Venous Thoracic Outlet Decompression In Patients With A Dysfunctional Arteriovenous Hemodialysis Access
Gina M. Cavallo, MD, Kevin V. James, MD.
Morristown Medical Center, Morristown, NJ, USA.
OBJECTIVES: Central venous obstruction is a known cause of arteriovenous hemodialysis access failure. Transaxillary first rib resection is an accepted technique for treatment of venous outflow obstruction at the thoracic outlet. We reviewed our experience with thoracic outlet decompression in hemodialysis patients ipsilateral to a functioning arteriovenous access.
METHODS: Retrospective review of all patients who underwent surgical thoracic outlet decompression ipsilateral to an arteriovenous dialysis access by a single surgeon over a seven year period.
RESULTS: A total of 21 patients underwent transaxillary first rib resection ipsilateral to a functioning arteriovenous access between January 2011 and February 2018. Indications included arm edema and access dysfunction. All patients underwent endovascular intervention with balloon angioplasty prior to surgery (mean 4.3 attempts). In eight patients, a subclavian vein stent was placed preoperatively. Additional indications for surgery included the observation of immediate post angioplasty elastic recoil, radiologic evidence of stent deformity and early recurrence of stenosis or occlusion after endovascular intervention. The mean time from creation of the access to initial endovascular intervention, creation of the access to first rib resection, and initial endovascular intervention to first rib resection was 35.5, 52.6, and 17.1 months respectively. There was no perioperative mortality or significant morbidity. Two patients suffered access thrombosis within 24 hours of surgery and were successfully treated with thrombectomy and angioplasty (one percutaneously, one open). No patient required catheter access during the perioperative period. Mean follow up was 34.9 months (range 5-104). All patients underwent post operative endovascular interventions to the thoracic outlet during follow up at an average rate of 2.4 interventions per year. Two patients underwent abandonment of ipsilateral access secondary to repetitive thrombosis and had placement of a new access in a different extremity. The remaining 19 patients had successful maintenance and continued use of the access for the duration of follow up.
CONCLUSIONS: Transaxillary first rib resection can be performed safely and is a useful adjunct in the maintenance of arteriovenous dialysis access. In combination with central venous angioplasty the long term durability of hemodialysis access can be extended.
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