Axillary to saphenous vein bypass for treatment of central venous obstruction in patients receiving dialysis
Article Outline
Objective
Venous hypertension due to subclavian or innominate vein stenosis coexisting with a functioning arteriovenous access in the ipsilateral arm is a complex problem in patients undergoing hemodialysis. Therapeutic solutions must optimally relieve symptoms, permit use of the angioaccess, and carry minimal surgical risk. The purpose of this study was to evaluate a simple surgical option, bypassing central venous obstruction to the great saphenous vein.
Methods
Eight patients undergoing hemodialysis with severe symptoms and signs of venous hypertension due to subclavian or innominate vein obstruction and ipsilateral arteriovenous fistula or graft underwent axillosaphenous bypass via a subcutaneous 8-mm polytetrafluoroethylene bridge graft.
Results
No intraoperative or immediate postoperative morbidity was observed. Early and 6-month patency rates were 100% and 87.5%, respectively. All patients reported improvement of symptoms, and the angioaccess was usable in all cases. Average follow-up was 21.5 months. One patient had a relapse at 5 months, which necessitated revision of the graft–saphenous vein anastomosis.
Conclusion
Bypassing a central vein occlusion to the saphenous vein relieves symptoms of venous hypertension and prolongs use of the hemodialysis angioaccess.
Stenosis or obstruction of the superior vena cava or more frequently its major tributaries is common in patients with end-stage renal failure undergoing maintenance hemodialysis.1 The situation causes no symptoms unless coexistence of an arteriovenous fistula or arteriovenous graft in the ipsilateral arm causes severe venous hypertension.1, 2 Mild edema may be tolerated by the patient; in contrast, severe incapacitating arm swelling, ulceration, high-pressure venous return during hemodialysis, or persistent bleeding from cannulation points require some therapeutic intervention. Abolition of the arteriovenous communication seems the simplest option3; nevertheless, it does not provide a solution to the underlying disorder, and furthermore it deprives the patient of a site of angioaccess. Venous reconstruction4 or bypass to the internal jugular vein, the external jugular vein, or the right atrium have been described as alternative options of surgical management.2, 5, 6, 7, 8, 9, 10, 11
We describe a new approach for bypassing the occluded central vein via a prosthetic graft to the saphenous vein. This approach was used in 8 patients with a functioning angioaccess in the ipsilateral arm.
Material and methods
Eight patients (4 men, 4 women) with a median age of 61 years (range, 47-63 years) had severe arm swelling and a functioning arteriovenous angioaccess. All patients had a history of ipsilateral subclavian vein catheter insertion, to be used as a temporary hemodialysis access. No accurate data concerning the number of catheter insertions, duration of use as an angioaccess, or infections were available. Previous deep venous thrombosis was ruled out by history; iliofemoral vein patency was confirmed at meticulous clinical and Doppler ultrasound examination. Clinical presentation and location of obstruction are presented in Table I.
Table I. Clinical data
| Patient | Symptoms at presentation | Type of access | Access construction to bypass (mo) | Location of central vein occlusion |
|---|---|---|---|---|
| 1 | Arm, face, and breast swelling; ectropion; thrombosis of jugulo-jugular graft | s-s A-V fistula | 18 | Left innominate |
| 2 | Arm, breast edema; difficulty cannulating fistula | s-s A-V fistula | 5 | Right innominate |
| 3 | Arm edema | e-s A-V fistula | No data | Left subclavian |
| 4 | Arm edema, hand ulcer, hyperpigmentation, bleeding cannulation sites | s-s A-V fistula | 8 | Right subclavian |
| 5 | Arm edema; difficulty cannulating fistula | A-V graft loop, forearm | 10 | Left subclavian |
| 6 | Arm edema, hand ulcer, hyperpigmentation | s-s A-V fistula | 7 | Right subclavian |
| 7 | Arm edema, prolonged bleeding time, breast edema, epiphlebon, ectropion | A-V graft mid-humer | 12 | Left innominate |
| 8 | Arm edema, impossible cannulation | s-s A-V fistula | 7 | Right subclavian |
Perioperative management
A single intravenous dose of 400 mg of teicoplanin was given preoperatively. Before preparation of the operative field a pneumatic tourniquet was applied to the ipsilateral arm to restrict extreme blood loss by inflation and occlusion of the arteriovenous communication in case of bleeding. Postoperatively no restriction in patient motility was advocated, and as a rule no anticoagulant agents or antiplatelet drugs were administered; no use of elastic stockings was recommended.
Surgical technique
The procedure was performed with the patient under local anesthesia in 7 cases. Systemic heparinization was used in 3 patients. The axillary vein was accessed through a 5-cm to 6-cm subclavicular incision in 6 patients, and through axillary incision in 2 patients. The long saphenous vein was dissected at the saphenofemoral junction and 5 to 6 cm distally. An 8-mm polytetrafluoroethylene (PTFE) graft was inserted subcutaneously to bridge the 2 veins. The graft was standard wall in 3 cases and thin wall externally supported in 5 cases. A 10-mm venotomy was made in the axillary vein, and a 20-mm venotomy in the saphenous vein. The graft was anastomosed end-to-side to the veins. The great saphenous vein was not ligated distally (Fig).
Schematic representation of bridge graft route from axillary vein (subclavian region, n = 6; axilla, n = 2) to long saphenous vein.
Graft patency during follow-up was controlled by murmur auscultation and Doppler ultrasound scanning every 3 months. In 2 patients color Doppler scanning was performed.
Results
No blood transfusion was required. The postoperative period was uneventful in all patients. The access was used on the first postoperative day. No leg edema or varicosities were recorded during follow-up. Four patients reported immediate improvement with regard to a sensation of heaviness. In all patients arm stiffness and swelling began to subside during the first postoperative day; within 7 to 10 days the affected arm had less than 4 cm difference in perimeter compared with the contralateral arm, and patients were absolutely symptom-free. Ipsilateral hand hyperpigmentation remained in 2 patients; however, 1 of those patients experienced healing of an accompanying ulcer. Follow-up ranged from 7 to 56 months. One graft failed 5 months after insertion; patency of this graft was restored with thrombectomy and revision. Infection of an inguinal wound was observed in this patient, which resolved after drainage. Bridge graft and access patency data are presented in Table II.
Table II. Results
| Patient | Follow-up (mo) | Bridge graft patency (mo) | Access patency (mo) | Clinical outcome |
|---|---|---|---|---|
| 1 | 56 | 56 | 54 | Bridge graft thrombosed owing to diminished arteriovenous fistula patency; no relapse of any symptom or sign |
| 2 | 18 | 18 | 18 | Death from unrelated reason; bridge graft and access patent |
| 3 | 36 | 36 | 36 | Lost to follow-up |
| 4 | 20 | 20 | 20 | Graft still functioning |
| 5 | 17 | 17 | 17 | Graft still functioning |
| 6 | 8 | 8 | 8 | Graft still functioning |
| 7 | 7 | 5 | 7 | Thrombectomy and dilation of graft-saphenous anastomosis in postoperative month 5; partial resolution of edema, access in use, bridge graft patent |
| 8 | 10 | 10 | 10 | Graft still functioning |
Discussion
Marked edema has been reported in 11% of patients with a history of subclavian vein catheter after A-V fistula creation.1 Functional disability of the involved extremity remains the major side effect, occurring in approximately 75% of patients.5 Treatment options include closure of the fistula, percutaneous transluminal angioplasty, and bypass of the occluded vein segment. Ligation of the access is a simple and effective method for correcting symptomatic stenosis or occlusion of a central vein, and is probably the most frequently performed procedure.1, 2, 3 However, such treatment not only destroys the functional A-V access in a patient critically dependent on hemodialysis, but renders the limb unsuitable for future use as an angioaccess site. Percutaneous transluminal angioplasty is widely performed as a less invasive procedure, with satisfactory short-term results, but high reccurence rates with balloon dilation alone have led to the widespread adoption of stenting.12 In a series comparing surgical and transcutaneous procedures, primary symptomatic relief at 1 year was achieved in 88% of patients in the surgical group versus 36% in the angioplasty group. One-year and 2-year success rates with repeated angioplasty were 86% and 66%, respectively.13 Complication rates of stent therapy have ranged from 0% to 50%.12, 13, 14 Direct repair of the stenotic vein seems to be the most reasonable approach, but requires a major surgical procedure. The results of this approach do not seem to differ markedly from those of other procedures.4
Surgical bypass of the thrombosed area enables conservation of the fistula and preserves other areas for future access sites9; it is currently considered the gold standard,12 given satisfactory long-term patency and low perioperative morbidity rates. A spiral vein15 or PTFE10 graft has been used to bridge the axillary, subclavian, or innominate vein with the right atrium. Nevertheless, there are concerns about the magnitude of such a procedure in a patient population at high risk. Ipsilateral, or rarely contralateral, internal jugular vein has most commonly been used, either as a conduit 6, 7, 16 or as a site of anastomosis of the bypassing graft from the axillary or the distal subclavian vein.2, 5, 8, 16 Although internal jugular vein is a suitable option for bypass, because of its vicinity to the axillary vein, it is associated with 2 main disadvantages. First, if the vein is used as a conduit, it must be ligated and transected, depriving the patient of a site for possible future catheter insertion. Furthermore, the procedure is feasible only if the contralateral internal jugular vein is normal. Second, contrast agent–enhanced studies rarely permit precise localization of the obstruction or accurate estimation of its length, because abundant collateral vessels often obscure the region of obstruction, and frequently the vascular defect extends farther from the previous catheter insertion point.4 Thus, if the obstruction happens to be located or extends proximally to the jugular-subclavian junction, this kind of bypass is useless. This problem is also relevant to use of external jugular vein9, 11 as a receptor site of the bypass. Although bypass to the saphenous vein is free of all of these disadvantages, previous experience with the procedure is limited, focused on management of superior vena cava syndrome.17, 18
A major concern is the patency of such a long venovenous graft. Many factors contribute to poor patency rates of conduits used in vein reconstruction,16 including inadequate flow, material thrombogenicity, and graft collapsibility. Autologous vein grafts (long saphenous vein either reversed or sewn in a spiral pattern) have been used for vein reconstruction or bypass, because of minimal material thrombogenicity, but the technique depends absolutely on the availability and quality of the saphenous vein. Moreover, vein conduits are collapsible, and in the case of axillary-saphenous bypass their length is inadequate to bridge the gap between the 2 vessels, and their occlusion rate is high.19 PTFE conduits are less thrombogenic than other synthetic grafts, and less collapsible, especially in the externally supported version, and thus are widely used.
A well-established treatment of the low velocity problem in vein reconstructive surgery is creation of an A-V fistula distal to the reconstruction.20 This is a preexisting advantage in these patients, and must be considered as the main factor maintaining graft patency.8 In our first patient the graft became thrombosed after deterioration of the A-V fistula; that was the reason for no symptom relapse. The success of surgery in this group of patients should be judged on the duration of A-V fistula function.4 In 1999 Schindler et al12 published a meta-analysis of 5 series with a total number of 53 patients who had undergone surgical bypass to treat superior vena cava syndrome since 1990. Most of those patients received a PTFE graft; spiral vein grafts were used less often. Primary patency rates ranging from 67% to 100%, secondary patency rates of up to 100%, and 5-year patency rate of 86% were reported.12 In patients undergoing hemodialysis after different surgical procedures, Bhatia et al20 reported 100% initial patency, 92% 6-month patency, and 83% 1-year patency. In the present study the initial patency was 100%, primary 6-month patency was 87.5%, and secondary 6-month patency was 100%.
Satisfactory results have been reported with internal jugular vein–superior vena cava transposition, but multiple incisions are necessary, most probably along with resection of the clavicle. Internal jugular vein is sacrificed, therefore precluding its use for temporary access, hemodynamic monitoring, or even outflow for A-V fistulas. The procedure is contraindicated if there is occlusion of the contralateral internal jugular vein or innominate vein. Unless the clavicle is resected to enable complete mobilization of the internal jugular vein down to the innominate vein, the internal jugular vein kinks and may be functionally obstructed at the point where it is turned back to reach the superior vena cava.4 The recently reported technique of decompression of A-V graft to the ipsilateral femoral vein21 offers a solution only to the excess pressure problem, leaving the arm unsuitable for further use in case of occlusion of the decompressed graft. Graft dissection in an arm with venous hypertension is not an attractive option, and the method is of questionable applicability in cases of A-V fistula. Use of femoral vein is also a less safe alternative in a complicated case. An axillosaphenous bypass is a much more simple procedure, accomplished easily with the patient under local anesthesia, and carries substantially less risk, with comparable results.
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Competition of interest: none.
PII: S0741-5214(04)00926-7
doi:10.1016/j.jvs.2004.07.009
© 2004 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
