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A wire transposition technique for recanalization of chronic complex central venous occlusions A Massmann, A Rostam, P Fries and A Buecker Phlebology published online 1 September 2014 DOI: 10.1177/0268355514550260 The online version of this article can be found at: http://phl.sagepub.com/content/early/2014/08/31/0268355514550260
Published by: http://www.sagepublications.com
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Phlebology OnlineFirst, published on September 1, 2014 as doi:10.1177/0268355514550260
Short Report
A wire transposition technique for recanalization of chronic complex central venous occlusions
Phlebology 0(0) 1–4 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0268355514550260 phl.sagepub.com
A Massmann, A Rostam, P Fries and A Buecker
Abstract Purpose: A minimal-invasive interventional technique for recanalization of complex chronic central venous total occlusions is described to overcome difficulties in case of failure of common approaches. Method: We present a patient with a central venous occlusion that caused severe venous congestion of her upper extremity and significant impairment of her forearm hemodialysis shunt. Since the usual transbrachial and transfemoral attempts for recanalization of occluded right subclavian, brachiocephalic, superior vena cava, and proximal internal jugular veins (IJV) failed, the approach was changed to a transjugular access. Only the IJV and subclavian vein occlusions were passed from transjugular. Results: The key procedure was the switch of a jugular-brachial wire to a femoral-brachial setting. The wire transposition was achieved by snaring the looped stiff end of the jugular-brachial wire outside the jugular sheath from the opposite femoral access. Conclusion: Different approaches should be considered for the recanalization of challenging central venous occlusions. After failed attempts via common access sites, a guidewire transposition maneuver using a combined approach may be particularly helpful for safe and effective endovascular treatment of complex situations.
Keywords Central venous catheterization, venous thoracic outlet syndrome, endovascular, angioplasty, upper extremity deep vein thrombosis
Introduction Central venous stenosis (CVS) is a common cause of impaired hemodialysis shunt function and leads to congestion, thrombosis, and increased bleeding after dialysis. Furthermore, central venous line or lead placement may be impossible. Endovascular treatment shows high success rates. Previous trauma and inflammation of venous vessel wall related to catheter placement resulting in microthrombus, intimal hyperplasia, and fibrosis are discussed as the underlying reasons for the development of CVS.1
Indianola, PA, USA) was performed. Additionally, a chronic complex central venous occlusion was detected including the right subclavian vena cava (SV), brachiocephalic vena cava (BCV), superior vena cava (SVC), and proximal internal jugular veins (IJV). On the following day, acute shunt reocclusion occurred that was mostly likely attributable to the central venous occlusion. Recanalization of the occluded central veins was considered mandatory to achieve persistent shunt patency (Figure 1(a)).
Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
Materials and methods A 35-year-old female presented with an acute thrombosis of her forearm hemodialysis shunt, which remained patent since its creation 2 years ago. After the patient’s written informed consent, hydrodynamic shunt thrombectomy (AngioJet Ultra, Bayer-Medrad,
Corresponding author: Dr. med. Alexander Massmann, Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Kirrberger Straße, 66421 Homburg/Saar, Germany. Email: alexander.massmann@ uks.eu
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Figure 1. (a) Phlebography depicts a central venous occlusion including the right SV, BCV, proximal IJV, and SVC with multiple venous collaterals. The IJV and SVC are not filled with contrast media. (b) Venography after stent implantation (SinusRepoVisual-6F 10/40 mm, OptiMed) into the right SV extended with a funnel-shaped overlap into the right BCV/SVC (SinusVenous-10F 12/80 mm, OptiMed) depicts an excellent angiographic result. There is complete decrease of venous collaterals without stent compression between clavicle and first rib. Clinically, the patient reports a substantial relief of upper extremity congestion.
Results
Switch of the jugular-brachial to a femoral-brachial setting
Transfemoral-jugular recanalization Usual transbrachial and transfemoral recanalization of the right SV, BCV, and SVC failed. A femoral 8F/ 90-cm sheath was advanced to the obstructed SVC. Only the right IJV was accessible transfemorally using a hydrophilic 0.89 mm/0.03500 wire (GlidewireAdvantage, Terumo-Medical, Tokyo, Japan) and 4Fsupport catheter (NaviCross, Terumo-Medical, Tokyo, Japan; Figure 2(a) light green line). An 8F/10-cm sheath was inserted into the right IJV. The Glidewire was snared from jugular resulting in a jugular-femoral pull-through-wire to secure the access from the SVC to the IJV.
Transjugular-subclavian recanalization The jugular sheath was advanced toward the SVC occlusion. Wire passage into the SVC from jugular was impossible although the aforementioned access from femoral to the right IJV was established. The right IJV/BCV occlusion was intraluminally passed from jugular using a manually shaped hydrophilic 0.36 mm/0.01400 wire (Hi-Torque Command-ES, Abbott-Laboratories, AbbottPark, Chicago, IL, USA; Figure 2(a) dark green line). After successful jugular-subclavian recanalization, the Command-ES was exchanged for an atraumatic 0.36-mm wire (Spartacore, Abbott-Laboratories, AbbottPark, Chicago, IL, USA) and advanced deep into the basilic vein (Figure 2(b)).
A snare was advanced from femoral out of the jugular sheath via the pull-through-wire. The free stiff end of the Spartacore, which was going down from jugular into the right arm was snared extracorporally outside the jugular sheath. The free end of the wire was then pulled back through the jugular sheath and finally pulled out of the opposite femoral sheath. A path from femoral through the occluded SVC/BCV into the basilic vein was finally established (Figure 2(c, d)). The Spartacore was exchanged for a stiff 0.89-mm guidewire (Supracore, Abbott-Laboratories, AbbottPark, Chicago, IL, USA). The femoral 90-cm sheath was advanced into the right SV after simultaneous predilatation of the right IJV at the junction to the BCV (6/40 mm) and the SVC/BCV (6/40 mm). Relevant recoil of the right SV required a 10/40-mm stent (SinusRepoVisual-6F, OptiMed Medizinische Instrumente, Ettlingen, Germany). A 12/80-mm stent (SinusVenous-10F, OptiMed-Medizinische Instrumente, Ettlingen, Germany), which is characterized by high radial force and flexibility due to a segmental stent design, was used for stent extension into the right BCV/SVC. Phlebography after postdilatation (12/40 mm) confirmed an excellent result with complete absence of venous collaterals (Figure 1(b)). No procedure-associated complications occurred. Peri-interventional medication included 5000 IU of unfractionated heparin. Postinterventional therapeutic heparinization was continued for one week.
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Figure 2. (a, b) Both, brachial and inguinal (90-cm 6F sheath with 5F-cobra catheter in SVC) recanalization attempts failed (red lines). Difficult access to the right IJV from transfemoral approach was achievable (light green line). After transfemoral recanalization of the SVC and insertion of a 0.89 mm/0.03500 pull-through-wire (*), transjugular recanalization of the right BCV/SV was achieved (dark green line). (c, d) The pull-through-wire (*) connects the right IJV and SVC via a femoral and jugular access. After transjugular-brachial recanalization, a 0.36 mm/0.01400 Spartacore wire (X) was positioned deep into the SV from the right IJV. For the switch of the jugularbrachial to a femoral-brachial setting, the stiff end of the Spartacore wire, which was going down from the jugular approach into the right arm, was snared jugular outside the patient. The snared Spartacore wire was pulled back all the way down out of the femoral sheath. Finally, a path from the right atrium through the occluded SVC/BCV into the basilic vein was established. SVC: superior vena cava; SV: subclavian vena cava; IJV: internal jugular veins.
Follow-up after 12 months revealed an asymptomatic patient without congestion. Despite high biomechanical stress, duplex ultrasound and venography confirmed patency of the hemodialysis shunt, central venous stents, and the right IJV.
Discussion Recanalization of CVS may be challenging. Several approaches are described either from cranial or femoral access. Our patient suffered from CVS including right BCV, proximal IJV, and SVC. Recanalization via usual brachial and femoral accesses failed. A combined femoral and jugular approach was essential. The key to success was the presented transpositioning maneuver of the guidewire from jugular-brachial into femoralbrachial position. Generally, a standard guidewire and 4F catheter supported by a sheath is adequate for recanalization. Otherwise, nonstandard approaches dealing with chronic venous occlusions are described. The ‘‘false’’ stiff end of guidewires is used to enter hard occlusions. Reentry devices,2 intended for the usage in peripheral artery disease, microdissection (Frontrunner, Cordis),3 LASER (Excimer-Laser-System, Spectranetics),3 and radiofrequency wires4 also proved beneficial for venous recanalization. More aggressive, sharp recanalization techniques include percutaneous puncture
with vessel puncture needles or even Ro¨sch-Uchida needles intended for transjugular portosystemic shunt procedure.5 In the reported patient, the occlusion was overcome by an alternative technique on the basis of standard approaches. Thus, potentially severe complications associated with more aggressive approaches can be avoided. In conclusion, different access sites should be taken into consideration for recanalization of challenging CVS. Snaring a guidewire for transpositioning may be particularly helpful for treatment. Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Kalra M, Gloviczki P, Andrews JC, et al. Open surgical and endovascular treatment of superior vena cava syndrome caused by nonmalignant disease. J Vasc Surg 2003; 38: 215–223. 2. Anil G and Taneja M. Revascularization of an occluded brachiocephalic vein using Outback-LTD re-entry catheter. J Vasc Surg 2010; 52: 1038–1040.
Downloaded from phl.sagepub.com at OhioLink on November 9, 2014
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3. Worley SJ, Gohn DC, Pulliam RW, et al. Subclavian venoplasty by the implanting physicians in 373 patients over 11 years. Heart Rhythm 2011; 8: 526–533. 4. Guimaraes M, Schonholz C, Hannegan C, et al. Radiofrequency wire for the recanalization of central
vein occlusions that have failed conventional endovascular techniques. J Vasc Interv Radiol 2012; 23: 1016–1021. 5. Honnef D, Wingen M, Gu¨nther RW, et al. Sharp central venous recanalization by means of a TIPS needle. Cardiovasc Intervent Radiol 2005; 28: 673–676.
Downloaded from phl.sagepub.com at OhioLink on November 9, 2014
A wire transposition technique for recanalization of chronic complex central venous occlusions A Massmann, A Rostam, P Fries and A Buecker Phlebology published online 1 September 2014 DOI: 10.1177/0268355514550260 The online version of this article can be found at: http://phl.sagepub.com/content/early/2014/08/31/0268355514550260
Published by: http://www.sagepublications.com
Additional services and information for Phlebology can be found at: Email Alerts: http://phl.sagepub.com/cgi/alerts Subscriptions: http://phl.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Sep 1, 2014 What is This?
Downloaded from phl.sagepub.com at OhioLink on November 9, 2014
XML Template (2014) [27.8.2014–6:15pm] //blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/PHLJ/Vol00000/140106/APPFile/SG-PHLJ140106.3d
(PHL)
[1–4] [PREPRINTER stage]
Phlebology OnlineFirst, published on September 1, 2014 as doi:10.1177/0268355514550260
Short Report
A wire transposition technique for recanalization of chronic complex central venous occlusions
Phlebology 0(0) 1–4 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0268355514550260 phl.sagepub.com
A Massmann, A Rostam, P Fries and A Buecker
Abstract Purpose: A minimal-invasive interventional technique for recanalization of complex chronic central venous total occlusions is described to overcome difficulties in case of failure of common approaches. Method: We present a patient with a central venous occlusion that caused severe venous congestion of her upper extremity and significant impairment of her forearm hemodialysis shunt. Since the usual transbrachial and transfemoral attempts for recanalization of occluded right subclavian, brachiocephalic, superior vena cava, and proximal internal jugular veins (IJV) failed, the approach was changed to a transjugular access. Only the IJV and subclavian vein occlusions were passed from transjugular. Results: The key procedure was the switch of a jugular-brachial wire to a femoral-brachial setting. The wire transposition was achieved by snaring the looped stiff end of the jugular-brachial wire outside the jugular sheath from the opposite femoral access. Conclusion: Different approaches should be considered for the recanalization of challenging central venous occlusions. After failed attempts via common access sites, a guidewire transposition maneuver using a combined approach may be particularly helpful for safe and effective endovascular treatment of complex situations.
Keywords Central venous catheterization, venous thoracic outlet syndrome, endovascular, angioplasty, upper extremity deep vein thrombosis
Introduction Central venous stenosis (CVS) is a common cause of impaired hemodialysis shunt function and leads to congestion, thrombosis, and increased bleeding after dialysis. Furthermore, central venous line or lead placement may be impossible. Endovascular treatment shows high success rates. Previous trauma and inflammation of venous vessel wall related to catheter placement resulting in microthrombus, intimal hyperplasia, and fibrosis are discussed as the underlying reasons for the development of CVS.1
Indianola, PA, USA) was performed. Additionally, a chronic complex central venous occlusion was detected including the right subclavian vena cava (SV), brachiocephalic vena cava (BCV), superior vena cava (SVC), and proximal internal jugular veins (IJV). On the following day, acute shunt reocclusion occurred that was mostly likely attributable to the central venous occlusion. Recanalization of the occluded central veins was considered mandatory to achieve persistent shunt patency (Figure 1(a)).
Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
Materials and methods A 35-year-old female presented with an acute thrombosis of her forearm hemodialysis shunt, which remained patent since its creation 2 years ago. After the patient’s written informed consent, hydrodynamic shunt thrombectomy (AngioJet Ultra, Bayer-Medrad,
Corresponding author: Dr. med. Alexander Massmann, Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Kirrberger Straße, 66421 Homburg/Saar, Germany. Email: alexander.massmann@ uks.eu
Downloaded from phl.sagepub.com at OhioLink on November 9, 2014
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Figure 1. (a) Phlebography depicts a central venous occlusion including the right SV, BCV, proximal IJV, and SVC with multiple venous collaterals. The IJV and SVC are not filled with contrast media. (b) Venography after stent implantation (SinusRepoVisual-6F 10/40 mm, OptiMed) into the right SV extended with a funnel-shaped overlap into the right BCV/SVC (SinusVenous-10F 12/80 mm, OptiMed) depicts an excellent angiographic result. There is complete decrease of venous collaterals without stent compression between clavicle and first rib. Clinically, the patient reports a substantial relief of upper extremity congestion.
Results
Switch of the jugular-brachial to a femoral-brachial setting
Transfemoral-jugular recanalization Usual transbrachial and transfemoral recanalization of the right SV, BCV, and SVC failed. A femoral 8F/ 90-cm sheath was advanced to the obstructed SVC. Only the right IJV was accessible transfemorally using a hydrophilic 0.89 mm/0.03500 wire (GlidewireAdvantage, Terumo-Medical, Tokyo, Japan) and 4Fsupport catheter (NaviCross, Terumo-Medical, Tokyo, Japan; Figure 2(a) light green line). An 8F/10-cm sheath was inserted into the right IJV. The Glidewire was snared from jugular resulting in a jugular-femoral pull-through-wire to secure the access from the SVC to the IJV.
Transjugular-subclavian recanalization The jugular sheath was advanced toward the SVC occlusion. Wire passage into the SVC from jugular was impossible although the aforementioned access from femoral to the right IJV was established. The right IJV/BCV occlusion was intraluminally passed from jugular using a manually shaped hydrophilic 0.36 mm/0.01400 wire (Hi-Torque Command-ES, Abbott-Laboratories, AbbottPark, Chicago, IL, USA; Figure 2(a) dark green line). After successful jugular-subclavian recanalization, the Command-ES was exchanged for an atraumatic 0.36-mm wire (Spartacore, Abbott-Laboratories, AbbottPark, Chicago, IL, USA) and advanced deep into the basilic vein (Figure 2(b)).
A snare was advanced from femoral out of the jugular sheath via the pull-through-wire. The free stiff end of the Spartacore, which was going down from jugular into the right arm was snared extracorporally outside the jugular sheath. The free end of the wire was then pulled back through the jugular sheath and finally pulled out of the opposite femoral sheath. A path from femoral through the occluded SVC/BCV into the basilic vein was finally established (Figure 2(c, d)). The Spartacore was exchanged for a stiff 0.89-mm guidewire (Supracore, Abbott-Laboratories, AbbottPark, Chicago, IL, USA). The femoral 90-cm sheath was advanced into the right SV after simultaneous predilatation of the right IJV at the junction to the BCV (6/40 mm) and the SVC/BCV (6/40 mm). Relevant recoil of the right SV required a 10/40-mm stent (SinusRepoVisual-6F, OptiMed Medizinische Instrumente, Ettlingen, Germany). A 12/80-mm stent (SinusVenous-10F, OptiMed-Medizinische Instrumente, Ettlingen, Germany), which is characterized by high radial force and flexibility due to a segmental stent design, was used for stent extension into the right BCV/SVC. Phlebography after postdilatation (12/40 mm) confirmed an excellent result with complete absence of venous collaterals (Figure 1(b)). No procedure-associated complications occurred. Peri-interventional medication included 5000 IU of unfractionated heparin. Postinterventional therapeutic heparinization was continued for one week.
Downloaded from phl.sagepub.com at OhioLink on November 9, 2014
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Figure 2. (a, b) Both, brachial and inguinal (90-cm 6F sheath with 5F-cobra catheter in SVC) recanalization attempts failed (red lines). Difficult access to the right IJV from transfemoral approach was achievable (light green line). After transfemoral recanalization of the SVC and insertion of a 0.89 mm/0.03500 pull-through-wire (*), transjugular recanalization of the right BCV/SV was achieved (dark green line). (c, d) The pull-through-wire (*) connects the right IJV and SVC via a femoral and jugular access. After transjugular-brachial recanalization, a 0.36 mm/0.01400 Spartacore wire (X) was positioned deep into the SV from the right IJV. For the switch of the jugularbrachial to a femoral-brachial setting, the stiff end of the Spartacore wire, which was going down from the jugular approach into the right arm, was snared jugular outside the patient. The snared Spartacore wire was pulled back all the way down out of the femoral sheath. Finally, a path from the right atrium through the occluded SVC/BCV into the basilic vein was established. SVC: superior vena cava; SV: subclavian vena cava; IJV: internal jugular veins.
Follow-up after 12 months revealed an asymptomatic patient without congestion. Despite high biomechanical stress, duplex ultrasound and venography confirmed patency of the hemodialysis shunt, central venous stents, and the right IJV.
Discussion Recanalization of CVS may be challenging. Several approaches are described either from cranial or femoral access. Our patient suffered from CVS including right BCV, proximal IJV, and SVC. Recanalization via usual brachial and femoral accesses failed. A combined femoral and jugular approach was essential. The key to success was the presented transpositioning maneuver of the guidewire from jugular-brachial into femoralbrachial position. Generally, a standard guidewire and 4F catheter supported by a sheath is adequate for recanalization. Otherwise, nonstandard approaches dealing with chronic venous occlusions are described. The ‘‘false’’ stiff end of guidewires is used to enter hard occlusions. Reentry devices,2 intended for the usage in peripheral artery disease, microdissection (Frontrunner, Cordis),3 LASER (Excimer-Laser-System, Spectranetics),3 and radiofrequency wires4 also proved beneficial for venous recanalization. More aggressive, sharp recanalization techniques include percutaneous puncture
with vessel puncture needles or even Ro¨sch-Uchida needles intended for transjugular portosystemic shunt procedure.5 In the reported patient, the occlusion was overcome by an alternative technique on the basis of standard approaches. Thus, potentially severe complications associated with more aggressive approaches can be avoided. In conclusion, different access sites should be taken into consideration for recanalization of challenging CVS. Snaring a guidewire for transpositioning may be particularly helpful for treatment. Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Kalra M, Gloviczki P, Andrews JC, et al. Open surgical and endovascular treatment of superior vena cava syndrome caused by nonmalignant disease. J Vasc Surg 2003; 38: 215–223. 2. Anil G and Taneja M. Revascularization of an occluded brachiocephalic vein using Outback-LTD re-entry catheter. J Vasc Surg 2010; 52: 1038–1040.
Downloaded from phl.sagepub.com at OhioLink on November 9, 2014
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3. Worley SJ, Gohn DC, Pulliam RW, et al. Subclavian venoplasty by the implanting physicians in 373 patients over 11 years. Heart Rhythm 2011; 8: 526–533. 4. Guimaraes M, Schonholz C, Hannegan C, et al. Radiofrequency wire for the recanalization of central
vein occlusions that have failed conventional endovascular techniques. J Vasc Interv Radiol 2012; 23: 1016–1021. 5. Honnef D, Wingen M, Gu¨nther RW, et al. Sharp central venous recanalization by means of a TIPS needle. Cardiovasc Intervent Radiol 2005; 28: 673–676.
Downloaded from phl.sagepub.com at OhioLink on November 9, 2014
