistula (AVF) or graft is created in the ipsilateral arm or forearm for hemodialysis, it then becomes a major problem for the patient. These patients usually present with increased venous pressure during hemodialysis; in more severe case, there is swelling of the arm bearing the AVF, and finally the AVF or graft may be thrombosed. Hemodialysis through the same arm is no more feasible.
CVS may be due to a variety of causes, previous subclavian vein catheter placement for hemodialysis plays the most important role. ,,,, Previously, it was believed that internal jugular venous catheter placement would rarely cause CVS,  but this was disproved by several studies, ,, though the incidence was less. Other procedures causing possible central vein thrombosis can also cause CVS; this includes cardiac pacing and central venous line insertion. CVS has also been reported in patients without any previous central venous catheter placement or other procedures causing thrombosis.  The incidence of unsuspected CVS in patients with functioning grafts was reported as 29%. 
CVS is important to patients on chronic hemodialysis. First, a swollen arm is very uncomfortable and disturbing for the patient, the edematous skin is easily injured and wound healing is a problem. The swollen skin and subcutaneous soft tissue also make venepuncture for hemodialysis difficult. The venous pressure is high and it is difficult to maintain adequate hemodialysis. The worst of all is that stenosis is usually near the final common pathway; the amount of collaterals formed around the mediastinum and chest wall is usually insufficient to maintain adequate dialysis or to let the arm swelling subside. In the period when endovascular therapy for vascular diseases was not popular, the patient used to be put on anticoagulant, hoping that enough collaterals would form with time, and the patient might still use the ipsilateral limb for hemodialysis. The AVF or graft has to be ligated, and another AVF or graft is fashioned in the opposite limb, hoping that there are good peripheral and central veins in it. After the AVF is ligated, the collaterals are usually enough for venous drainage from an upper limb and the swelling will subside readily. The other option is the surgical creation of a nonanatomical route to bypass the stricture. , The detailed description of the surgical operation is outside the scope of this paper. Suffice to say, this is a major procedure, which may involve thoracotomy. Currently, the endovascular treatment for vascular diseases is widely available; hence, thoracotomy for creation of such bypass is rarely performed. 
| Endovascular Treatment of CVS|| |
The two most important endovascular means for treatment of CVS are balloon angioplasty and endovascular stenting. Balloon angioplasty should always be the first treatment of choice. It can be repeated if there is recurrent stenosis. Metallic stent is used only when there is immediate elastic recoil after angioplasty or there is rapid recurrence of stenosis.  The National Kidney Foundation suggests the use of metallic stent for CVS if there is recurrence of stenosis within three months. 
The access point may be the basilic or brachial vein in the arm, the internal jugular vein or the femoral vein. The author prefers the basilic vein or brachial vein in the arm, they are bigger than veins in the forearm, the course is straight and the direction of catheter or guidewire insertion is the same as that of blood flow, the venous valves will not obstruct the movement of the equipment, which may occur when the femoral route is chosen, and retrograde manipulation of catheter or guidewire is necessary. In the arm, the cephalic vein should be avoided, since it passes through the clavipectoral fascia and this point may prevent forward movement of a big balloon catheter or stent. If the CVS is not a complete occlusion, transfemoral procedure may be attempted, since the radiologist usually gets used to work from the femoral route and there is more working space on the fluoroscopic couch as compared with working through the upper limb or neck. The transjugular route is good for stenosis involving only the brachiocephalic vein and superior vena cava, but the working space is usually quite limited.
A vascular sheath is inserted in the access vein; the size of the sheath depends on the anticipated size of the balloon catheter or stent used. It may vary from 7 Fr to 10 Fr. With the advance of endovascular therapy, one rarely has to go beyond 10 Fr. A pre-procedural computerized tomography (CT) scan is useful to judge the size and length of the central vein, especially when this set of CT is taken with multidetector CT. The latest multidetector CT can acquire real isotropic data and create useful coronal reformation images. Besides the diameter of the vein, one can also diagnose the site, the extent and length of occlusion. If a pre-procedural CT is not available, one will have to perform a set of venogram first. The venous size is measured with aid of a marker tape put in front of the chest. Using an undercouch X-ray tube, the diameter of the vein will be overestimated, but this will not affect the choice of the angioplasty balloon or stent, since one will usually overdilate or choose a larger stent by 10-20%. The central veins are immediately under the sternum, the magnification factor is thus usually small. Another option is to calibrate the venous diameter with the diameter of the diagnostic catheter. However, since the magnitude of the catheter and the vein differ significantly, one will also magnify the error introduced during the electronic calibration.
The patient is put on systemic anticoagulation with intravenous heparin and the stricture is passed with a guidewire; we usually use a hydrophilic guidewire for this purpose. The tip of the guidewire is then steered through the right atrium and placed in the inferior vena cava. This step is important if one approaches from the upper limb or neck; a guidewire in the right ventricle will easily induce ventricular arrhythmia. A stiffer guidewire is then exchanged using a 4 or 5 Fr angiographic catheter and the stricture is dilated with a balloon catheter over the stiff guidewire. In the hemodialysis patient, the vein usually measures more than 10 mm and it is not uncommon to see a vein bigger than 20 mm. We usually dilate the vein to the diameter of the subclavian or brachiocephalic vein immediately before the stenosis. If the normal venous portion measures more than 20 mm, one has to decide whether a balloon bigger than 20 mm will be used; in such situation, an access sheath bigger than 10 Fr will be necessary.
The effect of angioplasty is assessed with venogram after withdrawal of the balloon catheter; the guidewire should be kept in situ in case another angioplasty or stent was necessary. The result of angioplasty may be considered unsatisfactory if the residual stenosis is more than 50%. If the stricture is less than 50%, we may choose to observe and use it for continual hemodialysis. We are more ready to accept residual stricture after angioplasty in central vein as the next step will be stent insertion. Pull-back pressure measurement may be used to assist in decision making. There is no solid evidence for any pressure gradient that should be considered as acceptable. If the pressure gradient across a residual stricture is more than 10mmHg, repeated angioplasty may prolong the patency. 
Pharmaceutical thrombolysis or mechanical thrombectomy may be necessary if there is evidence of fresh clot formation distal to the CVS. Urokinase and tissue plasminogen activator are the two commonly used drugs. They have specific side effects, including major hemorrhage in the other parts of the body. Mechanical thrombectomy devices are mainly designed for removal of arterial clots in the iliac artery and femoropopliteal artery. It usually does not remove the clot completely in big veins and supplementary thrombolysis has to be used. If clot formation is detected, one should be careful not to dislodge a big clot into the pulmonary artery. It may cause a sudden increase in pulmonary arterial pressure and precipitate right heart failure.
Angioplasty will produce immediate improvement (residual stenosis les than 50%) in 70% of patients.  For those with residual stenosis of more than 50% or those with elastic recoil, one may consider the use of metallic stent according to the recommendation of the National Kidney Foundation  [Figure - 1],[Figure - 2],[Figure - 3],[Figure - 4],[Figure - 5].
There is no study to show a particular metallic stent being superior to the others. The general principle is to choose the shortest stent, which should be balanced against the risk of stent migration during and after deployment.  As the commonest cause of delayed stent occlusion is intimal hyperplasia developing inside a stent, a stricture inside a short stent can be corrected easily with endovascular methods, such as further angioplasty or another stent placement. The stent should not extend beyond the first rib, as there is a risk of stent fracture due to impingement by the adjacent muscles and bones. The stent should not extend into the right atrium; this may cause severe cardiac tamponade if there is perforation of the atrium.
The diameter of the stent should be 10 to 20% larger than the normal segment to prevent stent migration. One can choose a self expandable stent or a balloon expandable stent; the choice is probably of personal preference. However, if a Wallstent (Boston Scientific, Boston, MA, USA) is used, there is significant shortening during deployment and the operator should be familiar with its use. Delayed shortening of Wallstent weeks to months later has also been reported. 
One should note that when a stent is placed for stenosis in the medial end of the subclavian vein or in a short right brachiocephalic vein, the internal jugular vein may be bridged. This may prevent the future use of the patent internal jugular vein for placement of a permanent central catheter. Though a catheter may be placed across the stent mesh, it is more difficult, the patient and referring physician should be aware of this. 
After successful angioplasty or stenting, the heparinization is reversed with protamine sulphate and the sheath is removed. If a 7 Fr or smaller sheath is used, one can apply pressure for hemostasis. If a larger sheath is used, pressure alone may take a long time for hemostasis. The wound may be closed with purse string and the thread is removed a few hours to 24 hours later. One may also use the Woggle's technique for application of the purse string.  The sheath may also be kept in situ for immediate hemodialysis.
As there is high blood flow through the central vein, the risk of acute thrombosis is low and we do not routinely give warfarin for prevention of acute thrombosis. There is no evidence that warfarin can prevent late restenosis. One may give aspirin for thrombosis prophylaxis; 80 mg to 325mg daily dose of aspirin is usually enough.
| Results of Endovascular Treatment|| |
Unfortunately, the primary patency after angioplasty or stenting is low. Kovalik et al reported that in those who had angioplasty alone, 7% failed angioplasty, 70% had 50% or more improvement in the luminal diameter while 23% showed no improvement due to elastic lesions. Subsequently, 81% of those patients with a successful angioplasty restenose at an average of 7.6 months; 100% of those with elastic lesions occlude in an average of 2.9 months.  Glanz et al reported a one-year patency of 35% and two-year patency of 6%.  If a stent is used, the one-year primary patency ranges from 20% to 70% and the oneyear secondary patency ranges from 35% to 100%. ,,,,, In a prospective study comparing angioplasty versus stent placement in the treatment of CVS, the primary and secondary patency rates of angioplasty at 360 days were 12% and 100%; while the patency rates for stenting were 11% and 78%. There was no difference in the patency rates (p=0.54). 
The mechanism in restenosis after angioplasty or stenting is likely related to intimal hyperplasia. The action may be accelerated due to the high flow and turbulence. After angioplasty, the stenosis usually recurs at the same site. After stenting, the restenosis may be inside the stent, or at the venous segment just next to the stent; this may be due to the vascular injury caused by the balloon catheter, which is used to expand the vein before or after stenting.
| Other Endovascular Treatments|| |
Various means have been used to prevent the formation of intimal hyperplasia and hoping to increase the patency of the veins after intervention. Unfortunately, the results are disappointing. Endovascular irradiation has been used to suppress the intimal hyperplasia.  This idea was borrowed from endovascular irradiation of the coronary artery and peripheral arteries; both have shown significant prolongation of patency after endovascular irradiation. However, the patency was not prolonged after irradiation of the central veins. It may be due to the lack of centering catheter suitable for endovascular irradiation, or the response of the vein is different from that of arteries. The original stenosis is obviously suppressed and the recurrent stenosis seems to occur in new locations, mostly in the peripheral portion of the stent or in the adjacent non-stented venous segment; despite these areas are included in the irradiation field.  This may provide a direction for future research.
Stent grafts have also been used for this purpose. The result is also disappointing. Restenosis tends to occur in the peripheral portion of the stent graft, and the patency is not prolonged. Using polytetrafluoroethylene (PTFE) covered stent, the 360-day primary and secondary patency rates were 32% and 39%.  Using Dacron covered stents, the patency rates were 29% and 64%. 
Other potential endovascular treatments for central venous stenosis include the use of drug eluting stents and cutting balloon. Drug eluting stents have shown promising result in the coronary arteries and in early study of the peripheral arteries. , They suppress the formation of intimal hyperplasia, while it does not prevent the process of re-endothelialization. When compared with endovascular irradiation, the advantage of a drug eluting stent is its close proximity to the vessel wall, where the action of the drug is needed. However, it still does not prevent the formation of stenosis at the rim of the stent. If we look at the experience of irradiation and stent graft, there is a high chance that stenosis will recur.
If we refrain from using stent for recanalization, we may try to enhance the effect of balloon angioplasty with a cutting balloon. A cutting balloon has 4 blades embedded in the balloon, which is supposed to produce better result of angioplasty due to more predictable cut in the vessels and it is also useful for elastic and fibrotic strictures. The cutting balloon has been used in the angioplasty of strictures in the peripheral AVF and the prior treatment with a cutting balloon facilitates subsequent balloon dilatation at lower pressure.  However, the largest balloon available now is 8 mm and it is doubtful whether the manufacturer will make larger balloons for central veins due to the small market potentials.
| Conclusion|| |
Prevention is better than cure. To prevent central venous stenosis, the best way is to avoid subclavian venous puncture. Jugular catheter should also be used with care. Before the creation of an AVF in the upper limb, one may survey the peripheral and the central veins to avoid unnecessary complications.
| References|| |
|1.||Hernandez D, Diaz F, Rufino M, et al. Subclavian vascular access stenosis in dialysis patients: natural history and risk factors. J Am Soc Nephrol 1998;9:1507-10. |
|2.||Spinowitz BS, Galler M, Golden RA, et al. Subclavian vein stenosis as a complication of subclavian catheterization for hemodialysis. Arch Intern Med 1987;147:305-7. |
|3.||Schwab SJ, Quarles LD, Middleton JP, Cohan RH, Saeed M, Dennis VW. Hemodialysis-associated subclavian vein stenosis. Kidney Int 1988;33:1156-9. |
|4.||Barrett N, Spencer S, McIvor J, Brown EA. Subclavian stenosis: a major complication of subclavian dialysis catheters. Nephrol Dial Transplant 1988;3:423-5. |
|5.||Hernandez D, Diaz F, Suria S, et al. Subclavian catheter-related infection is a major risk factor for the late development of subclavian vein stenosis. Nephrol Dial Transplant 1993;8:227-30. |
|6.||Cimochowski GE, Worley E, Rutherford WE, Sartain J, Blondin J, Harter H. Superiority of the internal jugular over the subclavian access for temporary dialysis. Nephron 1990;54:154-61. |
|7.||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. |
|8.||Jassal SV, Pierratos A, Roscoe JM. Venous stenosis and thrombosis associated with the use of internal jugular vein catheters for hemodialysis. ASAIO J 1999;45:356-9. |
|9.||Jean G, Vanel T, Chazot C, Charra B, Terrat JC, Hurot JM. Prevalence of stenosis and thrombosis of central veins in hemodialysis after a tunneled jugular catheter. Nephrologie 2001;22:501-4. |
|10.||Morosetti M, Meloni C, Gandini R, et al. Late symptomatic venous stenosis in three hemodialysis patients without previous central venous catheters. Artif Organs 2000; 24:929-31. |
|11.||Lumsden AB, MacDonald MJ, Isiklar H, et al. Central venous stenosis in the hemodialysis patient: incidence and efficacy of endovascular treatment. Cardiovasc Surg 1997;5:504-9. |
|12.||Bhatia DS, Money SR, Ochsner JL, et al. Comparison of surgical bypass and percutaneous balloon dilatation with primary stent placement in the treatment of central venous obstruction in the dialysis patient: oneyear follow-up. Ann Vasc Surg 1996;10:452-5 |
|13.||El-Sabrout RA, Duncan JM. Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment option. J Vasc Surg 1999;29:472-8. |
|14.||NKF-K/DOQI Clinical Practice Guidelines for Vascular Access: Update 2000. Guideline 20 Treatment of Central Vein Stenosis. Available from URL: http://www.kidney.org/ professionals/kdoqi/guidelines_updates/doq iupva_v.html#20 |
|15.||Kovalik EC, Newman GE, Suhocki P, Knelson M, Schwab SJ. Correction of central venous stenoses: use of angioplasty and vascular Wallstents. Kidney Int 1994;45:1177-81. |
|16.||Funaki B, Kim R, Lorenz J, et al. Using pullback pressure measurements to identify venous stenoses persisting after successful angioplasty in failing hemodialysis grafts. AJR Am J Roentgenol 2002;178:1161-5. |
|17.||Verstandig AG, Bloom AI, Sasson T, Haviv YS, Rubinger D. Shortening and migration of Wallstents after stenting of central venous stenosis in hemodialysis patients. Cardiovasc Intervent Radiol 2003;26:58-64. |
|18.||Vesely TM, Hovsepian DM, Pilgram TK, Coyne DW, Shenoy S. Upper extremity central venous obstruction in hemodialysis patients: treatment with Wallstents. Radiology 1997;204:343-8. |
|19.||Turmel-Rodrigues L, Bourquelot P, Raynaud A, Sapoval M. Primary stent placement in hemodialysis-related central venous stenoses: the dangers of a potential "radiologic dictatorship". Radiology 2000;217:600-2. |
|20.||Simons ME, Rajan DK, Clark TW. The Woggle technique for suture closure of hemodialysis access catheterization sites. J Vasc Interv Radiol 2003;14:485-8. |
|21.||Glanz S, Gordon DH, Lipkowitz GS, Butt KM, Hong J, Sclafani SJ. Axillary and subclavian vein stenosis: percutaneous angioplasty. Radiology 1988;168:371-3. |
|22.||Maskova J, Komarkova J, Kivanek J, Danes J, Slavikova M. Endovascular treatment of central vein stenoses and/or occlusions in hemodialysis patients. Cardiovasc Intervent Radiol 2003;26:27-30. |
|23.||Mickley V, Gorich J, Rilinger N, Storck M, Abendroth D. Stenting of central venous stenoses in hemodialysis patients: long-term results. Kidney Int 1997;51:277-80. |
|24.||Vorwerk D, Guenther RW, Mann H, et al. Venous stenosis and occlusion in hemodialysis shunts: follow-up results of stent placement in 65 patients. Radiology 1995; 195:140-6. |
|25.||Gray RJ, Horton KM, Dolmatch BL, et al. Use of Wallstents for hemodialysis accessrelated venous stenoses and occlusions untreatable with balloon angioplasty. Radiology 1995;195:479-84 |
|26.||Haage P, Vorwerk D, Piroth W, Schuermann K, Guenther RW. Treatment of hemodialysisrelated central venous stenosis or occlusion: results of primary Wallstent placement and follow-up in 50 patients. Radiology 1999; 212:175-80. |
|27.||Quinn SF, Schuman ES, Demlow TA, et al. Percutaneous transluminal angioplasty versus endovascular stent placement in the treatment of venous stenoses in patients undergoing hemodialysis: intermediate results. J Vasc Interv Radiol 1995;6:851-5. |
|28.||Kwok PC, Wong KM, Ngan RK, et al. Prevention of recurrent central venous stenosis using endovascular irradiation following stent placement in hemodialysis patients. Cardiovasc Intervent Radiol 2001; 24:400-6. |
|29.||Quinn SF, Kim J, Sheley RC. Transluminally placed endovascular grafts for venous lesions in patients on hemodialysis. Cardiovasc Intervent Radiol 2003; 26:365-9. |
|30.||Farber A, Barbey MM, Grunert JH, Gmelin E. Access-related venous stenoses and occlusions: treatment with percutaneous transluminal angioplasty and Dacron-covered stents. Cardiovasc Intervent Radiol 1999; 22:214-8. |
|31.||Morice MC, Serruys PW, Sousa JE, et al. A randomized comparison of a sirolimuseluting stent with a standard stent for coronary revascularization. N Engl J Med 2002;346:1773-80. |
|32.||Duda SH, Pusich B, Richter G, et al. Sirolimus-eluting stents for the treatment of obstructive superficial femoral artery disease: six-month results. Circulation 2002;106:1505-9. |
|33.||Bittl JA, Feldman RL. Cutting balloon angioplasty for undilatable venous stenoses causing dialysis graft failure. Catheter Cardiovasc Interv 2003;58:524-6. |
Philip Chong-hei Kwok
Department of Radiology and Imaging, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon
Hong Kong S.A.R.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]