Excimer Laser Recanalization of a Central Venous Occlusion to Salvage A Threatened Arteriovenous Fistula: A Case Report
Matthew R. Janko, MD, Mohammad Hajjiri, MD, Robert I. Hacker, MD.
MetroHealth Hospital, Cleveland, OH, USA.
OBJECTIVES: Endovascular recanalization of central venous occlusions has been described in only a few reports exist and alternative wire-based options are extremely rare.
METHODS: A 51 year old woman with a history of end-stage renal disease and multiple upper extremity central venous catheters was status-post first-stage left brachiobasilic A-V fistula. Prior to her second stage operation she developed the stigmata of left central venous stenosis such as arm and neck swelling. Before performing a second-stage basilic vein transposition further workup was performed. A fistulagram revealed a complete occlusion of the innominate vein with reconstitution by complex collaterals in the chest. This occlusion was presumed to be the result of years of central catheter usage. Basic endovascular attempts to treat this lesion were attempted but unsuccessful. A second elective treatment was performed utilizing laser recanalization, angioplasty and stenting of the of the innominate vein was performed. The A-V fistula was accessed and a sheath was advanced to the occlusion. A .9mm Excimer laser was used with an Agilis sheath to pass a .014" wire through the occlusion. Once snared via the groin access side, through and through access was achieved. Sequential upsizing of the laser filament as performed until a 14fr catheter was passed. Angioplasty was the performed with a 14mm Atlas balloon then a 13mm Viabahn stent was placed to retain patency. The patient was discharged on aspirin the following day.
RESULTS: At one month follow up her arm and facial swelling were resolved and she underwent her second stage vein transposition. One year post-operatively she continues to be symptom and complication free via the AV fistula.
CONCLUSIONS: Laser recanalization of an innominate vein occlusion can be performed safely and offers potential long-term complication free alternatives to standard endovascular therapies. Additionally, this technique provides new access options to ESRD patients who would normally not have been candidates for access on the ipsilateral side of a central stenosis. 
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