Infraclavicular First Rib Resection For Outflow Obstruction Of Hemodialysis Access
Katherine E. Yared, MD, Robert E. Heidel, Ph.D., Michael R. Buckley, MD, Michael M. McNally, MD, Oscar H. Grandas, MD, Scott L. Stevens, MD, Michael B. Freeman, MD, Mitchell H. Goldman, MD, Joshua D. Arnold, MD.
University of Tennessee Medical Center Knoxville, Knoxville, TN, USA.
OBJECTIVES: Loss of hemodialysis access secondary to venous thoracic outlet obstruction is a frequent occurrence in patients with end-stage renal disease. Outflow stenosis frequently necessitates repeated operative interventions for arteriovenous fistula salvage. Interventions to relieve outflow obstruction involve percutaneous angioplasty, or less commonly stenting. Endovascular treatments have high rates of recurrence. We evaluated infraclavicular first rib resection for treatment of thoracic outlet obstruction as a method for dialysis access salvage in patients who previously failed percutaneous outflow interventions.
METHODS: We performed a retrospective review of a series of nineteen patients who underwent first rib resection for thoracic outlet decompression via infraclavicular approach. Primary outcomes included primary patency, primary-assisted patency, and secondary patency of dialysis access. Patency was defined as ability to cannulate and dialyze patients successfully. Secondary outcomes included average rate of pre-intervention and post-intervention procedures related to outflow preservation, rate of complications associated with intervention such as pneumothorax, estimated blood loss during the procedure, and hospital length of stay.
RESULTS: Primary patency data was available for 18 of 19 patients following first rib resection and averaged 85 days. Primary-assisted patency was 95% (18 of 19 fistulas) at time of last follow-up and was 386 days, consisting of percutaneous angioplasty of the outflow. Secondary patency was available for 7 of 19 patients and averaged 311 days. Patency rates were limited by lack of follow-up data. Average rate of pre-intervention angioplasty for thoracic outflow obstruction was 4.11 interventions per patient. Average rate of post-intervention angioplasty was 2.05 interventions per patient. Two of 19 patients required fistula ligation due to recurrent central venous occlusion and extremity edema. Other notable interventions after rib resection included plication, ulcer excision, aneurysm resection, and fistula resection after transplant related to aneurysmal dilatation occurring prior to first rib resection. Average estimated blood loss was 45 milliliters per case, and three patients required intraoperative thoracostomy tube placement due to violation of the pleura. Median hospital length of stay was 4 days.CONCLUSIONS: First rib resection via an infraclavicular approach and planned subsequent percutaneous venous angioplasty is a safe intervention to relieve outflow obstruction in the hemodialysis patient. It may offer a durable solution to preserving venous outflow and may decrease the number of percutaneous interventions required to maintain a functional access.
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