Annals of Vascular Surgery
Volume 22, Issue 2 , Pages 203-209, March 2008

Surgical Bypass of Symptomatic Central Venous Obstruction for Arteriovenous Fistula Salvage in Hemodialysis Patients

  • Ahmed Suliman
    • ,
  • Joshua I. Greenberg
    • ,
  • Niren Angle

      Affiliations

    • Corresponding Author InformationCorrespondence to: Niren Angle, MD, RVT, FACS, Section of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, 200 West Arbor Drive, Mail Code 8403, San Diego, CA 92103, USA

Section of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, School of Medicine, San Diego, CA

Article Outline

Venous hypertension due to proximal central venous outflow obstruction coexisting with a functioning arteriovenous fistula in the ipsilateral arm presents with a complex management problem in hemodialysis patients. Ligation of the arteriovenous communication is the simplest procedure to relieve symptoms; however, this sacrifices the patient's hemodialysis access, which may be the only available access in that patient. Surgical bypass of the occlusion is a potential option as it obviates the symptoms of venous hypertension while preserving dialysis access. Our objective was to evaluate our experience and outcome with dialysis patients undergoing surgical bypass for symptomatic central venous obstruction and dialysis access salvage. There were three hemodialysis patients with severe venous hypertension secondary to subclavian vein obstruction who had functioning ipsilateral arteriovenous fistulae. All underwent cephalic vein (n = 2) or axillary vein (n = 1) to internal jugular vein bypass of the obstructed subclavian segment via an 8-mm polytetrafluoroethylene bridge graft. All patients had unsuccessful percutaneous transluminal angioplasty (PTA) attempts prior to surgical bypass. In two patients, a wire could not be passed through the occlusion; in the third, PTA was only transiently successful despite four repeated procedures. All patients had complete resolution of symptoms without operative mortality. The bypass grafts remained patent, allowing the arteriovenous fistulae to provide functional access for the entire duration of follow-up after surgery (3-8 months). Surgical bypass of a central vein obstruction relieves the symptoms of venous hypertension and prolongs the use of the existing hemodialysis access. This surgical option should be well recognized within the dialysis community.

 

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Introduction 

Central venous outflow obstruction resulting from venous thrombosis or stenosis is a well-known complication of indwelling catheters and may result in severe venous hypertension.1, 2, 3 Central vein obstruction (CVO) is asymptomatic in most patients due to the formation of collaterals around the occluded venous segment; however, when an arteriovenous communication, with either a fistula or a graft, is fashioned downstream of the venous obstruction, the patient can develop significant arm edema; and this can also compromise the quality of dialysis and, in some cases, put the access at risk.2, 3 A patient with no clinical evidence of CVO at the time of access surgery may develop venous hypertension months after the successful placement of an arteriovenous access.

To address outflow obstruction leading to venous hypertension after an access has been created, the most recent guidelines of the National Kidney Foundation Dialysis Outcomes Quality Initiative suggest the use of angioplasty or stenting to treat the central venous lesion.4 Ligation of the access will improve symptoms; however, it terminates a functioning access and precludes any further arteriovenous reconstructions in that arm. Although percutaneous angioplasty and stenting to manage CVO has demonstrated acceptable short-term results, frequent restenosis or an inability to recanalize the vein may limit the utility of this approach.3, 5, 6, 7

Surgical bypass of the venous obstruction has the advantage of promptly relieving symptoms while maintaining the existing dialysis access and preserving the extremity for future access reconstructions. We present our experience and management of three patients who underwent surgical bypass of a CVO for ipsilateral arteriovenous fistula (AVF) salvage.

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Materials and Methods 

A retrospective review of medical records with prior institutional review board approval was conducted of all dialysis patients from July 2003 to the present. Three patients were identified over this period who underwent venous bypass to salvage their functioning AVF.

Patient 1 

A 29-year-old male with end-stage renal disease (ESRD) secondary to lupus nephritis presented with a 2-month history of massive debilitating upper extremity edema and difficulty with hemodialysis (HD) from his left brachiocephalic AVF placed 5 months prior. He had a history of a right internal jugular vein (R IJV) HD catheter. Clinical exam and vein mapping prior to creation of his fistula did not demonstrate evidence of CVO. A left extremity venogram demonstrated a patent fistula and occlusion of the left subclavian vein (L SCV). We were unable to traverse a wire through the lesion. Magnetic resonance venogram (MRV) redemonstrated the occluded L SCV and showed a patent superior vena cava (SVC), left internal jugular vein (L IJV), and innominate veins.

Patient 2 

A 66-year-old female presented with a 3-month history of debilitating upper extremity edema and pain. She had a left brachiocephalic AVF placed 1 year prior, with no prior history of SCV catheterization. An extremity venogram demonstrated L SCV thrombosis, and a wire could not be traversed through the lesion (Fig. 1). MRV demonstrated L SCV occlusion, R IJV occlusion, R SCV stenosis, and a patent L IJV.

  • View full-size image.
  • Fig. 1 

    A Left upper extremity venogram of patient 2 demonstrating (left) a patent AVF and (right) occlusion of the L SCV with retrograde filling of the AVF. B MRV demonstrating proximal occlusion of the L SCV at its insertion into the innominate vein, occluded R IJV, and stenotic R SCV. AV, axillary vein; occl, occlusion; sten, stenosis.

Patient 3 

A 51-year-old male presented with a 1-year history of recurrent upper extremity edema and worsening dialysis through his left brachiobasilic AVF, which was placed 2 years prior. He had L SCV stenosis, which had been managed on four separate occasions with percutaneous transluminal angioplasty (PTA) at 3-month intervals with only a transient improvement in symptoms. MRV revealed L SCV stenosis, occlusion of both the R IJV and SCV, and a patent L IJV.

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Operative Technique and Results 

All patients underwent extra-anatomic bypass of the obstructed subclavian vein segment using 8-mm polytetraflouroethylene (PTFE) grafts under locoregional anesthesia. Patients 1and 2 underwent cephalic vein to IJV bypass, and patient 3 underwent axillary vein to IJV bypass. Two separate incisions were used: an axillary incision to expose the cephalic or axillary vein and a lateral neck incision to expose the IJV. The PTFE graft was sewn to the dialysis access outflow vein in an end-to-side fashion. The graft was tunneled subcutaneously over the clavicle wherein it was anastomosed end-to-side to the IJV.

No complications related to the surgical bypass procedure occurred. Marked improvement in symptoms and venous flow rates occurred immediately. All patients experienced near complete resolution of symptoms within 2 weeks after the procedure. Patients 1 and 3 had both graft and fistula patent at 4 months of follow-up; however, they died of unrelated causes. Patient 2 had both IJV bypass graft and AVF patent at latest follow-up of 8 months without the need for a secondary intervention (Table I).

Table I. Patient profiles
PatientAge (years)SexDialysis accessSymptomsTime of presentation after AVF creation (months)Anatomy of obstructionBypass procedureLength of dialysis access function (months)
129ML BC AVFMassive UE edema, ID3L SCV occlL CV to IJV with 8-mm PTFE4 (till death due to unrelated complications)
266FL BC AVFMassive UE edema, pain7L SCV occl, R SCV sten, R IJV occlL CV to IJV with 8-mm PTFE8 (at latest follow-up)
351ML BB AVFRecurrent UE edema, ID12R SCV occl, L SCV sten, R IJV occlL axillary vein to IJV bypass with 8-mm PTFE4 (till death due to unrelated complications)

AVF, arteriovenous fistula; L, left; BC, brachial artery to cephalic vein; UE, upper extremity; ID, inadequate dialysis; SCV, subclavian vein; occl, occlusion; CV, cephalic vein; IJV, internal jugular vein; PTFE, polytetrafluoroethylene; R, right; sten, stenosis; BB, brachial artery to basilic vein.

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Discussion 

Symptomatic venous hypertension can develop when an AV access is established ipsilateral to a proximal venous obstruction.2, 3 It is estimated that up to 29% of patients with functioning AV grafts will have occult central vein stenosis.8 Most, however, will be asymptomatic; and placement of AV access distal to this can cause significant venous hypertension, resulting in massive arm swelling, pain, skin ulceration, difficult dialysis, and even thrombosis of the access.8, 9 In the majority of cases, CVO will be clinically silent; however, patients can develop symptoms months to years after the establishment of a permanent AVF. Such was the case with the three patients presented in this report.

Although preoperative duplex scanning in patients who have had proximal vein cannulation has been advocated, this technique may not adequately visualize the central veins; and in such cases, contrast or MRV is recommended if the patient has a strong history or clinical findings suggestive of CVO.4, 10, 11

In this case series, patients developed central vein occlusion or stenosis 3-12 months after successful placement of a functioning AVF. Their symptoms were profound and mandated intervention. When confronted with management of symptomatic proximal vein thrombosis in the setting of a functioning AVF, there are several treatment options that need to be considered. Closure of the fistula will promptly relieve symptoms, but this sacrifices a precious functioning access and precludes the limb from being available for future access surgery. Percutaneous interventions, namely angioplasty and/or stenting, provide good short-term results and symptom relief if technically successful; yet durability remains an issue, with significant restenosis rates.2, 5, 6, 7 In two of our patients, the occlusion could not be crossed with a wire despite several attempts; in the third patient, angioplasty was only transiently effective despite multiple reinterventions.

Several surgical techniques have been described to alleviate the symptoms of CVO while preserving a functioning distal AV access.7, 12, 13, 14, 15, 16, 17, 18, 19, 20 The common tenet among these reconstructions is that they utilize an extra-anatomic bypass via autogenous vein or prosthetic graft to bypass the central venous occlusion. Bilateral venography, whether through conventional contrast venography, computed tomographic (CT) venography, or MRV, is critical to delineate the ipsilateral and contralateral anatomy and plan the appropriate bypass technique. Depending on the anatomic location of the central vein lesion, the proximal anastomosis can be made to the ipsilateral IJV (end-to-side or turndown),12, 13 contralateral IJV,14 external jugular vein,15 innominate vein,7 SVC,16 right atrium,17 saphenous vein,18 or femoral vein19 or via an IJV to IJV transposition.20 These reconstructions take advantage of the well-known phenomenon of having a distal AVF that aids in maintaining patency of a venous bypass graft.21 For most patients surgical bypass may be accomplished without entering the thoracic cavity or using a lengthy extra-anatomic bypass.

Our technique of extra-anatomic IJV bypass of the obstructed vein segment using a PTFE prosthetic graft is simple, uses two small incisions, is associated with minimal morbidity, and preserves the IJV for future AV reconstructions. We have routinely used non-externally supported PTFE grafts with favorable results. By using a prosthetic graft we are not limited by length and the graft is easily tunneled subcutaneously over the clavicle. This approach is optimal in patients who do not have suitable autogenous vein and obviates the need for an extensive dissection in an extremity affected by venous hypertension. The disadvantages of using a prosthetic graft are those expected with the use of vascular prosthetic grafts in general and include the higher infection and reduced patency rates compared to native vein. However, one would expect a better than average patency rate for prosthetic grafts used in this setting secondary to the presence of a distal functioning AVF.

The jugular venous turndown technique, in which the ipsilateral IJV is divided high in the neck and anastomosed to the distal subclavian or axillary vein, has been used commonly due to the ease of IJV access, its vicinity to the arm veins, and the requirement of only one anastomosis. However, it has several drawbacks. The IJV must be ligated and transected, and this eliminates the vessel from being the site of future catheter placement and/or AVF creation. An extensive dissection and even resection of the clavicle may be required for complete mobilization of the IJV down to the innominate vein to provide adequate length and prevent kinks. This procedure is only feasible if the contralateral IJV is patent, and in two of the patients reported here this would not have been possible due to occlusion of these vessels.

Although the effectiveness of venous bypass procedures is based mainly on retrospective observational studies, Chandler et al.22 has one of the largest single series of 12 patients with mean follow-up of 16 months. They demonstrate rates of salvaged HD access of 100% at 1 month and 80% at 1 year. Several reports compare endovascular treatment with surgical bypass of CVO.7, 23, 24 Bhatia et al.23 compared surgical bypass with PTA and stenting and found no statistically significant differences in patency between the two groups at 1 year. Criado et al.7 showed that patients who initially failed PTA and underwent bypass had 100% patency over a 13-month follow-up period and concluded that catheter therapy is less efficacious in treating venous occlusions compared to stenotic lesions. Wisselink et al.,24 in their comparison of surgical bypass with PTA, demonstrated an 88% primary patency rate in the surgical group vs. 36% in the angioplasty group at 1 year. However, there was no overall difference in patency between the surgical group and the angioplasty group (88% vs. 86%, respectively) when repeated angioplasties were performed. These studies suggest that the long-term patency of bypass grafts are comparable with the assisted patency rates of angioplasty and stenting, with likely equal rates of morbidity and mortality.

Primary stenting does not seem to be superior to primary angioplasty for the management of central venous stenosis, and although both are equivalent in maintenance of the access, they require multiple repeat interventions.6 Indeed, PTA of asymptomatic high-grade central venous stenosis in HD patients may contribute to lesion progression compared to no intervention.25 A recent review of CVO in the HD population summarized an 80-100% 1-year primary patency rate with surgical management.2 When reinterventions for both PTA with and without stenting were compared, secondary patency rates approached those of surgery, further supporting that the long-term patency of bypass grafts and the assisted patency rates of endovascular interventions may share clinical equipoise.

Due to the steady growth of the HD population, CVO will likely be frequently encountered and its effective management will likely be a continuous challenge for the vascular access surgeon. Based on the available literature and our experience, we attempt to preserve all AV HD access in the setting of symptomatic CVO, especially in young patients, those with a reasonable life expectancy, and those with limited access options (Fig. 2). The candidacy for IJV bypass ultimately rests on clinical judgment. If patients have severe signs and symptoms of venous hypertension, including pain, edema, and tissue ulceration, and have failed percutaneous interventions, we consider them for IJV bypass almost immediately. In cases of mild to moderate symptoms we may elect conservative management initially and then, if there is no improvement, proceed with our algorithm. Because IJV bypass is a relatively simple procedure with minimal morbidity, it may also be used in the setting of AV grafts. In a patient with a recent AV graft that has never been used but develops significant venous hypertension, we would proceed with IJV bypass, with the intent of maintaining access patency as well as ensuring that were dialysis to be initiated, the graft could be easily accessed.

Our initial approach is to obtain contrast venography of the affected limb, and if the occlusion can be traversed, we perform angioplasty. If the lesion cannot be recanalized or if symptoms recur despite multiple angioplasty attempts, then bilateral venography is obtained. For the effective surgical management of venous hypertension in the setting of CVO, evaluation must include bilateral venograms of the upper central venous system to determine patency of the internal jugular, external jugular, subclavian, axillary, and cephalic veins as well as the SVC in all patients to determine operative strategy. We traditionally have used MRV; however, we recently have minimized the use of this modality due to increasing reports of gadolinium-induced nephrogenic systemic fibrosis. 26 Currently, we rely on conventional or CT venography.

Patients are followed clinically, and graft imaging is obtained only if clinically warranted. We do not use antiplatelet or anticoagulant medications for graft patency as we rely on the high flow to keep the fistula or graft open. One of the patients in this report came to our attention after four failed angioplasty attempts. In a patient with recurrent stenosis, placement of a stent would have been a reasonable option; however, in the setting of multiple failures and severe symptoms, we elected to proceed with IJV bypass for the aforementioned reasons. Surgical bypass is a viable option for access salvage as it obviates the need for temporary dialysis catheter placement, facilitates uninterrupted dialysis, and results in the prompt resolution of symptoms.

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Conclusion 

Surgical bypass of an obstructed central venous segment is successful at providing both symptomatic relief and salvage of a functioning ipsilateral AV dialysis access. Study of the central venous system is essential in selecting the appropriate bypass procedure. Our experience suggests that subclavian vein bypass is an effective low-risk surgical option with acceptable patency to prolong the life of a functioning HD access.

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References 

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 Presented at the 25th Annual Meeting of the Southern California Vascular Surgical Society, San Diego, CA, May 6, 2007.

PII: S0890-5096(08)00006-X

doi:10.1016/j.avsg.2007.11.001

Annals of Vascular Surgery
Volume 22, Issue 2 , Pages 203-209, March 2008

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