CASE REPORT

J Vasc Bras. 2012;11(3):246-249.

Introduction

Stenosis or central vein occlusion is a common problem in patients with chronic renal failure, and it is usually related to the previous use of catheters1. The incidence of this entity has been reported in the literature in 25 to 40% of patients on hemodialysis2. These stenosis are usually long and non-yielding and, when occluded, recanalization is difficult. They may be asymptomatic, but may cause limb edema ipsilateral to the arteriovenous access or edema of the face and neck1. According to the Kidney Disease Outcomes Quality Initiative (KDOQI), all arteriovenous fistulas (AVF) presenting central vein stenoses of at least

50% must be treated3. The therapeutic options available are: ligation of the AVF, surgical intervention with performance of a venous shunt or the endovascular approach with transluminal percutaneous angioplasty of the lesion with or without stenting1.

Although the literature lacks studies indicating the superiority of stenting technique over balloon angioplasty to treat such cases, it is well known that some patients are not responsive to simple balloon angioplasty only, and thus require stenting4,5. The use of stent-grafts have shown better outcomes compared to uncovered stents, with patency reported to be 100% in 9 months4,5.

Abstract

Central vein stenosis is one of the most common conditions found in patients with chronic renal failure in regular hemodialysis program. In these cases, angioplasty using stent-grafts has achieved good results. The stent-graft delivery system is usually large in diameter, which can interfere with the management of severe stenosis or tortuosities. The through-and-through technique, commonly used for endovascular treatment of aortic aneurysms, allows easy navigation and safe of the endograft in the veins to be treated. In this paper, we report a case of central venous stenosis in which the through-and-through technique was used to cross the lesion with a stent-graft.

Keywords: arteriovenous shunt, surgical; angioplasty; renal dialysis.

Resumo

A estenose de veia central é uma das situações mais frequentes em pacientes com insuficiência renal crônica em hemodiálise. A angioplastia com o uso de stent-graft tem obtido bons resultados nestes casos. O sistema de liberação dos stents é de calibre maior, podendo dificultar sua navegabilidade em áreas de estenose ou tortuosidade acentuadas. A técnica do varal é comumente utilizada para o tratamento endovascular do aneurisma de aorta, permitindo atingir bom mecanismo de estiramento e facilitando a navegação do sistema de entrega da endoprótese. Descrevemos o caso de uma angioplastia de veia central com stent-graft na qual foi utilizada a técnica do varal para permitir a transposição da área de estenose.

Palavras-chave: derivação arteriovenosa cirúrgica; angioplastia; diálise renal.

Utilization of the through-and-through technique for central vein angioplasty using stent-graftUtilização da técnica do varal para angioplastia de estenose de veia central com stent-graft

Ricardo Wagner da Costa Moreira1, David Domingos Rosado Carrilho2, Liana Berúcia Freire de Oliveira3, Charmy Cleython Fernandes de Araújo4, Raissa Gabriela Vieira da Câmara Barros5, Bruno Alexandre Barbosa do Nascimento5

From Hospital Promater – Natal (RN), Brazil.Presented at the SoBRICE 2011, August 10th to 13th, 2011, Búzios (RJ).1 Vascular Surgeon at Clínica Vascular de Natal; Assistant professor at Universidade Federal do Rio Grande do Norte (UFRN) – Natal (RN), Brazil.2 Vascular Surgeon at Clínica Vascular de Natal – Natal (RN), Brazil.3 Vascular Surgeon at Clínica Vascular de Natal; Vascular Surgeon at UFRN – Natal (RN), Brazil.4 Nephrologist at Hospital Estadual Monsenhor Walfredo Gurgel and Natal Hospital Center – Natal (RN), Brazil.5 Medical Student at UFRN – Natal (RN), Brazil.Financial support: noneConflict of interest: nothing to declareSubmitted on: 05.12.11. Accepted on: 02.03.12.

Through-and-through technique for central vein angioplasty - Moreira RWC et al. J Vasc Bras 2012, Vol. 11, Nº 3 247

Case description

Male patient, 57 years old, with hypertension and diabetes, on hemodialysis through a left brachio-basilic arteriovenous fistula. History of multiple medium-term and long-term catheters in the cervical and femoral regions, bilaterally. Three months earlier, the patient developed progressive swelling on the left upper limb and the face associated with small flow variations during hemodialysis sessions, but never less than 350 mL/min. Physical examination showed marked edema on the entire left upper limb and left hemiface, besides an AVF with good thrill.

The patient underwent angiography, which showed a patent brachio-basilic AVF and the presence of significant stenosis along the left brachiocephalic vein, with collateral circulation at the cervical level (Figure 1).

After that, endovascular treatment for the stenosis was planned using a stent-graft. The basilic vein was punctured and a 4F introducer was inserted for the performance of follow-up angiographies during the procedure. The right common femoral vein was punctured and a 12F introducer was inserted. Systemic heparin (5,000 UI) was given to the patient. The area of stenosis was crossed from below using a hydrophilic 0,035” guidewire and a Headhunter 5F catheter; the 0,035” guidewire was then replaced by another measuring 0,025”, adequate to the stent-graft. A Viabahn® 13×100 mm stent-graft was used (W. L. Gore, Flagstaff, EUA), but the lesion could not be crossed by the delivery system of the Viabahn, and any attempt of advancing the system would cause the guidewire to flip back from the stenotic segment, which require a new crossing of the lesion.

The placement of stent-grafts in central veins requires larger calibers devices because of the diameters of the subclavian and brachiocephalic veins. The catheter through which the stent-graft will be deployed has larger diameter, which may cause the navigation to be more difficult in areas of tortuosity or the transposition in areas of marked stenosis, conditions that are common in patients with stenosis of the central vein. The endovascular treatment of aortic-abdominal and thoracic aneurysms is made using large-caliber endoprostheses in the delivery system and, in tortuous or narrowed aortas, the navigation may be difficult. In such situations, some techniques have shown to be useful, as it is the case of the through-and-through technique6,7.

The through-and-through technique, used in the repair of aortic aneurysms, consists of the passage of a guidewire from the femoral through the brachial artery and posterior traction of their extremities, with adjustment by a stretching mechanism. In this way, it allows the delivery system to pass freely and the stent to be placed more easily4,8,9.

This paper aims to describe the procedure of angioplasty in a brachiocephalic vein using stent-graft in association with the through-and-through technique as a means of overcoming the difficulty in the progression of the release system, thus allowing a successful endovascular procedure.

The Ethics Committee of Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte, determines that papers structured as case reports must be accompanied by the informed consent form signed by the patient, a requirement that was met in our study.

Figure 1. Long stenosis involving the whole left brachiocephalic vein, with collateral circulation.

Through-and-through technique for central vein angioplasty - Moreira RWC et al.J Vasc Bras 2012, Vol. 11, Nº 3248

Discussion

Stenosis and marked tortuosity may make the progression of balloon catheters and stent-graft delivery system extremely difficult because of their larger caliber. In this case, the difficulty was due to the size of the delivery system of the stent-graft impeding its passage through the area of stenosis, and especially due to the difficulty in navigation at tortuous areas along the subclavian and brachiocephalic veins.

The through-and-through technique is classically described as aimed for the endovascular repair of abdominal and thoracic aortic aneurysms2,6,7. We managed to use the experience acquired with this technique to solve the problem found during a procedure of central vein angioplasty. In this case, the guidewire was introduced from the femoral vein until the AVF, providing stretching that allowed the navigation of the stent-graft release system.

Through the introducer placed in the basilic vein, a goose-neck catheter was inserted, and the tip of the 0.025” guidewire placed in the axillary vein was captured, thus establishing the through-and-through technique, which provided a proper support for navigation of the system (Figure 2). Afterwards, the Viabahn® stent-graft was made to cross the lesion, and it was properly positioned and released.

Post-dilation was performed with Conquest® 12×40 mm balloon catheter (Bard, Covington, EUA). To place the balloon properly, the through-and-through technique was maintained, but using a 0.035” guidewire, Amplatz Extra-stiff (Figure  3). The introducers were removed, and local compression was performed for hemostasis.

Follow-up angiography showed that the treatment was adequate, with disappearance of collateral circulation, a sign of the effectiveness of the angioplasty.

Figure 2. Through-and-through technique using goose-neck catheter, inserted by an introducer placed at the basilic vein.

Figure 3. Release of the stent-graft after balloon-catheter dilation and final aspect with no collateral circulation.

Through-and-through technique for central vein angioplasty - Moreira RWC et al. J Vasc Bras 2012, Vol. 11, Nº 3 249

7. Yang J, Zuo J, Yang L,  et  al. Endovascular stent-graft treatment of thoracic aortic dissection. Interact Cardiovasc Thorac Surg. 2006;5(6):688-91. http://dx.doi.org/10.1510/icvts.2006.135442

8. Ingrund JC, Nasser F, Jesus-Silva SG,  et  al. Tratamento híbrido das doenças complexas da aorta torácica. Rev Bras Cir Cardiovasc.  2010;25(3):303-10. http://dx.doi.org/10.1590/S0102-76382010000300005

9. Neves AAG, Oliveira AGNM, Beck RT, Santos RV, Moreira FCP, Amato ACM. Tratamento endovascular de pseudoaneurisma de aorta torácica com fístula aorto-brônquica em pós-operatório tardio de cirurgia de correção de coarctação de aorta. J Vasc Bras.  2011;10(1):64-7. http://dx.doi.org/10.1590/S1677-54492011000100012

Correspondence: Ricardo Wagner da Costa Moreira

Av. Campos Sales, 759 – apt. 800 – Tirol CEP: 59020-300 – Natal (RN), Brazil E-mail: ricardowcm@yahoo.com.br

Authors’ contributionsStudy conception and design: RWCM

Data analysis and interpretation: RWCM, DDRC, LBFO Data collection: RGVCB, BABN

Writing: RWCM, RGVCB, BABN Critical analysis: DDRC, LBFO, CCFA

Final approval*: RWCM, DDRC, LBFO, CCFA, RGVCB, BABN Statistical analysis: RWCM

Overall responsibility: RWCM *All authors have read and approved the final version of the paper submitted

to J Vasc Bras.

Thus, the through-and-through technique shows to be reliable not only in cases of endovascular treatment for aortic aneurysms, but also in cases of central vein angioplasty.

References

1. Lucas C, Gil C, Martinho A, Pais MJ. Terapêutica endovascular de estenoses venosas centrais: uma avaliação prospectiva. Rev Port Nefrol Hipert. 2006;20(2):117-23.

2. Lumsden AB, MacDonald MJ, Isiklar H, et al. Central venous stenosis in the hemodialysis patient: incidence and efficacy of endovascular treatment. Cardiovasc Surg. 1997;5(5):504-9. PMid:9464608.

3. National Kidney Foundation [Internet]. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF DOQI). [updated 2006 Jan 01; cited 2011 Dec 05]. Available from: http://www.kidney.org/professionals/kdoqi/

4. Kundu S. Central venous disease in hemodialysis patient: prevalence, etiology and treatment. J Vasc Access. 2010;11(1):1-7. PMid:20119911.

5. Jones RG, Willis AP, Jones C, McCafferty IJ, Riley PL. Long-term results of stent-graft placement to treat central venous stenosis and occlusion in hemodialysis patients with arteriovenous fistulas. J Vasc Interv Radiol. 2011;22(9):1240-5. PMid:21764328.

6. Carnevale FC, Nasser F, Oliveira C, Borges MV, Affonso BB. Aneurismas de aorta: até onde expandir a indicação do tratamento endovascular? Rev Bras Cardiol Invas. 2006;14(1):82-8.