When is Enough Enough? A Comparison of Options for Hemodialysis Patients with Central Venous Obstruction Refractory to Balloon Angioplasty: Stenting vs. HeRO
Daisy Proksch, BS1, Limael E. Rodriguez, MD2, Maggie Lin, MD2, Animesh Rathore, MD1, Samuel N. Steerman, MD1, Jean M. Panneton, MD2
1Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, VA, USA, 2Eastern Virginia Medical School, Division of Vascular Surgery, Norfolk, OR
Introduction: Central venous occlusive disease is a common cause of upper extremity, arteriovenous (AV) access failure in hemodialysis patients. When refractory to balloon angioplasty, treatment options include the Hemodialysis Reliable Outflow (HeRO) graft and central venous stenting. The purpose of this study is to evaluate the outcomes of these options.
Methods: A retrospective review was performed of patients who underwent central venous stenting or HeRO placement for central venous obstruction between December 2008 and March 2018. Primary outcomes were re-intervention rates, patency, and mortality.
Results: Seventy-five hemodialysis patients were identified after failed balloon angioplasty for central venous obstruction. Forty-four patients underwent central venous stenting comprising coverage of the subclavian vein (27), innominate vein (18), or superior vena cava (5). Six stent patients later underwent HeRO placement. The stents used were 76% stent grafts (Viabahn (9), Fluency/Flair (17), and iCast (2)) and 24% bare metal stents (Wall-stent (4), Protégé (1), Cobalt (1), or other (3)). Thirty-seven HeROs were placed. The venous outflow component insertion sites were internal jugular (22), external jugular (2), subclavian (6), axillary (4), or other (2). Four patients underwent revision of a pre-existing, functional AV access by attachment of the venous outflow component to the access. The HeRO and stent groups were similar in previous central venous intervention rates; 2.1 versus 2.3 per year (p = 0.75). After the index procedure, there was no difference between groups for frequency of dialysis circuit interventions per year (4.2 vs. 3.1; p = 0.20) nor central venous interventions (i.e. angioplasties of the central veins or within the portion of the HeRO inside central veins) per year (1.4 vs. 2.2; p = 0.26). One-year access circuit primary patency was 27.3% for HeRO and 13.2% for stenting (p = 0.16). Two-year access circuit secondary patency was 54% for HeRO and 44% for stenting (p = 0.42). All-cause mortality was similar at 1 year (3.2% vs. 2.8%; p = 0.91) and 2 years (14.3% vs. 7.4%; p = 0.49).
Conclusions: Central venous stenting and HeRO were shown to have similar rates of re-intervention and patency. This pilot study with small patient groups suggests the multiple treatment options for this problematic disease process may yield similar results when careful patient selection is applied.
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