Topic: Optimal management of cephalic vein arch and central vein stenosis in AV access

Abstract

The arteriovenous fistula (AVF) is the recommended vascular access to provide hemodialysis for patients with end-stage renal disease (ESRD) and most common type of AVF is brachiocephalic fistula (BCF). The cephalic arch is an area of active and persistent geometric remodeling due to abnormal hemodynamic flow initiated with the surgical creation of the BCF. Meanwhile, patients on chronic hemodialysis often develop central venous stenosis or occlusion in all type hemodialysis access limbs. These central venous lesions are usually associated with venous shear stress, trauma caused by previous central venous cannulation and pacemaker leads, and anatomical compression by the clavicle and first rib. Cephalic arch stenosis (CAS) is known to occur in 26-60% of patients with upper arm AVF, and central vein stenosis (CVS) is known to occur in 10-13% of patients with total AVF or arteriovenous graft (AVG).
The most well-known treatment for CAS or CVS is percutaneous transluminal angioplasty (PTA) or venous stenting. However, the patency of PTA is 60-70% in 1 year and 50% in 3 years for CAS, and it is only 55% in 1 year and 25-30% in 2 years for CVS. The results of stent-graft are slightly better than PTA, and there is a recent expectation that paclitaxel-coated PTA will be more effective for CAS. Technological development of stents and development of stents specialized for veins are highly anticipated as they increase radial force and improve patency. Recently, HeRO (Hemodialysis Reliable Outflow) catheter is used for central venous stenosis as a device that combines surgical graft and central venous tube. In a meta-analysis involving a total of 34 studies, the primary patency rate of HeRO was 50% and 36% at 6 and 12 months, respectively, and the secondary patency rate was 6 and 12 months, respectively. 76% and 65%, respectively, in months.
However, not only treatment after CAS or CVS, but also efforts to reduce these complications at the time of AVF formation and discussion with experts in related fields are required.