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Single Center Experience With Thoracic Central Venous Reconstruction For Dialysis Access Salvage
Bright Benfor, MD, Eric K. Peden, MD.
Houston Methodist Hospital, Houston, TX, USA.
OBJECTIVES: Thoracic central venous obstruction (TCVO) presents a persistent challenge in hemodialysis patients due to the frequent utilization of central venous catheters. This paper evaluates our institutional experience and outcomes of open surgical repair of TCVOs for dialysis access salvage.
METHODS: This was a retrospective review of dialysis patients undergoing central venous reconstructions for upper extremity dialysis access salvage between 2006 and 2022. The primary endpoint was access usage at one year.
RESULTS: The cohort comprised 23 subjects, with a mean age of 46±14 years and 21% with a history of kidney transplant. Fistulas were evenly distributed among radiocephalic (n=7), brachiocephalic (n=7), and brachiobasilic (n=7) configurations. The median access age was 36 months (IQR: 16-48 months), with 91% having a history of central venous catheter use before surgery. Clinical presentations included edema in 22 (96%), high pressures in 15/23, pain in 11/23, and aneurysmal changes in 7/23. Preoperative CT venogram revealed a type 3 TCVO in 61% (n=14). Surgical repair involved bypass graft in 22/23 cases and jugular vein to axillary vein transposition in 1/23. The right atrium was used as the outflow in 70%(n=16) with a 12 mm-ringed PTFE. All procedures were conducted under general anesthesia, with a mean duration of 218±25 minutes. The median length of stay was 6 [4-13] days, with a median of 2 [1-3] nights spent in the ICU. Thirty-day complications were reported in 8 cases (34%), including 3 cases of hemothorax, but no deaths were recorded. Graft thrombosis occurred in 3 patients (13%) during follow-up. The one-year access usage rate was 87%, and freedom from target lesion reintervention was 82%.
CONCLUSIONS: Our study demonstrates a highly favorable one-year access usage rate, portraying central venous reconstruction as a viable option for access salvage following unsuccessful endovascular attempts. Despite the positive longitudinal outcomes, the non-negligible 30-day morbidity underscores the importance of optimal patient selection to enhance overall outcomes.
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