Re-Establishment of Vascular Access After Superior Vena Cava Occlusion in Hemodialysis Patients

Objective To evaluate the application of percutaneous right atrial puncture and tunneled cuffed catheter insertion and the establishment of peripheral arteriovenous (AV) access in hemodialysis patients with superior vena cava occlusion (SVCO), and to provide evidence-based support for the re-establishment of vascular access in patients with limited vascular resources.

Methods Patients with SVCO were enrolled. Then, either right neck percutaneous puncture catheterization or peripheral AV access construction was performed on the patients according to their personal preference. The patients were divided into the catheter group and the AV access group accordingly. Under the guidance of double C-arm digital subtraction angiography, a puncture was made in the right brachiocephalic vein or the stump of superior vena cava. Portal venous shunt instrument RUPS100 was then inserted through the guide wire, and the hard end of the guide wire was used to puncture the right atrium to achieve sharp recanalization of the occlusive superior vena cava. Afterwards, balloon expansion of the obstructive superior vena cava lesion and the subsequent implantation of the tunneled-cuffed catheter were performed. In AV access group, after evaluating the collateral veins by venougraphy and the peripheral vessel by ultrasound, autologous AV fistula or graft was established according to the vascular conditions of the patient and their personal preferences. The demographic information and clinical outcomes, such primary and primary assisted patency of access, were documented and the incidence of complications was monitored. With the duration of patent access defined as the survival time, Kaplan-Meier survival analysis was performed to compare the patency rates of the two groups.

Results A total of 45 SVCO patients were enrolled and underwent re-establishment of vascular access. Among them, 21 cases were in the catheter group and 24 cases were in the AV access group. All patients had their vascular access successfully constructed and received hemodialysis, and no relevant complications or deaths occurred during the procedure. Over the mean follow-up period of (471.22±125.94) days, the primary patency rates in the catheter group 95.2% and 85.7% at 6 and 12 months, respectively, and the primary assisted patency rates were 100% and 95.2%, respectively. The primary patency rates of the AV access group were 79.2% and 62.5% at 6 and 12 months, and the primary assisted patency rates were 95.8% and 87.5%, respectively. No significant difference was observed between the two groups. Kaplan-Meier survival analysis showed that the median survival time (defined as the duration of patent access) was 670.00 (468.99, 871.01) days in the catheter group and 450.00 (339.24, 560.76) days in the AV access group, with the catheter group outperforming the AV access group. The primary patency rate of the catheter group was better than that of the AV access group (P=0.049). On the other hand, no significant difference was observed in the primary assisted patency rates of the two groups.

Conclusions Long-term vascular access can be established for SVCO patients by either percutaneous catheterization through the right atrium of superior vena cava stump or the establishment of peripheral AV access. The comprehensive plan, which includes the establishment of AV access first and the subsequent catheterization, is expected to improve the total duration of long-term vascular access and prolong the overall survival of dialysis patients, which provides new ideas for re-establishing dialysis access in patients with exhausted central venous resources.