INSIDE-OUT ACCESS CATHETER SYSTEM AS RELIABLE APPROACH FOR CENTRAL VAIN OCCLUSION

 Central vain occlusion is relatively common problems in patient on long term haemodialysis .it associated with increase morbidity .and complication like superior vena cava syndrome. also it limit the maturation and lead to primery failure of arteriovenous fistula .and decrease the chance of succefull future AV access creation.

   We reported a 68  years old male .ESRD on Haemodialysis.he is also  Hypertension. Type 2 diabetes.arterial fibrillation on anti coagulation and  PVD s/p left AKA .He had multiple vascular access problems with history of multiple  previous central tunnelled dialysis access which cause for him central vain occlusion which failed to recanalize with endovascular intervention as well as history of failed  multiple AVF /AVG. he lefted  with right femoral tunnelled dialysis access.unfortunatly he is not fit for peritoneal dialysis because of big abdominal hernia.we performed for him Inside-out access cathter procedure for placement of tunnelled dialysis access to overcome the central vain occlusion. later on followed by placment of hemolysis reliable outflow HeRO graft .maintained on heamolysis with good adequacy and the femoral cathter removed .

Central vain occlusion is common among haemodialysis patients .the main risk factors includes  long term haemodialysis catheter , pace makers/AICD leads, central vain ports ,catheters for TPN and  radiation . unfortunately it takes only few weeks to develop central vain stenosis and even placement of one catheter can lead to central stenosis .further more after removal of the catheter the cascade of scaring still there and may associated with the risk of central stenosis.

The pathophysiology of central vain stenosis resulting from venous wall thickening associated with de novo neointimal hyperplasia.

an organized mural thrombus, fibrosis, the endoluminal obstruction is a common finding following repeated central venous catheter .

In patients with chronically occluded central veins, the current approach is to move to another vein. eg femoral vein catheter placement is a frequently used alternative when thoracic central veins are obstructed and can not recanalized by endovascular procedure.

  but this site is burdened by an increased rate of device malfunction, infection  and thrombosis .

alternative catheter placement through the lumbar approach in the inferior vena cava (IVC) or hepatic veins but these techniques are technically difficult and may be associated with higher risk of complications increasing patient morbidity and in addition to the overall cost of care.

The Inside-Out access cathter system approach allow to change the standard of care.The System is inserted through the femoral vein and navigated to an exit point in the right internal jugular (RIJ) vein.This proprietary Inside-Out approach achieves access to an occluded RIJ vein .

the inside-out  system consists of 4 components, including a device consisting of needle guide,needle wire, and a specialized handle. The workstation sheath, which is 7-F in diameter and 95 cm in length, has a lumen which enables advancement of the device through the femoral vein .a radiopaque exit target is used as an external marker to indicate the desired exit site for the needle wire at the supraclavicular exit location. peel-away introducer used for percutaneous access to the venous system over the externalized needle wire•

The procedure is reliable •in one review 100% (12 of 12) of patients underwent successful central venous access placement.  100% (12 of 12) of patients maintained patency of central venous access through long-term follow-up visit .no device-related adverse events were reported within 48 hours and at 14-day follow-up visit.the procedure is easier, minimally invasive compared to surgical bypass for patients with totally occluded central veins .supports the achievement of permanent AV access which reduces hemodialysis provider cost and downtime by decreasing catheter-associated morbidity and complications.

  Central vain occlusion is common among haemodialysis patients. associated with increase morbidity. and decrease and limit maturation of permanent arteriovenous fistula creation . The Inside-Out system allow to recanalization of internal jugular and placement of tunnelled dialysis access .and this can be  change in the future to heamolysis reliable outflow access (HeRO Graft.) and allow the placement and maturation of permanent AV access .