Surgical treatment of hemodialysis-related central venous stenosis or occlusion: another option to maintain vascular access.

Abstract

The most common cause of graft failure in patients undergoing hemodialysis is outflow venous stenosis. Long-term compromise of venous central trunks must be resolved. This study was undertaken to evaluate an unusual surgical option, bypass to decompress a long-term vascular graft to the femoral vein, improving venous outflow, alleviating symptoms of venous hypertension, and restoring vascular integrity for dialysis. The study included 3 patients with end-stage renal disease with signs and symptoms of dysfunctioning grafts. Angiographic studies showed occlusion or stricture of the central venous tract and venous outflow compromise. All patients had multiple temporary and long-term vascular access sites for hemodialysis, which were revised several times. Venous decompression was performed with a bridge to the ipsilateral femoral vein. A 6 mm reinforced polytetrafluoroethylene graft was tunneled subcutaneously along the thoracoabdominal wall. Patients were released 48 hours after the procedure, and periodic follow-up was carried out to detect changes in graft patency and function. There were no preoperative or intraoperative complications. Clear improvement in signs and symptoms of venous hypertension were observed. Venous pressures decreased. Average follow-up was 16.3 months. In 1 patient the new graft malfunctioned, and it was revised and repaired at 25 months. The presence of deep venous thrombosis and pulmonary embolism required peritoneal dialysis. Two other patients, with no change in graft patency, died of concomitant disease. Decompression of the femoral vein enables preservation of vascular graft patency and improves symptoms of venous hypertension.