Retrograde Veno-Cutaneous Approach to Establish Central Venous Access in Chronic Central Venous Occlusions
MedStar Heart and Vascular Institute, Washington, DC
INTRODUCTION: Central venous occlusion (CVO) in patients with end stage renal disease is a major cause of hemodialysis access failure resulting in significant morbidity and potential mortality especially with infection complications associated with femoral access. We report a novel technique to establish central venous access in chronic central venous occlusions in patients who exhausted other venous access options.
METHODS: Patients with CVO who exhausted other options for hemodialysis access due to occlusion or infection participated in our novel approach. Once standard antegrade CVO revascularization was deemed to be unsuccessful, our retrograde veno-cutaneous approach was used. In this technique, femoral venous access is established, Guide wire/catheter techniques are used to navigate a wire to the occlusion stump or to a venous collateral as close to the subcutaneous tissue as possible on either side of the neck. Support is provided by a long 6F sheath and angled catheter to direct the wire to the desired location. Once adequate positioning of the catheter/wire is obtained, sharp recanalization is used to safely direct the back end of a stiff glidewire into the subcutaneous tissue, if the wire is not directly under the skin, the floppy end of the wire can then be directed towards the subcutaneous tissue with the support of an angled catheter. Once the wire is directly under the skin, a small cut-down is created and with minimal blunt dissection, the wire is located and retrieved. At this point, a peal-away sheath is inserted over the retrieved wire to the central venous system using body-floss technique. Once Central venous access is established, a tunneled catheter or Hemodialysis reliable outflow (HeRO) graft is inserted. The subcutaneous incision is closed primarily.
RESULTS: Between 2015 and May 2017, 5 Patients underwent successful retrograde recanalization of the CVO and placement of tunneled dialysis catheter or placement of HeRO graft. Average age was 49.4 years, 4 were males, average procedural time was 157.6 minutes, average fluoroscopy time was 33.5 minutes, average blood loss was 104 ml, we inserted 2 HeRO grafts at the time of the procedure, 1 patient had HeRO graft inserted the next day and 2 patients had tunneled catheters pending conversion to HeRO graft. There were no immediate or late complications associated with the procedure. Hemodialysis was immediately resumed in all patients. All dialysis accesses were patent on follow up.
CONCLUSIONS: Retrograde Veno-Cutaneous approach in central venous occlusions is a novel, safe and effective technique in patients who have exhausted standard hemodialysis access options.
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