Indications

• Achieve long-term neck (aka “up top”) access for hemodialysis catheters in a pt with chronically narrowed or occluded central veins

• Provide symptom relief for pts with upper extremity and/or neck swelling when central veins are occluded and collateral venous flow back to the heart is inadequate.

• Provide symptom relief for pts with apical lung ca or mediastinal ca causing compression of the SVC.

Contraindications

• Central venous thrombosis (acute clot should be anticoagulated first to prevent PE)

• Inadequate sites for access

• Uncorrectable coagulopathy

• Systemic infection (stent is at high risk for prosthetic infection)

• Contrast allergy that cannot be premedicated

Imaging Review

• CT venogram is often required to fully evaluate the length of stenoses/occlusions as well as more acute thrombus.

• Is there a wisp of contrast to pass a wire through? Or is this almost certainly a sharp recanalization or PowerWire (RF-emitting wire) situation?

• Relationship of occluded vein to problematic structures, such as the pericardium. Longer occlusions become exponentially more difficult to recanalize and riskier.

Tips for Workup

• How acute are the symptoms? Facial swelling with airway compromise = emergency; otherwise, the procedure can often be performed the next day or even as an outpatient.

• Access: Typically IJ and femoral, if available; sometimes AV fistula can be used for access

• Anesthesia: GA is often preferred for recanalization that are anticipated to be longer and more complex

• Consent:

  • • Injury to target veins, pericardial tamponade, mediastinal hemorrhage, death, infection, contrast-induced nephropathy, inability to cross lesion, stent migration / malposition / occlusion