**9. Options for patients with CVS needing VA**

They can change to peritoneal dialysis if feasible. One can plan for thigh AVF or graft. But if both these are not the options, one is left with exploring central venous access with angioplasty and insertion of HD catheters, with TCC or Hemodialysis Reliable Outflow (HeRO®) device. For the purpose of this chapter, we would focus on upper limb CVS. Not to forget the fact that in the presence of SVC stenosis, no AVF or upper limb grafts will be feasible if the SVC stenosis is tight and has a chance for recurrence in spite of SVC angioplasty with or without stent. With improved dialysis survival, there are increasing numbers of patients who have exhausted definitive access options due to central venous stenosis and are maintaining dialysis on a central venous catheter. The HeRO allows an alternative by providing a definitive access solution [16].

## **10. The procedure: approaching and crossing stenosis**

The approach to central vein could be from femoral veins, internal jugular veins, and brachial or cephalic veins. One needs to have thorough history, clinical examination, and Doppler study to arrive at a conclusion about suspected site of CVS. When these are unable to point the site of likely lesion, one may perform contrast-enhanced computer tomography (CT) venogram. The problem with CT venography is the need to inject iodinated contrast. This can be a problem in HD patients at times, who have no peripheral access to inject contrast. In such cases, magnetic resonance (MR) venography without gadolinium, using time-of-flight protocol, may yield equally good results and help plan the procedure. Gadolinium should be avoided in patients with eGFR of <30 ml/min due to risk of nephrogenic systemic fibrosis.

Once the procedure of angiography is decided, one needs to be ready with proper hardware, including various types of wires (0.35 and 0.14 regular and double length wires, hydrophilic wires, and stiff wires), various types of diagnostic and guiding catheters, larger-size high-pressure balloons, stents, or stent grafts. One may need large length vascular sheaths to provide stability to the catheter and guide wire, especially when femoral venous access is used.

#### **10.1 How are the target lesion approached?**

The indications to perform central vein angioplasty are either the patient is symptomatic with functioning vascular access in the upper limb, or the patient has had multiple vascular access failures in upper limb, and no reliable long-term vascular access is available. In such cases, the aim of central vein angioplasty is to create a passage to insert central dialysis catheter, which can be either TCC or hybrid graft if a reliable arterial inflow is available.

If the target lesion is right brachiocephalic vein or SVC, the right IJV is punctured, lesion attempted to be crossed with 0.014′ hydrophilic wire. If that is not successful, the right femoral vein is punctured and the lesion approached. The combination of this approach from either side helps take simultaneous angiographic shoots to define site and extent of lesion in terms of its length and diameter. We have encountered several cases, in which the thinnest of wires, sometimes even the coronary wires, or CTO wires (chronic thrombotic occlusion) fail to cross the lesion. In such cases, recanalization is attempted, which is described as sharp needle recanalization. When traditional endovascular methods fail, experienced interventionalists may utilize sharp or radiofrequency (RF)-assisted recanalization techniques. Sharp recanalization techniques require the use of the back end of a wire, 20- to 22-gauge (15–20 cm) percutaneous or transseptal needles, or transjugular intrahepatic portosystemic shunt needles [17]. In the absence of any other alternatives, we have been doing it with a long Chiba needle. One has to have simultaneous projections in anteriorposterior and lateral views to be sure that the puncture is in the proper venous plain and perforation is avoided. There is no true vessel wall, and a stent is placed to reconstitute the vessel wall if this is being done for upper extremity vascular access preservation. Otherwise, a catheter is inserted after balloon angioplasty of target lesion and creating enough venous diameters to allow smooth passage of the dialysis catheter. Recently, a new device called Surfacer® Inside-Out® access catheter system is available. The Surfacer Device offers a new approach for repeated venous access in patients with thoracic central venous occlusion (TCVOs) that enables the avoidance of left-sided catheter placement in individuals awaiting creation or maturation of permanent AV access or in patients who have exhausted all thoracic venous access options [18]. The author has no personal experience of using it; however, it is meant to restore and preserve access in the chronically occluded veins. Its advantages include restoration and sustenance of access, reliable and repeatable central venous access to the right IJV, preserving viability of secondary central veins, and optimization of the placement and maturation of permanent AV access.

TCVO [19], the authors divided TCVO as type 1, defined as any unilateral obstruction affecting either the internal jugular or subclavian vein. Type 2 includes all cases with ipsilateral occlusion of the brachiocephalic vein or ipsilateral obstruction of both internal jugular and subclavian veins. In TCVO type 3, both brachiocephalic veins are obstructed. Type 4 is characterized by central obstruction of the SVC. Thirtysix patients with TCVO treated in Vienna, Austria; Oxford, England; or Cologne, Germany, who required hemodialysis access between July 2016 and June 2018, with TCVO and history of multiple CVCs and AVF, were referred to the participating centers for vascular access. Thirty-two (89%) patients were eligible for the inside-out

**177**

*Hemodialysis Vascular Access with Central Venous Disease*

procedure of angioplasty is completed.

approach (IOA) approach. Thirty-nine treatments were performed, with seven patients undergoing the IOA procedure for the second time more than 3 months after initial CVC placement. Dialysis access was established successfully in 38 of 39 (97%) implementations of the IOA procedure. Median intervention time was 43 minutes. No complications occurred. This appears to be a promising method, although this was an

If CVS is bypassed, and adequate inflow with axillary artery is available, the HeRO® device can be implanted, which will avoid the need for external TCC and

a.If the target lesion is in the subclavian vein or cephalic arch or left brachiocephalic vein, approach from arm cephalic, basilic, or rarely brachial vein is required, usually combined with femoral vein approach. In cases of tight CTO, to provide adequate support and stability to the procedure of angioplasty, the wire from the arm vein is passed all the way down to the femoral vein and snared out. The hydrophilic wire is then changed over to a stiff wire, and the

b.If attempting to put femoral vein or inferior vena cava (IVC) TCC and dealing with iliac vein or IVC stenosis, approach will be from the femoral vein, and

PTA with balloon dilatation is the primary basis for endovascular therapy. If symptoms are present, PTA is performed; however, patency is poor, so repeat procedures are often required. If it is a first PTA and there is no elastic recoil of the vein on table, one should not consider stenting. Recent studies using intravascular ultrasound (IVUS) for CVS showed that, although the lesion was sufficiently enlarged on angiography after PTA, IVUS demonstrated insufficient dilation or extrusion by the balloon catheter [20]. In such cases, repeat angioplasty with larger-size and higherpressure balloons can be tried, keeping in mind the risk of central venous rupture. Insertion of stents in such situation can be tried. However, numerous studies showed failure of stent use, especially in HD VA, because of neointimal hyperplasia

again recanalization is attempted with thin wire or sharp needle.

within the stent, leading to a lower patency rate than that of PTA [21, 22].

The stent graft (SG) is a structure that applies graft material to the inside or outside of the stent to create a physical barrier to NIH. Various studies and author's experience have been that even the SGs do not provide long-term venous patency. There have been reports of using drug-coated balloons for CVS; however, at pres-

Stenting for TCVO is appropriate in the following situations, provided there are associated hemodynamic or clinical abnormalities: acute elastic recoil (>50%) following PTA and recurrent stenosis within a 3-month period of PTA. If balloon angioplasty achieves insufficient dilation (e.g., severe recoil) or leads to dissection or acute occlusion of the affected vein, bailout stenting is performed. [15]. Balloon angioplasty is a basic treatment for central venous lesion, but stent implantation is sometimes required. The self-expandable or balloon-expandable stent is chosen by the lesion location and characteristics. The lesion in SCV is generally treated by self-expandable stent, and right BCV is treated by balloon-expandable stent. The organic lesion of innominate vein with plaque is treated by self-expandable stent. Note that the innominate venous stenosis is sometimes caused by compression between the right brachiocephalic artery and the sternum and this lesion is treated by balloon-expandable stent because the radial force of balloon-expandable stent is stronger than self-expandable stent. It is important to understand the indication

observational study and no comparison was made to any other methods.

*DOI: http://dx.doi.org/10.5772/intechopen.93030*

minimize risk of CRBSI.

ent, the benefit seems limited.

and stent selection for central venous PTA [15].

*Hemodialysis Vascular Access with Central Venous Disease DOI: http://dx.doi.org/10.5772/intechopen.93030*

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

Once the procedure of angiography is decided, one needs to be ready with proper hardware, including various types of wires (0.35 and 0.14 regular and double length wires, hydrophilic wires, and stiff wires), various types of diagnostic and guiding catheters, larger-size high-pressure balloons, stents, or stent grafts. One may need large length vascular sheaths to provide stability to the catheter and

The indications to perform central vein angioplasty are either the patient is symptomatic with functioning vascular access in the upper limb, or the patient has had multiple vascular access failures in upper limb, and no reliable long-term vascular access is available. In such cases, the aim of central vein angioplasty is to create a passage to insert central dialysis catheter, which can be either TCC or hybrid graft if

If the target lesion is right brachiocephalic vein or SVC, the right IJV is punctured, lesion attempted to be crossed with 0.014′ hydrophilic wire. If that is not successful, the right femoral vein is punctured and the lesion approached. The combination of this approach from either side helps take simultaneous angiographic shoots to define site and extent of lesion in terms of its length and diameter. We have encountered several cases, in which the thinnest of wires, sometimes even the coronary wires, or CTO wires (chronic thrombotic occlusion) fail to cross the lesion. In such cases, recanalization is attempted, which is described as sharp needle recanalization. When traditional endovascular methods fail, experienced interventionalists may utilize sharp or radiofrequency (RF)-assisted recanalization techniques. Sharp recanalization techniques require the use of the back end of a wire, 20- to 22-gauge (15–20 cm) percutaneous or transseptal needles, or transjugular intrahepatic portosystemic shunt needles [17]. In the absence of any other alternatives, we have been doing it with a long Chiba needle. One has to have simultaneous projections in anteriorposterior and lateral views to be sure that the puncture is in the proper venous plain and perforation is avoided. There is no true vessel wall, and a stent is placed to reconstitute the vessel wall if this is being done for upper extremity vascular access preservation. Otherwise, a catheter is inserted after balloon angioplasty of target lesion and creating enough venous diameters to allow smooth passage of the dialysis catheter. Recently, a new device called Surfacer® Inside-Out® access catheter system is available. The Surfacer Device offers a new approach for repeated venous access in patients with thoracic central venous occlusion (TCVOs) that enables the avoidance of left-sided catheter placement in individuals awaiting creation or maturation of permanent AV access or in patients who have exhausted all thoracic venous access options [18]. The author has no personal experience of using it; however, it is meant to restore and preserve access in the chronically occluded veins. Its advantages include restoration and sustenance of access, reliable and repeatable central venous access to the right IJV, preserving viability of secondary central veins, and optimiza-

guide wire, especially when femoral venous access is used.

tion of the placement and maturation of permanent AV access.

TCVO [19], the authors divided TCVO as type 1, defined as any unilateral obstruction affecting either the internal jugular or subclavian vein. Type 2 includes all cases with ipsilateral occlusion of the brachiocephalic vein or ipsilateral obstruction of both internal jugular and subclavian veins. In TCVO type 3, both brachiocephalic veins are obstructed. Type 4 is characterized by central obstruction of the SVC. Thirtysix patients with TCVO treated in Vienna, Austria; Oxford, England; or Cologne, Germany, who required hemodialysis access between July 2016 and June 2018, with TCVO and history of multiple CVCs and AVF, were referred to the participating centers for vascular access. Thirty-two (89%) patients were eligible for the inside-out

**10.1 How are the target lesion approached?**

a reliable arterial inflow is available.

**176**

approach (IOA) approach. Thirty-nine treatments were performed, with seven patients undergoing the IOA procedure for the second time more than 3 months after initial CVC placement. Dialysis access was established successfully in 38 of 39 (97%) implementations of the IOA procedure. Median intervention time was 43 minutes. No complications occurred. This appears to be a promising method, although this was an observational study and no comparison was made to any other methods.

If CVS is bypassed, and adequate inflow with axillary artery is available, the HeRO® device can be implanted, which will avoid the need for external TCC and minimize risk of CRBSI.


PTA with balloon dilatation is the primary basis for endovascular therapy. If symptoms are present, PTA is performed; however, patency is poor, so repeat procedures are often required. If it is a first PTA and there is no elastic recoil of the vein on table, one should not consider stenting. Recent studies using intravascular ultrasound (IVUS) for CVS showed that, although the lesion was sufficiently enlarged on angiography after PTA, IVUS demonstrated insufficient dilation or extrusion by the balloon catheter [20]. In such cases, repeat angioplasty with larger-size and higherpressure balloons can be tried, keeping in mind the risk of central venous rupture. Insertion of stents in such situation can be tried. However, numerous studies showed failure of stent use, especially in HD VA, because of neointimal hyperplasia within the stent, leading to a lower patency rate than that of PTA [21, 22].

The stent graft (SG) is a structure that applies graft material to the inside or outside of the stent to create a physical barrier to NIH. Various studies and author's experience have been that even the SGs do not provide long-term venous patency. There have been reports of using drug-coated balloons for CVS; however, at present, the benefit seems limited.

Stenting for TCVO is appropriate in the following situations, provided there are associated hemodynamic or clinical abnormalities: acute elastic recoil (>50%) following PTA and recurrent stenosis within a 3-month period of PTA. If balloon angioplasty achieves insufficient dilation (e.g., severe recoil) or leads to dissection or acute occlusion of the affected vein, bailout stenting is performed. [15]. Balloon angioplasty is a basic treatment for central venous lesion, but stent implantation is sometimes required. The self-expandable or balloon-expandable stent is chosen by the lesion location and characteristics. The lesion in SCV is generally treated by self-expandable stent, and right BCV is treated by balloon-expandable stent. The organic lesion of innominate vein with plaque is treated by self-expandable stent. Note that the innominate venous stenosis is sometimes caused by compression between the right brachiocephalic artery and the sternum and this lesion is treated by balloon-expandable stent because the radial force of balloon-expandable stent is stronger than self-expandable stent. It is important to understand the indication and stent selection for central venous PTA [15].

It is also important to remember to choose a proper-sized stent. This is sometimes not possible to judge from the angiographic images, and what appears to be adequate angioplasty could be inadequate in terms of adequate vein diameter. IVUS is sometimes useful to guide the choice of proper balloon or stent size, as what appears to be an adequately treated vein could be having significant underlying stenosis, which is not possible to realize on conventional two-dimensional angiography. IVUS is an invasive modality that provides cross-sectional imaging of the veins but without the need for ionizing radiation or contrast administration. In addition to being a diagnostic tool that is easy and repeatable, it aids treatment decisionmaking. Though IVUS may be better suited than traditional venography to identify intraluminal narrowing and pre-/post-intervention outcomes, additional study is warranted to better characterize the value of IVUS in the VA-related CVS patient population. In a patient with CVS and prior allergy to iodinated contrast, angiography was performed using 1 cc of contrast, CVS confirmed, and the rest of the procedure of angioplasty and confirmation of adequate result was completed using IVUS (personal communication, Dr. Daniel Patel, Interventional Nephrologist, Volusia-Flagler Vascular Centre, Daytona Beach, Florida, USA).

If CRS is the cause for catheter malfunction, the same can be confirmed during catheter exchange procedure by doing pullback angiography prior to full removal of TCC. There can be only CRS, which can be tackled by balloon angioplasty and fibrin sheath disruption. Rarely (and in the authors' own experience), the CRS can be snared out. However, the CRS can be associated with CRAT. And it can become tricky to perform angioplasty, as the risk of pulmonary thromboembolism due to large CRAT, attached to TCC tip, is high. Sometimes, CRAT is attached to the wall of the right atrium. In such a case, if TCC is functioning well, the patient can be anticoagulated and kept under close observation. For a large CRAT or infected CRAT, attached to TCC tip, and where it is risky and not advisable to remove the CRAT, AngioVac thrombectomy device can be used. If these patients are poor candidates for conventional therapy of thrombolytics or surgical thromboembolectomy because of bleeding, failure of thrombolytics, or hemodynamic instability, they may benefit from percutaneous mechanical thrombectomy by AngioVac, which is proved to be effective for complete evacuation in most patients [23].

Surgical options may be considered for CVS, when the stenosis persists, and there are no alternative avenues to provide long-term reliable VA. One must assess the AVF for flow velocity, as this may be the cause of CVD. In such cases, inflow reduction either surgically or percutaneously can be performed. Another surgical option is unusual bypass including reconstruction surgery and claviculectomy or first rib resection if there is thoracic outlet syndrome. If an experienced vascular surgeon is available, the bypass surgery can be performed using graft (PTFE) from the brachial artery to ipsilateral or contralateral internal jugular veins or axillary or femoral veins. Direct connection to SVC or right atrium have also been attempted. One must remember that such surgeries are complicated and carries its own risks and complications.

There are occasions when there is coexistence of CVS and stenosis in the draining vein, either juxta-anastomotic or away from the site of anastomosis. In such situation, one must attempt and achieve patency of CVS lesion. Failure to do so can lead to severe swelling of the ipsilateral arm. The best way to relieve symptomatic CVS is closure of AVF. But it is not possible in patients, who have the last surviving access and shortage of vascular estate.

But, sometimes, there are more than one possible approach to a problem, and the opinion varies as per the specialist handling the case. For example, refer to **Figure 4**, a middle-aged lady on hemodialysis with CVS who had undergone angioplasty with stenting and resolution of right upper limb painful edema. She

**179**

**12. Conclusion**

**Figure 4.**

*Right SCV in-stent thrombosis.*

*Hemodialysis Vascular Access with Central Venous Disease*

1/3rd claviculectomy to relieve her symptoms.

**11. Cardiovascular consequences of AVF**

presented with the same symptoms 6 months later. The angiography image shows in-stent stenosis. It was difficult to negotiate the stenosis. Various opinions were sought. The interventional nephrologist found that it was the high-flow fistula (flow volume 2600 ml/min, very high) which was responsible for her symptoms, and the patient should undergo flow reduction procedure. The interventional radiologist said that attempt to do in-stent angioplasty, followed by stent placement within the stent, should be the first option. The vascular access surgeon said that the stenosis is due to external compression and the patient should undergo middle

Sometimes very-high-flow AVFs can lead to VH, progressive aneurysmal dilatation of vein with skin ulceration, hemodialysis access-induced distal ischemia, and high-output heart failure with or without pulmonary hypertension. AVFs have effects on cardiac functions related to the increase in preload and cardiac output (CO). It is difficult to define cardiovascular consequences due to AVF in a precise manner. This is due to the fact that patients requiring long-term hemodialysis tend to have volume overload due to water and salt retention. There could also be pressure load due to arterial sclerosis and hypertension and increased CO secondary to chronic anemia. In addition, many hemodialysis patients have significant pre-existing myocardial, valvular, or coronary heart disease, as the vascular calcification due to CKD-MBD (chronic kidney disease—mineral and bone disorder). Congestive heart failure (CHF) is highly prevalent among patients with ESRD. Approximately 35–40% of patients with ESRD have an established CHF diagnosis at initiation of hemodialysis. Worsening in cardiac functions soon after AVF creation has also been observed favoring a causative effect of the AVF on certain cardiac functions [24].

CVD is a common occurrence in HD patients, either due to mechanical or hemodynamic factors. It could be related to catheters or AVF. It can be symptomatic or asymptomatic. Interventions will be required in symptomatic patients and in those who have VA malfunction. There are various options, and one needs to choose the modality based on the patient's need. The outcomes cannot be predicted as each vein behaves differently. Proper knowledge of anatomical lesion, pathophysiology of the lesion, patient needs, and expertise available will determine the intervention

*DOI: http://dx.doi.org/10.5772/intechopen.93030*

*Hemodialysis Vascular Access with Central Venous Disease DOI: http://dx.doi.org/10.5772/intechopen.93030*

**Figure 4.** *Right SCV in-stent thrombosis.*

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

It is also important to remember to choose a proper-sized stent. This is sometimes not possible to judge from the angiographic images, and what appears to be adequate angioplasty could be inadequate in terms of adequate vein diameter. IVUS is sometimes useful to guide the choice of proper balloon or stent size, as what appears to be an adequately treated vein could be having significant underlying stenosis, which is not possible to realize on conventional two-dimensional angiography. IVUS is an invasive modality that provides cross-sectional imaging of the veins but without the need for ionizing radiation or contrast administration. In addition to being a diagnostic tool that is easy and repeatable, it aids treatment decisionmaking. Though IVUS may be better suited than traditional venography to identify intraluminal narrowing and pre-/post-intervention outcomes, additional study is warranted to better characterize the value of IVUS in the VA-related CVS patient population. In a patient with CVS and prior allergy to iodinated contrast, angiography was performed using 1 cc of contrast, CVS confirmed, and the rest of the procedure of angioplasty and confirmation of adequate result was completed using IVUS (personal communication, Dr. Daniel Patel, Interventional Nephrologist,

If CRS is the cause for catheter malfunction, the same can be confirmed during catheter exchange procedure by doing pullback angiography prior to full removal of TCC. There can be only CRS, which can be tackled by balloon angioplasty and fibrin sheath disruption. Rarely (and in the authors' own experience), the CRS can be snared out. However, the CRS can be associated with CRAT. And it can become tricky to perform angioplasty, as the risk of pulmonary thromboembolism due to large CRAT, attached to TCC tip, is high. Sometimes, CRAT is attached to the wall of the right atrium. In such a case, if TCC is functioning well, the patient can be anticoagulated and kept under close observation. For a large CRAT or infected CRAT, attached to TCC tip, and where it is risky and not advisable to remove the CRAT, AngioVac thrombectomy device can be used. If these patients are poor candidates for conventional therapy of thrombolytics or surgical thromboembolectomy because of bleeding, failure of thrombolytics, or hemodynamic instability, they may benefit from percutaneous mechanical thrombectomy by AngioVac, which is

Volusia-Flagler Vascular Centre, Daytona Beach, Florida, USA).

proved to be effective for complete evacuation in most patients [23].

Surgical options may be considered for CVS, when the stenosis persists, and there are no alternative avenues to provide long-term reliable VA. One must assess the AVF for flow velocity, as this may be the cause of CVD. In such cases, inflow reduction either surgically or percutaneously can be performed. Another surgical option is unusual bypass including reconstruction surgery and claviculectomy or first rib resection if there is thoracic outlet syndrome. If an experienced vascular surgeon is available, the bypass surgery can be performed using graft (PTFE) from the brachial artery to ipsilateral or contralateral internal jugular veins or axillary or femoral veins. Direct connection to SVC or right atrium have also been attempted. One must remember that such surgeries are complicated and carries its own risks

There are occasions when there is coexistence of CVS and stenosis in the draining vein, either juxta-anastomotic or away from the site of anastomosis. In such situation, one must attempt and achieve patency of CVS lesion. Failure to do so can lead to severe swelling of the ipsilateral arm. The best way to relieve symptomatic CVS is closure of AVF. But it is not possible in patients, who have the last surviving

But, sometimes, there are more than one possible approach to a problem, and the opinion varies as per the specialist handling the case. For example, refer to **Figure 4**, a middle-aged lady on hemodialysis with CVS who had undergone angioplasty with stenting and resolution of right upper limb painful edema. She

**178**

and complications.

access and shortage of vascular estate.

presented with the same symptoms 6 months later. The angiography image shows in-stent stenosis. It was difficult to negotiate the stenosis. Various opinions were sought. The interventional nephrologist found that it was the high-flow fistula (flow volume 2600 ml/min, very high) which was responsible for her symptoms, and the patient should undergo flow reduction procedure. The interventional radiologist said that attempt to do in-stent angioplasty, followed by stent placement within the stent, should be the first option. The vascular access surgeon said that the stenosis is due to external compression and the patient should undergo middle 1/3rd claviculectomy to relieve her symptoms.
