Proksch Daisy M, Rodriguez Limael E, Rathore Animesh, Steerman Samuel N, Panneton Jean M
Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va.
Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va.
J Vasc Surg Venous Lymphat Disord. 2021 Sep;9(5):1136-1144. doi: 10.1016/j.jvsv.2021.01.001. Epub 2021 Jan 13.
Central venous occlusive disease is a common cause of upper extremity arteriovenous access dysfunction in hemodialysis patients. When refractory to balloon angioplasty, the treatment options include central venous stenting and hemodialysis reliable outflow (HeRO; Merit Medical, South Jordan, Utah) graft. The purpose of the present study was to evaluate the outcomes of these options.
A retrospective review was performed of patients who had undergone central venous stenting or HeRO placement for central venous obstruction from December 2008 to March 2018. The primary outcomes were the reintervention rates, patency, and mortality.
A total of 75 hemodialysis patients were identified after failed balloon angioplasty for central venous obstruction. Of the 75 patients, 44 underwent central venous stenting comprising coverage of the subclavian vein (n = 27), innominate vein (n = 18), and/or superior vena cava (n = 5). Six stent patients later underwent HeRO placement. The stents used were stent grafts in 65% (Viabahn, n = 9; Fluency/Flair, n = 19; iCast, n = 2; and other, n = 1) and bare metal stents in 35% (Wall-stent, n = 6; Protégé, n = 1; Cobalt, n = 1; and other, n = 9). The remaining 31 patients underwent HeRO graft placement. The venous outflow component insertion sites were the internal jugular (n = 20), external jugular (n = 1), subclavian (n = 6), axillary (n = 2), and other (n = 2). The stent and HeRO groups were similar in the previous central venous intervention rates (median, 0.6 [interquartile range (IQR), 0-3.0]; vs median, 3.5 [IQR, 0-10.1] annually; P = .679). After the index procedure, no difference was found between the two groups in the frequency of dialysis circuit interventions annually (median, 2.0 [IQR, 0-6.0]; vs median, 2.0 [IQR, 0-7.0]; P = .291) nor central venous interventions (ie, angioplasty of the central veins or within the portion of the HeRO inside the central veins) annually (median, 2.0 [IQR, 0-4.1]; vs median, 0 [IQR, 0-2.4]; P = .419). The 1-year access circuit primary patency was 8.1% for stenting and 22.2% for HeRO (P = .109). The 2-year access circuit secondary patency was 40.0% for stenting and 52.4% for HeRO (P = .401). The all-cause mortality was similar at 1 year (3.7% vs 4.8%; P = .856) and 2 years (11.8% vs 23.5%; P = .368).
Central venous stenting and HeRO were shown to have similar rates of reintervention and patency. The results from the present study suggest that the multiple treatment options available for this problematic disease process can yield similar results when careful patient selection is applied.
中心静脉闭塞性疾病是血液透析患者上肢动静脉通路功能障碍的常见原因。当球囊血管成形术效果不佳时，治疗选择包括中心静脉支架置入术和血液透析可靠流出道（HeRO；Merit Medical，美国犹他州南乔丹）移植物。本研究的目的是评估这些治疗选择的效果。
对2008年12月至2018年3月因中心静脉阻塞接受中心静脉支架置入术或HeRO植入术的患者进行回顾性研究。主要结局指标为再次干预率、通畅率和死亡率。
共确定75例中心静脉阻塞球囊血管成形术失败的血液透析患者。75例患者中，44例行中心静脉支架置入术，包括锁骨下静脉（n = 27）、无名静脉（n = 18）和/或上腔静脉（n = 5）的覆盖。6例支架置入患者后来接受了HeRO植入术。使用的支架中，65%为覆膜支架（Viabahn，n = 9；Fluency/Flair，n = 19；iCast，n = 2；其他，n = 1），35%为裸金属支架（Wall-stent，n = 6；Protégé，n = 1；Cobalt，n = 1；其他，n = 9）。其余31例患者接受了HeRO移植物植入术。静脉流出道组件的插入部位为颈内静脉（n = 20）、颈外静脉（n = 1）、锁骨下静脉（n = 6）、腋静脉（n = 2）和其他（n = 2）。支架组和HeRO组之前的中心静脉干预率相似（中位数，0.6[四分位间距（IQR），0 - 3.0]；每年对比中位数，3.5[IQR，0 - 10.1]；P = 0.679）。在索引手术之后，两组每年透析回路干预的频率无差异（中位数，2.0[IQR，0 - 6.0]；每年对比中位数，2.0[IQR，0 - 7.0]；P = 0.291），每年的中心静脉干预（即中心静脉或HeRO在中心静脉内部分的血管成形术）也无差异（中位数，2.0[IQR，0 - 4.1]；每年对比中位数，0[IQR，0 - 2.4]；P = 0.419）。1年时通路回路的初级通畅率，支架置入术为8.1%，HeRO为22.2%（P = 0.109）。2年时通路回路的次级通畅率，支架置入术为40.0%，HeRO为52.4%（P = 0.401）。全因死亡率在1年时相似（3.7%对4.8%；P = 0.856），在2年时也相似（11.8%对23.5%；P = 0.368）。
中心静脉支架置入术和HeRO显示出相似的再次干预率和通畅率。本研究结果表明，对于这一疑难疾病过程，当进行仔细的患者选择时，多种可用的治疗选择可产生相似的结果。
