A Single Institution's Experience With The Use Of Covered Stents For Central Venous Stenosis In Hemodialysis Patients
Mina Boutrous, MD1, Alejandro Alvarez, MD2, Obi Okoye, MD1, Jennifer Clancy, MS1, Bradley Bowles, MD1, Matthew Smeds, MD1, Donald Jacobs, MD1.
1St. Louis University, Saint Louis, MO, USA, 2SSM Health St. Mary's Hospital, Saint Louis, MO, USA.
ABSTRACT:
Objectives: Central venous occlusion may occur in hemodialysis patients resulting in arm or facial swelling and failure of dialysis access. Endovascular management with balloon angioplasty or stenting has been described, but there is minimal data on the use of covered stents in this pathology. We sought to review a single institution’s experience with the use of covered stents for central venous occlusive disease in hemodialysis patients.
Methods: A retrospective review of all patients undergoing placement of covered stents between April 2014 and December 2016 for central venous occlusive disease to preserve a failing dialysis access was performed. Patients’ records were reviewed to identify demographics, medical co-morbidities, operative variables, primary patency rates and secondary interventions.
Results: A total of 29 patients were included in the analysis. Viabahn (W.L. Gore and associates, Flagstaff, AZ) stent-grafts were exclusively used in all patients. Technical success rate was 100%. The patients were predominantly female (65.5%), with a mean age of 67.9±12.1, and medical co-morbidities of hypertension (86%), diabetes (76%), and tobacco use (7%). The majority (86%) had prior angioplasty and 17/29 (59%) had previous central venous catheters. The right brachiocephalic vein was the most commonly stented vessel (28%). The median stent length and diameter utilized was 50 millimeters (range 25-100 millimeters) and 13 millimeters (range: 9-13 millimeters) respectively. The majority of patients (83%) received a single stent, with only two patients requiring more than one. Median follow up was 24 months (range: 6–41 months). 4/29 (13.8%) patients developed symptomatic stent re-stenosis requiring secondary intervention, all of which occured in patients with primary stenosis between 50 and 75%. When compared to the patients without residual stenosis, stent length was found to be significantly associated with re-stenosis (62.5 centimeters [IQR: 0] vs 50 centimeter [IQR: 0], p=0.002). Primary patency rates were 92.9%, 91.7%, and 80.0% at 6, 12, and 24 months respectively. Secondary patency rates were 96.4%, 95.8%, and 93.3% at 6 months, 12 months, and 24 months respectively. The overall primary patency rate was estimated at 86.2% using Kaplan-Meier analysis at 30.5 months (95% CI: 26.5 - 34.5 months).
Conclusions: Covered stent-grafts have reasonable primary patency and excellent secondary patency when used for central venous stenosis in dialysis patients. Stent graft length is associated with poorer long-term patency rates.
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