Elsevier

Cardiovascular Surgery

Volume 5, Issue 5, October 1997, Pages 504-509
Cardiovascular Surgery

Central venous stenosis in the hemodialysis patient: incidence and efficacy of endovascular treatment

https://doi.org/10.1016/S0967-2109(97)00043-4Get rights and content

Abstract

Central venous stenosis occurs as a complication of central venous catheterization and significantly complicates delivery of dialysis through arteriovenous grafts in the ipsilateral upper limb. This report includes two separate studies. Functioning expanded polytetrafluorethylene grafts have been prospectively evaluated using duplex scanning and angiography performed in all patients with stenoses >50%. From this, it has been prospectively established that the incidence of unsuspected central venous stenoses in patients with functioning grafts is 29%. In the second part of the report, the authors' experience in the treatment of 25 central venous stenoses with percutaneous angioplasty and stent placement has been retrospectively reviewed. Initial technical success rate was 88%. Primary patency was 84% at 1 month, 42% at 6 months, and 17% at 1 year. Mean primary patency was 5.7 months. Stents were placed in five patients. Prevention of central venous stenosis by avoiding subclavian catheterization is optimal. Balloon angioplasty provides short-term patency, but it is the only option in most cases. The role for endovascular stent placement remains to be defined but early results are not optimistic.

Section snippets

Patients and methods

This study was performed in two parts. Part 1 was a prospective study of 141 patients with functioning expanded polytetrafluorethylene upper-extremity bridge grafts in whom a screening ultrasound scan detected a graft or perigraft stenosis of >50%. These patients were then referred for confirmatory angiography. During the angiographic phase, the entire arterial inflow tract and venous outflow tract to the level of the right atrium was studied. This provides an estimate of the number of central

Part 1

Of 141 patients screened for the study, 110 (78%) had expanded polytetrafluorethylene grafts. Forty-one of the 110 (37.2%) patients with such grafts had a stenosis of ⩾50% identified by color flow duplex imaging and were referred for angiography. Of the 41 grafts subjected to both color flow duplex imaging and angiography, 25 were located in the left upper arm, five in the right upper arm, eight in the left forearm, two in the right forearm, and one was in the right thigh. Twenty-two of the

Discussion

Vascular access continues to be the Achilles' heel of hemodialysis13, 14, 15. Although graft thromboses and graft infection account for the majority of access-related complications, 16% of all the venous stenoses detected by angiography in patients with functioning expanded polytetrafluorethylene bridge grafts were within the central venous circulation[16]. The development of central venous hemodialysis catheters revolutionized the management of the acutely occluded hemodialysis graft by

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