Endovascular Treatment Of Superior Vena Cava Occlusion In Dialysis Patients
Pablo V. Uceda, MD, Robert W. Feldtman, MD, FACS, Jasmine L. Richmond, MS, Sam S. Ahn, MD, FACS.
DFW Vascular Group, Dallas, TX, USA.
Objective: To report techniques and results of endovascular SVC reconstruction in dialysis patients.
Methods: From 2009 to 2019, 42 dialysis patients underwent SVC reconstruction. Indications for surgery were SVC obstruction/syndrome threatening the function of a pre-existing upper arm access or contraindicating placement of a new upper arm access. Patients were evaluated with preoperative venous ultrasound, digital pressures of upper extremities, and central venograms from upper extremity and femoral approach to determine the anatomy of the vein occlusion. Cases with difficult anatomy, were treated utilizing a transseptal needle to cross lesions intrathoracically or using an inside-out central venous access technique. Reconstruction of venous outflow was accomplished with angioplasty, stenting, and or placement of HeRO conduits. Successful reconstruction was followed by dialysis access revision, or new access placement. Pre-existing access were used within 24 hours of the procedure.
Mean age was 52 ±16.1. Twenty one (50%) were female. Most common risk factors were diabetes mellitus (61.9%) and hypertension (85.7%). Twenty four patients (57.1%) had symptoms of SVC syndrome which resolved after the procedure in all cases. Treatment of the SVC lesion was HeRO conduit in 19 cases (45.2%), stenting in 15 (35.7%), and PTA in 7 (16.6%). Crossing technique of the SVC lesion was using conventional catheter and wire in 24 cases (57.1%), transeptal needle in 16 (38.0%), including 11 using inside-out central venous access technique. Overall technical success was 95%. There were two intraoperative complications, one case of severe hypotension and another one with fatal cardiac tamponade. During the follow up period, 14 patients died of unrelated cases and 32 patients (76.1%) had functional access
In 16 patients with upper extremity access, access function was preserved in 13 (81.2%). In 23 out of 26 patients (88.4%), new arm access was successfully created following the SVC procedure. Overall success rate was 85.7%.
The average follow up was 19.1 ± 18 months. During these follow up, 22 patients underwent procedures to maintain access function, 19 patients underwent endovascular interventions and 11 underwent open procedures. Eight patients had infections (19%), 5 involving HeRO conduits that required excision with loss of access.
Conclusion: Endovascular SVC reconstruction seems to be safe and effective in relieving SVC symptoms and at maintaining function of upper extremity dialysis access.
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