Subclavian vein angioplasty during arteriovenous fistula surgery: case report and literature review

Angioplastia de veia subclávia no intraoperatório de fístula arteriovenosa: relato de caso e revisão de literatura

CASE REPORT

Subclavian vein angioplasty during arteriovenous fistula surgery: case report and literature review

Angioplastia de veia subclávia no intraoperatório de fístula arteriovenosa: relato de caso e revisão de literatura

Marcus Vinícius Martins Cury^I; Marcelo Fernando Matielo^I; Ana Carolina Calixtro^II; Giuliano de Almeida Sandri^I; Marcos Roberto Godoy^I; Roberto Sacilotto^III

^IAssistant doctor of Vascular and Endovascular Surgery Service at the HSPE - São Paulo (SP) Brasil

^IIResident doctor of Vascular and Endovascular Surgery Service at the HSPE - São Paulo (SP) Brasil

^IIIHead of Vascular and Endovascular Surgery Service at the HSPE - São Paulo (SP) Brasil

^{Correspondence}

ABSTRACT

Patients with chronic kidney disease stage 5 are generally treated by hemodialysis, preferentially performed via an arteriovenous fistula (AVF). We report the case of a 58-year-old male patient with diabetes mellitus, hypertension and end-stage renal disease in whom hemodialysis was conducted via a long-term catheter. His medical record described numerous central venous cannulations and several AVF creations. The patient developed subclinical subclavian stenosis that required creation of a new vascular access route. The purpose of this case report is to describe treatment of subclavian vein stenosis during AVF creation.

Keywords: renal insufficiency, chronic; arteriovenous fistula; angioplasty.

RESUMO

Pacientes portadores de Insuficiência Renal Crônica (IRC) estágio V são geralmente tratados por hemodiálise (HD), preferencialmente por fístula arteriovenosa (FAV). Descrevemos um relato de caso de um paciente de 58 anos, masculino, portador de diabetes mellitus, hipertensão arterial sistêmica e IRC terminal. Seus antecedentes demonstram múltiplos acessos para implante de cateter de hemodiálise, assim como tentativas prévias de realização de FAV. Esse paciente desenvolveu estenose subclínica da veia subclávia, limitando a HD pelo membro superior. O propósito deste relato foi descrever o tratamento endovascular de estenose de veia subclávia, concomitante à realização de uma nova FAV.

Palavras-chave: insuficiência renal crônica; fístula arteriovenosa; angioplastia.

Introduction

Hemodialysis is the main treatment in end-stage renal disease (ESRD). When possible, this treatment should be administered via an arteriovenous fistula (AVF), which of fers the best vascular access¹. Compared with other options of kidney replacement therapy, this modality of treatment is associated with reduction in infection complications and less morbidity and mortality².

In the United States, approximately 300,000 patients are treated by hemodialysis, and vascular access is the leading cause of hospitalization³. In Brazil, approximately 80,000 patients use hemodialysis treatment⁴.

Nearly 40% of patients who have previously received a subclavian vein hemodialysis catheter develop stenoses⁵. Unless these lesions are corrected, creation of an upper extremity AVF is limited⁶. Endovascular treatment has a high initial technical success, but it is associated with low primary patency and high failure rate with its consequences (e.g. development of upper limb edema)^7,8.

The purpose of this case report was to describe subclavian vein angioplasty during AVF creation.

Case report

A 58-year-old patient with diabetes mellitus, hypertension and chronic kidney disease (stage 5) had been treated by hemodialysis via a long-term catheter inserted in the right femoral vein. His past medical history included many central venous cannulations (right internal jugular, left internal jugular, right subclavian, left subclavian, right femoral and left femoral veins). The patient had had a previous left femoral deep venous thrombosis (DVT), and creation of an upper extremity AVF was attempted three times (radiocephalic and brachiocephalic in the right arm, and brachiobasilic in the left arm) without success.

A color Doppler study performed to investigate the cervical and upper extremity veins revealed the absence of arm veins suitable for new surgery and detected signs of previous axillary vein thrombosis. Upper extremity phlebography performed prior to attempting to create a new AVF showed left axillary vein occlusion and stenosis of the proximal right subclavian vein.

Surgery was then performed, by right axillary vein and ipsilateral brachial artery dissection. A loop subcutaneous tunnel was created in the anterior arm and a terminal-lateral nonringed polytetrafluoroethylene (PTFE) 6.0 mm anastomosis was performed with the vein. The prosthesis was then punctured and a 10 F sheath was introduced (Figure 1). Intraoperative phlebography was obtained (Figure 2) and a hydrophilic 0.035" guide wire (Roadrunner^® 260 cm; Cook) was passed beyond the subclavian lesion to reach the inferior vena cava. The diameter of the vein was estimated as 12 mm; after infusion of 5000 UI of intravenous heparin, subclavian vein angioplasty was performed using a 14×40 mm vascular balloon (XXL^®; Boston Scientific) inflated to 10 atm for 3 minutes. Recoil was noted following a second angiography, and a self-expanding stent (16x40 mm Wallstent^®; Boston Scientific) was satisfactorily deployed, preserving the right internal jugular ostium (Figure 3).

The PTFE graft was passed through the tunnel, and brachial anastomosis was performed. Lastly, the sheath was removed and the prosthesis closed with Prolene sutures. A thrill was identified at the axillary vein, and evolution of AVF and the patient was satisfactory. Clopidogrel and Aspirin were initiated on the first day after surgery.

Color Doppler study surveillance performed four weeks after surgery showed AVF patency, signs of PTFE integration and a flow rate of 640 mL/minute. Hemodialysis via the AVF was satisfactorily initiated six weeks after surgery.

Discussion

Many guidelines recommend that kidney replacement treatment should preferably be performed by an autogenous AVF^3,5. Until 2002 in the United States, access was created using prosthesis in approximately 80% of cases for reasons of accessibility, early cannulation and thrombectomy treatment in cases of occlusion⁹. Cumulative patency, infection rate and survival analysis have shown better results with autogenous conduits; however, these findings were derived from low-evidence reports¹⁰.

Central venous stenoses are common in central vein cannulation, especially in subclavian vein hemodialysis catheters. Almost 50% of patients with these catheters have stenoses or occlusions¹¹, which are a major impediment to upper extremity access⁸. After obtaining arteriovenous access, central venous stenoses sometimes lead to swelling of the arm; after obtaining prosthetic vascular access, attempts to treat these lesions can result in an arm hematoma and related complications. We could find no previous reports regarding central venous angioplasty during AVF creation.

Central venous lesions are short and have fibrotic features¹². This condition makes endovascular treatment a favorable approach that has high initial technical success (approximately 90%)¹³. The 1-year primary patency rate for balloon angioplasty is approximately 30%, but the feasibility of performing repeat angioplasty makes this treatment a feasible option⁸. Treatment by primary stenting has been studied previously, but is not associated with an increase in primary patency, and thus it should be used selectively^8,14. Stent placement is recommended in situations of recoil or failure, which is identified when a symptomatic patient returns for treatment (e.g. development of arm swelling, unsuccessful hemodialysis)¹⁴. The primary assisted program may require multiple angioplasties to achieve a 1-year cumulative patency (CP) result of 70%^8,13,15.

Preservation of the ostium of the internal jugular vein is important during stent placement to ensure that the possibility of future central venous cannulation is retained. Similarly, preservation of the ostium is also beneficial in stenting of the contralateral innominate vein¹⁶.

Wallstent^® self-expanding stents are generally used in treatment of central venous stenosis^7,8,13-16; the use of Nitinol stents is also reported for this purpose¹⁷. Both types produced similar results regarding primary patency and freedom from symptoms, but, in the United States, Nitinol stent placement is an off-label procedure for central veins. Considerations in stent selection are that elgiloy alloy (Wallstent^®) has better resistance to external compression, but that Nitinol has greater radial strength and conforms better to the wall of the vein.

Recently, Haskal et al. conducted a multi center study, in which dysfunctional access were randomized to receive balloon angioplasty or stent graft (Bard Flair stent^®). At six months follow-up, stent graft group had better results of freedom from reintervention and patency (51x23%; p<0.001)¹⁸.

Creation of lower extremity arteriovenous access is an alternative treatment in patients with upper extremity vein outflow obstruction. Saphenous vein tight transposition has 1-year cumulative patency of 93%, but sometimes the use of this conduit is not possible because of previous usage or the presence of peripheral arterial disease. Otherwise, there is the possibility of prosthetic vascular access, which has a rate of complications from infection of 20%¹⁹.

Surveillance of arteriovenous hemodialysis access remains controversial²⁰. Some types of surveillance are potentially beneficial: in particular, measurement of volume flow rate can detect early dysfunction of vascular access, and detection should be encouraged as a method of increasing vascular patency. This approach is reported as a method of reducing costs, hospitalization, morbidity and mortality. A flow rate of less than 600 mL/minute or a 20% reduction in flow rate over 1 month are predictive signs of arteriovenous occlusion^5,21.

Conclusion

The present case report describes an alternative treatment of subclavian stenosis that was performed via the axillary vein. This approach enabled treatment without another vein puncture and with the advantage of performing the angioplasty under favorable conditions (absence of arm swelling and hematoma development after prosthesis puncture). In the present patient, previous deep venous thrombosis of the lower extremity limited access through the inferior vena cava. The present procedure was successful. Previous reports regarding angioplasty and stenting favor endovascular treatment.

Submitted on: 28.07.11.

Accepted on: 02.01.12.

Financial support: none.

Conflict of interest: nothing to declare.

Author's contributions

Conception and design: MVMC, ACOC

Analysis and interpretation: MRG, GAS

Data collection: ACOC, GAS

Writing the article: MVMC, MFM

Critical revision of the article: MRG, RS

Final approval of the article*: MVMC, MFM, ACOC, GAS, MRG, RS

Statistical analysis: N/A

Overall responsibility: MVMC, MFM

*All authors have read and approved the final version submitted to J Vasc Bras.<

Study carried out at Vascular Surgery Department at the Hospital do Servidor Público Estadual São Paulo (HSPE) - São Paulo (SP), Brasil.

• 1. Ravani P, Marcelli D, Malberti F. Vascular acess surgery managed by renal physicians: the choice of native arteriovenous fistulas for hemodialysis. Am J Kidney Dis. 2002;40(6):1264-76.
• 2. Centers for Medicare & Medicaid Services: 2004 Annual Report. End-Stage Renal Disease Clinical Performance Measures Project. Baltimore, MD, Department of Health and Human Services, Centers for Medicare & Medicaid Services, Center for Beneficiary Choices, 2004.
• 3. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access.Am J Kidney Dis. 2006;48(Suppl):1-322.
• 4. Tordoir J, Canaud B, Haage P, et al. European best practice guidelines on vascular access. Nephrol Dial Transplant 2007;22(Suppl 2):ii88-117.
• 5. Padberg Jr FT, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J Vasc Surg 2008;48(Suppl):S55-80
• 6. Kim YC, Won JY, Choi SY, et al.Percutaneous treatment of central venous stenosis in hemodialysis patients: long-term outcomes. Cardiovasc Intervent Radiol. 2009;32(2):271-8
• 7. Bakken AM, Protack CD, Saad WE, Lee DE, Waldman DL, Davies MG. Long-term outcomes of primary angioplasty and primary stenting of central venous stenosis in hemodialysis patients. J Vasc Surg. 2007;45(4):776-83.
• 8. Huber TS, Carter JW, Carter RL, Seeger JM. Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review. J Vasc Surg. 2003;38(5):1005-11.
• 9. Murad MH, Elamin MB, Sidawy AN, et al. Autogenous versus prosthetic vascular access for hemodialysis: a systematic review and meta-analysis. J Vasc Surg. 2008;48(5 Suppl):34-47.
• 10. Schwab SJ, Quarles LD, Middleton JP, Cohan RH, Saeed M, Dennis VW. Hemodialysis-associated subclavian vein stenosis. Kidney Int. 1988;33(6):1156-9.
• 11. Begin V, Ethier J, Dumont M, Leblanc M. Prospective evaluation of the intra-access flow of recently created native arteriovenous fistulae. Am J Kidney Dis. 2002;40(6):1277-82.
• 12. Nael K, Kee ST, Solomon H, Katz SG. Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients: a single institutional experience in 69 consecutive patients. J Vasc Interv Radiol. 2009;20(1):46-51.
• 13. Maya ID, Saddekni S, Allon M. Treatment of refractory central vein stenosis in hemodialysis patients with stents. Semin Dial. 2007;20(1):78-82.
• 14. Oderich GS, Treiman GS, Schneider P, Bhirangi K. Stent placement for treatment of central and peripheral venous obstruction: a long-term multi-institutional experience. J Vasc Surg. 2000;32(4):760-9.
• 15. Haage P, Vorwerk D, Piroth W, Schürmann K, Günther RW. Treatment of hemodialysis-related central venous stenosis or occlusion: results of primary Wallstent placement and follow-up in 50 patients. Radiology. 1999;212(1):175-80.
• 16. Rajan DK, Saluja JS. Use of nitinol stents following recanalization of central venous occlusions in hemodialysis patients. Cardiovasc Intervent Radiol. 2007;30(4):662-7.
• 17. Antoniou GA, Lazarides MK, Georgiadis GS, Sfyroeras GS, Nikolopoulos ES, Giannoukas AD. Lower-extremity arteriovenous access for haemodialysis: a systematic review. Eur J Vasc Endovasc Surg. 2009;38(3):365-72.
• 18. Haskal ZJ, Trerotola S, Dolmatch B, et al. Stent graft versus balloon angioplasty for failing dialysis-access grafts. N Engl J Med. 2010;362(6):494-503.
• 19. Casey ET, Murad MH, Rizvi AZ, et al. Surveillance of arteriovenous hemodialysis access: a systematic review and meta-analysis. J Vasc Surg. 2008;48(5 Suppl):S48-54.
• 20. Malik J, Slavikova M, Svobodova J, Tuka V. Regular ultrasonographic screening significantly prolongs patency of PTFE grafts. Kidney Int. 2005;67(4):1554-8.
• 21. Kim YO, Yang CW, Yoon SA, et al. Access blood flow as a predictor of early failures of native arteriovenous fistulas in hemodialysis patients. Am J Nephrol. 2001;21(3):221-5.

Publication Dates

• Publication in this collection
  17 July 2012
• Date of issue
  June 2012

History

• Received
  28 July 2011
• Accepted
  02 Jan 2012