Endovascular therapy of central vein stenosis in

hemodialysis patients. Venous chimney graft to preserve

residual jugular vein

Poster No.: C-2358

Congress: ECR 2015
Type: Scientific Exhibit
Authors: R. Corti, P. Quaretti, F. Galli, L. P. Moramarco, G. Leati, I. Fiorina,
M. Maestri, F. Calliada; Pavia/IT
Keywords: Interventional vascular, Veins / Vena cava, Vascular, Catheter
venography, Stents, Angioplasty, Venous access
DOI: 10.1594/ecr2015/C-2358

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Aims and objectives

Central venous stenosis and obstruction (CVS) is an important and prevalent problem
in the management of hemodialysis patients. The risk factors are CVC and other
intravascular devices. CVS often results in symptoms due to venous hypertension as arm
edema, and complete occlusion renders the extremity unsuitable for vascular access that
may require the insertion of a temporary CVC.

Diagnosis includes clinical examination, duplex ultrasonography, Contrast media CT and

angiography. [1] Endovascular intervention is the only feaseble treatment in HD patients
with central vein stenosis. The treatment options include PTA, placement of BMSs and
stent grafts. [2-7]

One of the major concerns regarding the use of both stent grafts and BMSs for CVS
therapy is the preservation of collateral pathways for venous drainage and future vascular
access. Particularly is the need to avoid bridging the internal jugular vein (IJV) confluence.
[8]

We report the feasibility and safety of the chimney graft technique in the endovascular
treatment of central vein stenosis in hemodialysis patients.

Methods and materials

Four patients (mean age 64 y, 2 male, mean dialytic age 15 y) presented indications for
endovascular treatment with stent graft placement of symptomatic central vein stenosis
after multiple failure of conventional treatments. All patients were carriers of ipsilateral
arteriovenous access (2 AVF, 2 AVG) with arm and face edema and malfunctioning
hemodialytic venous access, that required the insertion of temporary CVC. Double
access was engaged from arm and femoral approaches. In three patients the pull through
tecnique was applied to cross the obstruction (fig. 1). A PTA of the brachiocephalic-
subclavian lesion was performed, followed by immediate elastic recoil (Fig 2-4). A self-
expandable PTFE stent-graft was transfemorally released in the sublcavian vein with
a safety wire in the jugular vein. A similar stent-graft was then released in the distal
internal jugular vein with distal ends parallel to the subclavian stent-graft (double barrel-
chimney graft) (Fig. 5-7). The procedure was completed with intra-stent low pressure
kissing ballooning.

Images for this section:

Page 2 of 15
Fig. 1: Pull throgh tecnique. Guide wire introduced through the jugular vein was captured
with a 15mm snare.

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Fig. 2: Fistulography showing a critical focal stenosis at the costoclavicular junction in
a woman previous failed renal transplantations. The patient had complained of arm and
left facial edema and venous hypertension-related bleeding after dialysis.

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Fig. 3: Angioplasty with a 8mm, 6cm balloon catheter of the subclavian vein. (A safe
guide wire in the jugular vein)

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Fig. 4: Angioplasty with a 8mm, 6cm balloon catheter of the internal jugular vein (folloed
by elatic recoil)

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Fig. 5: Pre-releasing control. A 13mm, 10cm Viabahn in the subclavian vein and a 10mm,
10cm were released across the stenosis.

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Fig. 6: Final venography. Stent-grafts released across the stenosis. The collateral veins
have disappeared. The patient remained clinically asymptomatic at six months.

Page 8 of 15
Fig. 7: CT control at 6 months shows patency of the stent-grafts.

Page 9 of 15
Results

All procedures were successful (technical success 100%). Symptoms cleared in all
patients in few days. The mean follow up was of 13 months (8-18 months). Six stent-grafts
(Viabahn, Gore, Flagstaff, AZ) (5-10cm long) were released. Two cases necessitated
a staged procedure. Jugular thrombolysis was necessary prior to chimney graft in one
patient. Stent-grafts remained patent until the end of the follow up in 2 patients and until
death in two patients at 8 and 18 months. Reintervention was required in one patient at
6 month follow up due to restenosis with arm edema and access disfunction (primary
patency of 86% at 6 months, assisted patency of 100% at 6 months). Two patients are
alive at 12 and 13 months.

Conclusion

The extimated incidence of CVS in the ESRD population is 19 - 41%. CVS may

remain asymptomatic because if the stenosis is not critical or there is development of

collateral flow.

CVS is associated with central venous catheter and intravascular device or

although it can be related to vessel wall shear stress due to AVF or AVG. [1-2]

The K/DOQI guidelines recommend PTA, with or without stent placement, as the
preferred treatment approach for central venous stenosis. While thoracic surgery is high
risky in the HD population due to many comorbidities.

The results for PTA and BMS placement in the setting of central venous

steno-obstruction demonstrate abetter technical success rate, in the range of 100% for
BMS, with variable short- and long-term patencies similar for both treatments. [3]

Recently, stent grafts have been shown in some monocentric studies to be effective in the
treatment of CVS, with loger primary patency avoiding multiple reintervention to maintein
vein patency. [4-7]

The disadvantages of CSs include covering collateral veins, which may provide critical
outflow in recurrent stenoses or occlusions. [8]

The Venous chimney graft technique may extend the limits of central vein stent-grafting
by preserving the patency of the internal jugular vein, (Fig. 8-10) that can be used for
further CVC insertion. [9,10]

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Images for this section:

Fig. 8: Central venous obstruction of the subclavian vein, with AVG malfunctioning and
clinical sympthoms, in patients with epicardial PM.

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Fig. 9: Patent jugular vein.

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Fig. 10: Final control. Two stent-grafts released in subclavian and internal jugular
vein.The patient remained clinically asymptomatic till the end of the follow up.

Page 13 of 15
Personal information

References

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[4]Verstandig AG, Berelowitz D, Zaghal I, et al. Stent grafts for central venous
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[5]Kundu S, Modabber M, You JM, et al. Use of PTFE stent grafts for hemodialysis-
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[7] Quaretti P, Galli F, Moramarco LP, Corti R, Leati G, Fiorina I, Maestri M. Dialysis
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May;15(3):364-9.

[8]Turmel-Rodrigues L, Bourquelot P, Raynaud A, Sapoval M. Primary stent placement

in hemodialysis-related central venous stenoses: the dangers of a potential "radiologic
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[9]Vicente S, Glenck M, Mayer D, Veith FJ, Lachat M, Pecoraro F. Chimney and periscope
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[10]Donas KP, Pecoraro F, Torsello G, Lachat M, Austermann M, Mayer D, Panuccio

G, Rancic Z. Use of covered chimney stents for pararenal aortic pathologies is safe
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