Page 2 - Carotid and peripheral vascular interventions textbook

CHAPTER 1 4
CAROTID AND PERIPHERAL VASCULAR INTERVENTIONS: STEP-BY-STEP

Endovascular Treatment of

Central Venous Disease

Thosaphol Limpijankit

INTRODUCTION Prevention of CVD is the key to prevent AV access failure

as well as other CVD complications. These measures
Central venous disease (CVD) is narrowing or are avoidance of catheter placement in CVD and timely
complete blockage of the large veins in the chest [i.e., placement of AV f stulas in prospective dialysis patients.
superior vena cava (SVC)], brachiocephalic, and subclavian In addition, more study of mechanisms of development
vein. In the past, if deep venous thrombosis presented in of CVD and invention of an effective device therapy will
the upper body, the main location of involvement was the probably result in better ways of treating CVD.
SVC (1,2). The thrombosis generally resulted from tumors
or their treatment such as radiation therapy (3). With the ANATOMICAL CONSIDERATIONS

rising use of indwelling subclavian catheters, subclavian
and brachiocephalic venous occlusion commonly occurs Veins of the upper extremity drain via the basilic or
nowadays. The majority of patients used to have previous cephalic systems. The basilic vein is located in the upper
hemodialysis catheter or pacemaker wire placed in the arm (course along the medial aspect) and the cephalic
subclavian vein (4,5). Subclavian and brachiocephalic vein (course along the lateral aspect) connect at the lower
occlusion is often asymptomatic, but usually develops border of the teres major muscle to become the axillary
sudden edema of ipsilateral upper extremity, face, neck vein. The axillary vein proceeds to the lateral border of
or chest when there is increased blood-f ow from an the f rst rib, at which point it becomes the subclavian vein,
arteriovenous (AV) graft or AV f stula (AVF). Furthermore, which enters the thoracic inlet posterior to the clavicle
CVD might result in diminished vascular access f ow, and anterior to the f rst rib and scalenus anticus muscle
elevated venous pressure, and consequently AV graft or (costoclavicular space) and connects with the internal
AVF thrombosis. jugular vein to form the brachiocephalic vein (13). The
Surgical management of central vein obstruction has most proximal valve is near the venous angle, where
demonstrated durability, with 1-year primary patency of the subclavian and jugular veins connect to become the
80-86% (6,7), but it predisposes to be challenging since brachiocephalic vein (Fig. 14-1). The left brachiocephalic
the blood vessels are deep within the chest. The morbidity vein traverses crossways downward, and the right passes
428 rate also has been reported as high as 30% (6). Currently, steeply downward behind the manubrium. They join

endovascular intervention is the mainstay treatment of CVD together to become the SVC. The left brachiocephalic
and has shown its eff cacy comparable to bypass surgery (8). vein is longer than the right, while neither has a valve.
This procedure using local anaesthesia is well-tolerated by Moreover, the left brachiocephalic vein obstruction may
the patients, and corresponds with shorter hospitalization. be caused by organic stenosis, or alternatively compression
Percutaneous transluminal angioplasty (PTA) using stent between the right brachiocephalic artery and the sternum
implantation for elastic and recoiled stenotic lesions (14). This pathology requires balloon-expandable stent to
provides excellent initial results with low technical failure scaffold and maintain blood-f ow.
and is able to recover the function of the vascular access There are additional signif cant anatomical variations
(9-11). Nevertheless, frequent or multiple procedures are in the paths of left and right central veins. The right internal
often necessary to extend long-term stent patency (9,12). jugular vein crosses the neck nearly straight into the SVC