Page 2 - Carotid and peripheral vascular interventions textbook
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                    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
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