Page 11 - Carotid and peripheral vascular interventions textbook

CHAPTER 14 • ENDOVASCULAR TREATMENT OF CENTRAL VENOUS DISEASE

In case of failure from arm approach, a common
Table 14-2. Indications for arm/central venography
femoral vein is normally used. A 6-Fr 70 cm Flexor
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To evaluate: Raabe sheath (Cook), DuraSheath (BMV Medical),
or Destination guiding sheath or a 7-Fr 70-80 cm
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• Anatomy for preoperative planning of dialysis access surgery
Brite-tip sheath (Cordis) is inserted in the common
(arteriovenous f stula or graft creation)
• Anatomy prior to central venous catheter (e.g., peripherally femoral venous access site and positioned near the
inserted central catheter [PICC], long-term central venous ostium of the brachiocephalic vein. For stent diameter
catheters, ports) or pacemaker placement up to 14 mm, 7-Fr diameter sheaths can be employed
• Upper extremity superf cial and/or deep vein thrombosis to delivered the stents.
• CVD secondary to long-term indwelling catheters, mediastinal
f brosis, thoracic malignancy, or radiotherapy CROSSING THE LESION
• Hemodialysis shunt dysfunction
• Central venous catheter related stenosis/occlusion
A 5-Fr or 6-Fr JR4 or MP diagnostic catheter is placed
inside a sheath and advanced up to the stenotic lesion
or occlusion site of the brachiocephalic or subclavian
SHEATH PLACEMENT vein. In general, it is preferable to treat the lesion from
the hemodialysis access, since it is simpler and a shorter
A 20-gauge Jelco catheter over needle is usually distance when compared with working from the femoral
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used to enter the venous outf ow of the AV f stula or approach, which may necessitate a long introducer sheath
graft or superf cial vein (e.g., cephalic or basilic) from to provide stable access. A 0.035” J-tip or angle-tip
the arm. Importantly, sterile technique is used and hydrophilic Glidewire (Terumo) is usually the wire of
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local anesthesia inf ltrated in area of access prior to choice to cross via the stenotic or occluded vein segment
access needle introduction. Once the needle tip is conf rmed (Fig. 14-7). The “J” shape tip protects from “digging”
to be within the lumen with pulsatile backf ow of blood, into the wall of the vein and potentially perforating out
a 0.018” guide wire is introduced and passed through of the side of the vein. Typical techniques include using
the lumen of vein graft. Sometimes, passing a guide coaxial support catheters and sheaths, back and front ends
wire via needle into vein is diff cult which is caused by of guide wires, and sharp needle techniques.
guide wire in side branch, guide wire against stenosis/ If the 5-Fr or 6-Fr catheter is not advanced, it is
occlusion or valve. It is recommended to pull back switched for a 4-Fr hydrophilic catheter (Glidecath ,
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the wire and redirect under f uoroscopy or advance Terumo) to cross or needed pre-dilatation with a 0.014”
the Jelco catheter over wire and perform AV or 0.018” small prof le coronary or peripheral balloon.
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f stulogram and central venogram to def ne anatomy When the stenotic lesion is traversed with the hydrophilic
or pathology. DSA using hand injection with 50:50 guide wire, the catheter is then forwarded over the lesion
contrast and saline is then performed. If a patient and switched for a 0.035” Amplatz super stiff™ wire
has central venous obstruction and requires angioplasty (Boston Scientif c) that offers increased support to passage
or stenting, the 20-gauge Jelco catheter is switched of a balloon catheter across the lesion.
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for a 6-Fr radial sheath placed into the graft access. 437
The sheath (together with the dilator inserted) is Wiring techniques for central
then introduced over the guide wire to the vein graft. venous occlusion

A small superf cial skin incision can be made where For occlusions that are unable to be easily crossed,
the guide wire enters through the skin to enable smooth two-way approach should be considered from AV shunt
crossing of the sheath. Once the sheath is completely access and common femoral vein. With an occlusion,
advanced, the guide wire and the dilator assembly can one should closely examine the venogram on both ends
be removed. The radial sheath can accept 0.035” guide for any “nipple” or focal beak-like area (venous stump)
wires over which it can be exchanged out for a larger that can be a starting point to begin probing with the
diameter sheath (7-Fr) and longer sheath (25 cm) depending Glidewire (Fig. 14-8). Antegrade approach from the
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on the procedure. arm access is sometimes useful to cross to another end