Cardiorenal Pathology

**169**

**Chapter 10**

**Abstract**

*Hemant J. Mehta*

central venous disease (CVD).

occlusion of central veins

**1. Introduction**

Hemodialysis Vascular Access with

Vascular access (VA) for hemodialysis (HD) is the lifeline of a patient. Arteriovenous fistula (AVF) is the gold standard of VA, but there are challenging situations when providing long-term VA becomes challenging, in the presence of central vein stenosis (CVS), which is common in patients on hemodialysis, but its exact prevalence is not known. It would be ideal to have proper venous mapping with imaging modality to be able to plan central venous access. This prior venous mapping will help to plan the target vein and delineate venous path to be able to place HD catheter in the best position or resolve the VA-related problems. However, digital subtraction angiography remains the gold standard of the procedure, during which the target vein is accessed via ultrasound guidance, and subsequent passage of wire is done under fluoroscopic guidance. Venous angiography and, if indicated, angioplasty are performed. For complete chronically occluded thrombotic veins, recanalization needs to be attempted. Stenting is reserved for a select group of patients. There are advances in endovascular techniques to deal with CVS, and it needs a multidisciplinary team approach to tackle the complex issues of VA-related

**Keywords:** hemodialysis vascular access, central venous disease, central venous stenosis, central vein angioplasty, central vein stenting, complete thrombotic

Long-term hemodialysis (HD) is dependent on reliable vascular access (VA), which is the lifeline of a patient. We have come a long way in the chronic HD treatment due to advances in VA. Starting from Scribbner's shunt to single-lumen HD catheters in the femoral vessels to double-lumen non-tunneled non-cuff HD catheters, to tunneled cuff catheters (TCC), and to early stick arteriovenous grafts; all for urgent start HD. Over the years, we also moved the catheters from subclavian veins (SCV) to internal jugular veins (IJV), for VA in the upper part of the body, basically for access draining to the superior vena cava (SVC). Unfortunately, the non-cuffed HD catheters became a tool to continue HD for a prolonged period (a practice very commonly encountered in the part of the world where the author is working, mainly due to nonavailability of VA expertise) in the absence of matured arteriovenous fistula (AVF) or graft. This led to injury to the vessel wall, leading to thrombosis and central vein occlusion and compromised VA for HD due to central venous stenosis (CVS). Even the TCCs are associated with CVS. Two major factors

Central Venous Disease
