The Michigan Vascular Access/MiDRE primer in Vascular Access
Chapter 7 - Radiologic examination of the dialysis access candidate
Indications for venography prior to access placement
Many patients come to a referral surgeon with multiple previous accesses or access attempts, prolonged time (greater than three months) on the dialysis catheter, with or without a history of upper extremity deep venous thrombosis, arm swelling, an ipsilateral pacemaker, in extremities with a history of arm swelling, and particularly in an extremity with a previously failed access. Central venous patency may have been compromised, limited, or obliterated by previous catheter placement, PICC lines, pacemakers or other devices. In these cases, central venous patency and status need to be clarified prior to committing to an access which may not only fail, but may confer an unacceptable complication on the patient.
Peripheral venous anatomy is also demonstrated by venography, but in most cases the peripheral anatomy can be adequately assessed with ultrasound. The primary value of venography is in the evaluation of the central veins.
In some cases there is mild to moderate central venous stenosis that can be managed within a long-range access plan – a stenosis may be detected at the time of access placement, dilated at the time of catheter removal, and the patient placed in a long-term close monitoring program for redilations or stenting as needed. In some cases, a central venous stenosis must be recanalize and stented prior to placing an access, and in some cases central venous damage precludes or in other ways leads us away from that extremity. Indeed, in some cases, it may be a question not of what access can be placed, but whether any access can be placed in the upper extremities at all, and with what effort.
In extreme chronic cases, a bilateral venogram may be ordered prior to the surgery to define access options, with possible femoral retrograde central venography to recanalize and manage difficult cases, but this takes time, and frequently central venous anatomy is not well demonstrated by injection through small IVs in peripheral veins. A comprehensive multi-access evaluation can be ordered as a HeRO evaluation, in which multiple approaches may be employed to the known difficult patient.
More frequently, we recommend a venogram to be included at the time of surgery, with the added benefit that, once in the vein, a catheter can be run up to the central veins for contrast injection and a clearer definition of the anatomy. Any lesion noted can be treated with venoplasty or stenting prior to placement of the access. In 2009, eighty patients were recommended to have an intraoperative venogram at the time of access placement. Six were found to have occluded central veins and the access placement was abandoned to avoid unacceptable complications. Seventy-four of the eighty went on to have an access placed, nineteen after venoplasty and four after stent placement.
One patient had fistula creation despite central venous occlusion as a calculated risk necessary due to the lack of other options – the risk was worthwhile, and the access became usable.
In conclusion, the incidence of catheter-related stenosis is so high and increasing by the year, that a comprehensive approach must be taken to the diagnosis of these problems and the management patients. Like any chronic illness, central venous stenosis can be managed successfully, even in conjunction with an ipsilateral access (Chapter 28).
Venography from the right, with normal central veins dumping down into the SVC
Venography from the left, with normal innominant vein traversing the chest, and then dumping into the SVC
Venography with normal veins coming from the left arm, traversing the chest, with a catheter in the left IJ. Okay for access creation, but catheter in outflow tract of access can produce long term problems, and should be re-investigated at time of catheter removal
Venogram with left IJ permacath, and left innominant vein occluded around the catheter. Plan fir immediate dilation, with or without stent at time of access creation, with or without removal and replacement of the catheter for, OR, delayed venoplasty at the time of catheter removal, hoping that disabling arm swelling does not occur in the meantime
Venogram from the right, with the right innominant occluded around the catheter. Plan fir immediate dilation, with or without stent at time of access creation, with or without removal and replacement of the catheter for access, OR, delayed venoplasty at the time of catheter removal, hoping that disabling arm swelling does not occur in the meantime. Note previous stent in SVC around catheter
Catheter removed over wire, occlusion dilated, and SVC restented. The catheter can be replaced over the wire through the stent is desired while access is healing/developing
Intraoperative venogram to ascertain the status of the peripheral and central veins