Efficacy of Balloon Angioplasty in Patients with Central Venous Stenosis or Obstruction Resulting from Central Vein Catheter Placement
Abbas Saroukhani, Akbar Sedighi
Department of Surgery, School of Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||23-Feb-2021|
|Date of Acceptance||04-Dec-2021|
|Date of Web Publication||31-Aug-2023|
Department of Surgery, School of Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Background: Prolonged catheter insertion in central veins of hemodialysis patients usually causes central venous stenosis (CVS). These patients present with upper limbs, head and neck, and chest edema or hemodialysis problems. This study was done to determine the clinical success of balloon angioplasty for the treatment of symptomatic CVS/obstruction.
Materials and Methods: Sixty-one hemodialysis patients who underwent endovascular treatment for CVS enrolled in this cross-sectional study between January 2017 and July 2018 at our institute. Enrollment included 29 female and 32 male subjects with a mean age of 58.9 ± 9.9 (range: 33–78) years.
Results: A total of 61 patients underwent interventions for endovascular treatment of central venous disease. 38 out of 61 patients completed all three phases of the study (the beginning, after 3 and 6 months). The average diameter of central vein in venography at the beginning of the study, 3 and 6 months later were 8.66 mm, 8.03 mm, and 7.66 mm, respectively. The average patency was 45%, and 54% and 51% at the beginning of the study, 3 and 6 months after the treatment, respectively. There was an increase in central vein patency after 3 months of treatment, with significant difference among 3 phases (P < 0.000).
Conclusion: Endovascular treatment is effective and safe for patients with central vascular stenosis with less complication rate compared to open surgical treatments, and the rate of venous patency in the treated veins with balloon angioplasty after 3 months is excellent, but this rate after 6 months is significantly reduced.
Keywords: Balloon angioplasty, central venous catheter, endovascular procedure, hemodialysis, venography
|How to cite this article:|
Saroukhani A, Sedighi A. Efficacy of Balloon Angioplasty in Patients with Central Venous Stenosis or Obstruction Resulting from Central Vein Catheter Placement. Adv Biomed Res 2023;12:223
|How to cite this URL:|
Saroukhani A, Sedighi A. Efficacy of Balloon Angioplasty in Patients with Central Venous Stenosis or Obstruction Resulting from Central Vein Catheter Placement. Adv Biomed Res [serial online] 2023 [cited 2023 Sep 28];12:223. Available from: https://www.advbiores.net/text.asp?2023/12/1/223/384995
| Introduction|| |
The central venous catheter plays an important role in management of the dialysis patients with end-stage renal disease (ESRD). However, prolonged catheter insertion is sometimes accompanied with serious complications. The central veins include the superior and inferior vena cava, right and left brachiocephalic, subclavian, and iliac veins. Central venous occlusive disease (CVOD) is defined as more than 50% of stenosis of these vessels.,
CVOD is often asymptomatic in patients not receiving dialysis.,,,,,, If symptomatic, there is a variety of clinical findings depending on the location of vascular obstruction and the capacity of collateral vessels. The most frequent finding is the moderate to severe and sometimes painful and incapacitating swelling of the arms and also head, neck, upper extremities, and chest edema. For example, when the subclavian vein is affected, collateral veins will become visible around the upper chest and the shoulders. In addition to the site of insertion, the incidence of central venous stenosis (CVS) depends on the laterality of the insertion and the type of the indwelling object. Skin ulceration and tissue loss can be due to extreme venous hypertension.,,, The other findings that also have been described are acral skin changes, pincer nail deformity, hypertension, and pseudo-Kaposi sarcoma. Unilateral face and breast swelling may additionally occur in more central (brachiocephalic or superior cava) vein obstruction.
Other complications include thrombosis, catheter malfunction, and catheter-related infection in long term.,,
Blood flow rate <300 mL/min often is used to define hemodialysis catheter dysfunction.
Other definitions of catheter dysfunction reported in the literature include frequent arterial and venous pressure alarms, poor conductance, and poor dialysis efficiency based on urea reduction ratio.
Prevalence of CVS is up to 51% in patients on hemodialysis or who had catheterization.,,, Prolonged central venous catheterization, intracardiac device, transvenous wires and high flow status in arteriovenous fistula (AVF) or graft with increased turbulence are the main causes of stenosis, consequently resulting in venous intimal hyperplasia and stenosis.,
It has also been reported that the CVS can occur without any of these reasons.,
Balloon angioplasty is a basic treatment for central venous lesions, but stent implantation is sometimes required.
The surgical methods have high primary patency at 1-year follow-up (80%–90%)., Evaluation of endovascular methods began in 1980s for the treatment of CVS.
Numerous studies have been performed on the effects and results of balloon angioplasty and stenting. In some studies, these two methods have been compared in terms of efficiency, and in some studies, their efficiency and results have been studied alone., In this study, we intended to evaluate the response to treatment in hemodialysis patients who have CVS through balloon angioplasty and to evaluate the retention of treated veins and recurrence of stenosis in the following months.
| Materials and Methods|| |
This was a cross-sectional study of all hemodialysis patients referred to vascular surgery clinic of Al-Zahra and Khurshid hospitals of Isfahan university of medical sciences. The eligible respondents were those who were adult conscious patients who agreed to participate and had been on hemodialysis and they had dialysis problems, Perm. Cath. or graft dysfunction, collateral vessels, and upper limbs edema who underwent balloon angioplasty in Khurshid hospital between January 2017 and July 2018. Pregnant women on dialysis were excluded from the study. The study was approved by ethical committee of our institute and after obtaining informed written consent, patients were screened to meet our inclusion criteria. Demographic data such as age and sex were noted. The patients were interviewed and their clinical records were reviewed to note down the duration of hemodialysis, past medical history of diabetes mellitus (DM), Hypertension and ischemic heart disease (IHD), hospitalizations and history of surgery, vascular access, and dialysis problems. All procedures were performed by the senior author (A. S). Moreover, the data were analyzed with NPar tests and Wicoxon signed-rank test.
| Results|| |
A total of 61 patients underwent interventions for endovascular treatment of CVOD. Thirty-two men (52.5%) and 29 women (47.5%) were the hemodialysis patients. As they had the upper limbs, head and neck or chest edema or hemodialysis problems, they underwent venography and the balloon angioplasty with the clinical diagnosis of CVS in Khurshid hospital Cath. Lab. 38 (62.3%) out of 61 patients presented in all three phases of the study (the beginning, after 3 and 6 months) and 23 cases (37.7%) did not complete the study.
Among 61 patients with CVS, 31 (50.8%) had right brachiocephalic/subclavian vein stenosis, 23 (37.7%) had left brachiocephalic/subclavian vein stenosis, and 7 (11.4%) had superior vena cava stenosis. Three (4.9%) had history of vascular thrombosis, 2 (3.3%) had history of vessels surgery, and 37 (60.7%) had history of Permcath insertion as an access type but 6 (9.8%) had history of Permcath + Graft and 8 (13.1%) had history of Permcath + AVF as access types of hemodialysis. Forty one (67.2%) had HTN, 20 (32.8%) had DM, 49 (80.3%) had neck edema, 34 (55.7%) had right upper limb edema, 29 (47.5%) had left upper limb, 46 (75.4%) had chest edema, 15 (24.6%) had AVF dysfunction, 17 (27.9%) had graft dysfunction, 28 (45.9%) had permcath dysfunction, 44 (72.1%) had collateral vessels, 49 (80.3%) had dialysis problems, 58 (95.1%) had ESRD, 10 (16.4%) had IHD. 23 patients failed to follow-up and were excluded from the study.
Finally, 19 males and 19 females with average ages of 58 ± 9.3 years were analyzed. Thirty-two (84%) of them had neck edema, 23 (60%) had right upper limb edema, 19 (50%) had left upper limb edema, 32 (84%) had chest edema, 28 (74%) had collateral vessels, and 33 (87%) had hemodialysis problems. Two (5.3%) out of 38 patients had history of vascular thrombosis and one (2.6%) had history of vascular surgery. Twenty seven (71.1%) had HTN, 14 (36.8%) had DM, and 6 (15.8%) had a history of IHD.
Twenty-nine patients (76%) were treated completely with balloon angioplasty, no patients were treated with stenting. Eight patients (21%) needed reintervention with balloon angioplasty in next follow-up (after 1 year). We did not have any mortalities but 9 patients (23%) had mild bleeding or hematoma in the site of catheter insertion which was controlled and treated with conservative measures. The average diameters of central vein in venography at the beginning of the study, 3 and 6 months later were (8.66 ± 1.43 mm), (8.03 ± 1.21 mm) and (7.66 ± 1.32 mm), respectively. Thus, the central vein diameters had a decreasing trend throughout the study. There was a significant difference between the beginning and the 6-month follow-up (P < 0.000, Wilcoxon test) and also a significant difference between the 3 steps in hemodialysis dysfunction (P < 0.000, N para test, Friedman test) and which was decreasing. The average patency at the beginning of the study was (45.79% ± 12.6%), and (54.74% ± 10.3%) and (51.32% ± 10.4%) at the 3 and 6 months after the treatment, respectively. There was an increased average in central vein patency after 3 months of treatment, and the difference between the 3 phases was significant (P < 0.000 *N par test, Friedman).
| Discussion|| |
There are more than 2 million patients worldwide with end stage kidney disease (ESKD) who are being treated.
In the recent years, as the number of patients with ESKD and their survival has increased, the chronic kidney disease patients with a peripherally inserted central venous catheter and the complications of dialysis access have also increased., Central vein thrombosis or obstruction is a common complication in these patients.
Without effective treatment, these patients will have a low quality of life.
In this study, we preferred not to use stenting because the presence of stents in the central veins would limit the endovascular and surgical treatments for these patients in the future.
Advantages of Endovascular treatment including but not limited to, being performed faster, less invasive than open surgeries, shorter hospital stays and overall recovery, lack of surgical wounds, and the start of hemodialysis shortly after the procedure, makes this method a very desirable alternative for these patients.
In this study, we evaluated 61 patients, of whom 38 eventually completed the study, while most similar studies have smaller sample size. In Ismail et al.'s study, 32 patients underwent endovascular treatment. Patient population in Mohamed et al. study was only 15 patients.
In the present study, the average patency at the beginning was (45.79% ± 12.6%), and (54.74% ± 10.3%) and (51.32% ± 10.4%) at the 3 and 6 months, respectively. In Boutrous et al.'s study, the primary patency rate was (87% ± 4.9%), (67.4% ± 6.9%), and (51.7% ± 7.4%) in the percutaneous transluminal angioplasty (PTA) group, respectively, and in another study, a 30-day patency rate was 81% and 12-month rate was 73% for the primary angioplasty (PTA) group. In Keerati et al. study, the primary patency rates at 6 months and 12 months were 93.8% and 31.2%, respectively.
In another study, in which 24 patients with CVS underwent venography, PTA was shown to be associated with a rapid progression of restenosis.
In Wong et al. study, the primary patency for the CVS group was 55% and 6% at 3 and 6 months, respectively.
They state that, their low primary patency rate at 6 months was due to their institutional practice of intervening as a result of their surveillance program.
In Lumsden et al. study, the primary patency was 84% at 1 month, 42% at 6 months, and 17% at 1 year.
In all the studies mentioned, the trend of central venous patency is decreasing, while in our study, the rate of venous patency initially increased but decreased in the later stage.
There are several limitations to our study. First, patients were enrolled based on the surgeon's individual criteria. Second, we performed only percutaneous transluminal angioplasty (PTA) treatment for our patients and did not use stents compared to several similar studies due to the effects of stenting on hemodialysis accesses in the future. Third, the follow-up period in our study was limited to 6 months. Furthermore, we did not separate the patients with CVS separately from patients with central venous occlusion. Finally, the severity of the CVS was determined only via venography and no hemodynamic measurements were made.
On the other hand, the major strengths of our study include a larger population size and that all patients were treated by a single surgeon in one center. We also examined changes in the size of the diameter of the veins.
The average diameters of central vein in venography at the beginning of this study, 3 and 6 months later were (8.66 ± 1.43 mm), (8.03 ± 1.21 mm), and (7.66 ± 1.32 mm), respectively. In fact, the mean central venous diameters decreased by 7.27% after 3 months and by 11.54% after 6 months compared to the beginning of the study. In Keerati et al. study, the mean diameter of central veins was 11.4 ± 1.8 mm after the initial procedure and the mean diameters of the central veins at 6 months and 12 months were 7.8 ± 1.3 mm and 6.9 ± 2.7 mm, respectively, and therefore, after 6 months and 12 months, the mean diameter of the central veins decreased by about 31% and 39%, respectively. Although we did not calculate the mean diameter of the central veins after 1 year, in our study, as in the study of Keerati et al., the trend in mean diameter was decreasing.
In fact, it can be concluded that the trend of increasing or decreasing the mean diameter of central veins is not necessarily in line with the trend of changes in the degree of patency of central veins.
| Conclusion|| |
In conclusion, CVS remains a difficult problem in end-stage renal failure patients on hemodialysis and should be managed in a multidisciplinary manner.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Adwaney A, Lim C, Blakey S, Duncan N, Ashby DR. Central venous stenosis, access outcome and survival in patients undergoing maintenance hemodialysis. Clin J Am Soc Nephrol 2019;14:378-84.
Park HS, Choi J, Baik JH. Central venous disease in hemodialysis patients. Kidney Res Clin Pract 2019;38:309-17.
Ismail OA, Eldien MT, Elhindawy KM. Endovascular management of central venous occlusive disease in hemodialysis patients with symptomatic venous hypertension. Egypt J Surg 2020;39:1069-76. [Full text]
Mackay DD, Takacs SM. Central venous obstruction-induced intracranial hypertension in hemodialysis patients: An underrecognized cause of elevated intracranial pressure. J Neuroophthalmol 2020;40:218-25.
Boutrous ML, Alvarez AC, Okoye OT, Laws JC, Jacobs DL, Smeds MR. Stent-graft length is associated with decreased patency in treatment of central venous stenosis in hemodialysis patients. Ann Vasc Surg 2019;59:225-30.
Wasse H. Cerebral hyperperfusion and other consequences of hemodialysis central vein catheters. J Vasc Access 2017;18:82-3.
Saad TF, Weiner HL. Venous hemodialysis catheters and cardiac implantable electronic devices: Avoiding a high-risk combination. Semin Dial 2017;30:187-92.
Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol 2003;26:123-7.
Da Costa SS, Scalabrini Neto A, Costa R, Caldas JG, Martinelli Filho M. Incidence and risk factors of upper extremity deep vein lesions after permanent transvenous pacemaker implant: A 6-month follow-up prospective study. Pacing Clin Electrophysiol 2002;25:1301-6.
Teruya TH, Abou-Zamzam AM Jr., Limm W, Wong L, Wong L. Symptomatic subclavian vein stenosis and occlusion in hemodialysis patients with transvenous pacemakers. Ann Vasc Surg 2003;17:526-9.
Tedla FM, Clerger G, Distant D, Salifu M. Prevalence of central vein stenosis in patients referred for vein mapping. Clin J Am Soc Nephrol 2018;13:1063-8.
Tatapudi VS, Spinowitz N, Goldfarb DS. Symptomatic central venous stenosis in a hemodialysis patient leading to loss of arteriovenous access: A case report and literature review. Nephron Extra 2014;4:50-4.
Irvine C, Holt P. Hand venous hypertension complicating arterio-venous fistula construction for haemodialysis. Clin Exp Dermatol 1989;14:289-90.
Mickley V, Görich J, Rilinger N, Storck M, Abendroth D. Stenting of central venous stenoses in hemodialysis patients: Long-term results. Kidney Int 1997;51:277-80.
Money S, Bhatia D, Daharamsy S, Mulingtapang R, Shaw D, Ramee S. Comparison of surgical bypass, percutaneous balloon dilatation (PTA), and PTA with stent placement in the treatment of central venous occlusion in the dialysis patient: One-year fallow-up. Int Angiol 1995;14:176.
Nael K, Kee ST, Solomon H, Katz SG. Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients: A single institutional experience in 69 consecutive patients. J Vasc Interv Radiol 2009;20:46-51.
Hwang SM, Lee SH, Ahn SK. Pincer nail deformity and pseudo-Kaposi's sarcoma: Complications of an artificial arteriovenous fistula for haemodialysis. Br J Dermatol 1999;141:1129-32.
Patel N, Petersen TL, Simpson PM, Feng M, Hanson SJ. Rates of venous thromboembolism and central line-associated bloodstream infections among types of central venous access devices in critically Ill children. Crit Care Med 2020;48:1340-8.
Abrantes C, Soares E Sr., Valério P, Furtado T, Barreto C. Hemodialysis catheter-related thrombi: A challenging patient. Cureus 2020;12:e8438.
Shin HS, Towbin AJ, Zhang B, Johnson ND, Goldstein SL. Venous thrombosis and stenosis after peripherally inserted central catheter placement in children. Pediatr Radiol 2017;47:1670-5.
Griffiths RI, Newsome BB, Block GA, Herbert RJ, Danese MD. Patterns of hemodialysis catheter dysfunction defined according to national kidney foundation guidelines as blood flow <300 mL/min. Int J Nephrol 2011;2011:891259.
Chan MR. Hemodialysis central venous catheter dysfunction. Semin Dial 2008;21:516-21.
Lumsden AB, MacDonald MJ, Isiklar H, Martin LG, Kikeri D, Harker LA, et al
. Central venous stenosis in the hemodialysis patient: Incidence and efficacy of endovascular treatment. Cardiovasc Surg 1997;5:504-9.
Davis D, Petersen J, Feldman R, Cho C, Stevick CA. Subclavian venous stenosis. A complication of subclavian dialysis. JAMA 1984;252:3404-6.
Hernández D, Díaz F, Rufino M, Lorenzo V, Pérez T, Rodríguez A, et al.
Subclavian vascular access stenosis in dialysis patients: Natural history and risk factors. J Am Soc Nephrol 1998;9:1507-10.
Aj A, Abdul Razak UK, Padmakumar R, Pai U, Sudhakar M. Percutaneous intervention for symptomatic central vein stenosis in patients with upper limb arteriovenous dialysis access. Indian Heart J 2018;70:690-8.
Oguzkurt L, Tercan F, Yildirim S, Torun D. Central venous stenosis in haemodialysis patients without a previous history of catheter placement. Eur J Radiol 2005;55:237-42.
Sato T, Sakurai H, Okubo K, Kusuta R, Onogi T, Tsuboi M. Current state of dialysis treatment and vascular access management in Japan. J Vasc Access 2019;20:10-4.
Wisselink W, Money SR, Becker MO, Rice KL, Ramee SR, White CJ, et al.
Comparison of operative reconstruction and percutaneous balloon dilatation for central venous obstruction. Am J Surg 1993;166:200-4.
Glanz S, Gordon D, Butt KM, Hong J, Adamson R, Sclafani SJ. Dialysis access fistulas: Treatment of stenoses by transluminal angioplasty. Radiology 1984;152:637-42.
Kootstra G, Slooff MJ, Meijer S, Tegzess AM. Venous hypertension of the hand caused by subcutaneous arteriovenous fistulae established for hemodialysis. Arch Chir Neerl 1979;31:43-7.
Robinson BM, Akizawa T, Jager KJ, Kerr PG, Saran R, Pisoni RL. Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: Differences in access to renal replacement therapy, modality use, and haemodialysis practices. Lancet 2016;388:294-306.
Babadjanov J, Bernstein R, Kirksey L. Surgical reconstruction of central venous obstruction in salvaging upper extremity dialysis accesses. J Vasc Access 2017;18:e39-41.
Wu TY, Wu CK, Chen YY, Lin CH. Comparison of percutaneous transluminal angioplasty with stenting for treatment of central venous stenosis or occlusion in hemodialysis patients: A systematic review and meta-analysis. Cardiovasc Intervent Radiol 2020;43:525-40.
Mohamed HA, Yousuf MT, Wahdan MM. Endovascular intervention for symptomatic complete central venous occlusion in hemodialysis patients. J Med Sci Res 2020;3:213-8. [Full text]
Hongsakul K, Bannangkoon K, Rookkapan S, Boonsrirat U, Kritpracha B. Paclitaxel-coated balloon angioplasty for early restenosis of central veins in hemodialysis patients: A single center initial experience. Korean J Radiol 2018;19:410-6.