Most Complex Brachiocephalic Vein Occlusion in Hemodialysis Patients Can be Treated with Simple Endovascular Techniques in an Office-based Angiosuite.

OBJECTIVE: Brachiocephalic vein (BCV) obstruction can cause dialysis access dysfunction and failure. Central vein stenosis involving the BCV may require advanced endovascular procedures. We report that most BCV occlusions can be treated using simple endovascular techniques on an outpatient basis.

METHODS: From Jan 2009 to Jan 2022, 115 hemodialysis patients underwent BCV endovascular revascularization. Seventy-three of the initial procedures were performed in an office-based angiosuite. Indications for the procedure were brachiocephalic vein occlusion endangering the performance of a previous arm access or making the creation of a new arm access unadvisable. We recorded and analyzed risk factors and procedural results, patency rates, complications, and mortality.

RESULTS: Median age was 62 years (range 23-91); 56% were female. Most prevalent associated conditions were diabetes mellitus (61%) and hypertension (68%). Fifty-six patients (48.7%) presented with severe upper extremity edema ipsilateral to the side of pre-existing functioning access. Obstruction recanalization was effective using standard catheter and wire in 106 cases (92.1%) and transseptal needle in 9 cases (7.8%), that included 7 using inside-out procedure. Initial management of the BCV stenosis was PTA alone in 74 patients (64.3%), stenting in 33 (28.7%), and HeRO conduit in 8 cases (7%). Treatment of other central venous lesions included 49 cases (42.6%). The procedure was successful in was 99.1%. No intraoperative complications ocurred. All 92 patients with previous arm access maintained adequate performance (100%). In 22 out of 23 patients (95.6%), new upper extremity access creation was effectively performed after the venous intervention. Overall clinical success rate was 92%. Mean post-op monitoring was 23 months, median 12, range 1-84 months. During this monitoring period, 266 endovascular procedures, 91% in the office and 9% in the hospital were required to preserve access performance. Eventually, 49 patients were stented (42.6%). Eleven patients (9.56%) had infections and, six required complete access removal. Other causes of access failure included two patients with central vein thrombosis and one with massive pulmonary embolus. At the end, nine patients had access failure (7.8%). Thirty-two patients (27.8%) died of unrelated causes during the follow up period. Seventy-six patients (66%) have maintained functional access. Kaplan-Meier curves determined median primary patency of 9.6 months, median primary assisted patency of 56.2 months and secondary patency of 75% at 80 months.

CONCLUSION: Successful endovascular revascularization of brachiocephalic vein obstruction can be treated safely, with simple endovascular techniques in an office-based context with minor complication rates and durable results.