SIR 2024
Renal and GU Interventions
Ajit Nair, MD
Attending Radiologist
Santa Clara Valley Medical Center
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James Zou, MD
Resident Physician
Santa Clara Valley Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Ehab Sorial, MD
Attending Surgeon
Santa Clara Valley Medical Center
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End stage renal disease is a common chronic disease which requires renal replacement therapy, most often in the form of hemodialysis. Most of these patients will, at some point, undergo hemodialysis using a tunneled dialysis catheter. Chronic dialysis catheters, stents and other intravascular devices can lead to thoracic central venous occlusion, which can complicate future vascular access for dialysis. The Surfacer Inside-Out Catheter Access System (Merit Medical) is a novel device that re-establishes central vascular access through occluded right brachiocephalic and internal jugular veins. This allows for preservation of the left brachiocephalic vein for future hemodialysis circuits, and in some cases provides a conduit for creation of future hemodialysis circuits in the right upper extremity. This study examines whether the complexity of central venous occlusions affects the success of this technique.
Materials and methods: Patients were identified by chart and imaging review on the hospital radiology information system. Using the SIR Reporting Standards for Thoracic Central Vein Obstruction {1}, we retrospectively examined whether occlusion type is predictive of technical success or failure of Surfacer-assisted tunneled hemodialysis catheter placement (defined as cases in which a tunneled catheter was placed using the Surfacer technique). Occlusion types were determined angiographically and by contrast-enhanced CT, when available. We analyzed the medical record for post-procedural complications and to determine reasons for technical failure.
Results:
At our single-center institution, we performed 35 Surfacer procedures on 30 patients from May 2018 to July 2023. 13 procedures were performed on 12 patients with type I occlusions, 16 procedures were performed on 13 patients with type II occlusions, and 6 procedures were performed on 5 patients with type III occlusions. No type IV occlusions were encountered. Rates of success were 84%, 75% and 67%, respectively (Chi-Square p-value = 0.66). Technical failures (n=7) were attributable to inability to safely pass the device through remnant vessels (n=3), tortuosity of iliac veins (n=3), and patient discomfort (n=1). There were two cases of vascular injury apparent on intraprocedural fluoroscopic images. There was no significant long term patient morbidity/mortality attributable to our intervention.
Conclusion:
Our data suggests a high rate of safety and technical success of right sided catheter placement using the Surfacer technique in patients with types I, II and III thoracic central venous occlusions.