Radiofrequency Guidewire Assisted Central Venous Occlusion Recanalization For Symptomatic Superior Vena Cava Syndrome In Two Patients With Arteriovenous Fistula
Anand V. Ganapathy, MD, William M. Lee, MD.
Keck Medicine of USC, Los Angeles, CA, USA.
DEMOGRAPHICS: We present two patients with end-stage renal disease on hemodialysis via arteriovenous fistula (AVF) who developed symptomatic superior vena cava (SVC) syndrome. The first patient is a 57-year-old female who receives dialysis via right brachiocephalic AVF. The second patient is a 31-year-old female who receives dialysis via left brachiobasilic AVF.
HISTORY: The first patient presented with worsening right upper extremity/facial swelling and was found to have an occlusion of the superior vena cava (SVC). She has a prior history of mitral valve endocarditis from a line infection who underwent mitral valve replacement complicated by severe pressor-induced distal limb gangrene requiring amputations. The second patient presented with worsening left upper extremity/facial swelling and was found to have an occlusion of the left innominate vein. She has a history of severe systemic lupus with pulmonary and cardiac manifestations, who is pending renal transplantation.
PLAN: After unsuccessful attempts at recanalization via traditional endovascular techniques, both patients underwent endovascular occlusion recanalization using a radiofrequency (RF) guidewire. From a femoral vein approach, the RF wire was used to cross the venous occlusion. Access was also obtained in the appropriate outflow vein of each fistula to guide the RF wire. After crossing the lesions, angioplasty balloons and stents were used to treat the occlusions. Completion angiograms showed successful treatment with patency maintained at follow-up visits. The figure shows before (left) and after (right) treatment of the occluded SVC in Patient 1.
DISCUSSION: SVC syndrome is commonly associated with dialysis catheter use, which these two patients previously had. It can reduce fistula patency leading to failure and decrease patientís quality of life. First-line treatment is endovascular intervention followed by open surgical bypass. Radiofrequency wire recanalization is a new method of treatment in which RF energy is used to burn a channel within an occluded vessel. We describe use of this technique within occluded central veins in patients with AVFs with successful maintenance of patency in follow-up. While conventional endovascular techniques should remain first-line treatment, RF wire recanalization can be considered in patients who fail standard therapy or are not good candidates for open surgical reconstruction.
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