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In hemodialysis (HD) patients, central venous stenosis (CVS) or occlusion can cause venous hypertension, leading to symptoms such as edema and/or pain of upper extremity, prolonged bleeding after dialysis. Percutaneous transluminal angioplasty (PTA) for central venous lesions carries a risk of vascular injury. This risk is particularly high in cases of chronic occlusion, where the non-straightforward passage of a guidewire often complicates recanalization.
Here, we report a case of left subclavian vein occlusion where initial PTA failed, but successful recanalization was achieved during a second attempt using a biplane angiography system and intravascular ultrasound (IVUS).
A 66-year-old male developed end stage kidney failure due to diabetic kidney disease began HD 14 years ago via a left forearm arteriovenous fistula (AVF). Although he had ultrasound-guided vascular access interventional therapy for AVF stenosis in the upper limb, he had no history of central stenosis. Two years ago, he underwent off-pump coronary artery bypass grafting for acute myocardial infarction. Two months ago, he developed painless edema of left upper limb and venous congestion in the superficial veins of the upper arms and anterior chest, raising suspicion of central venous hypertension due to CVS. Angiography revealed reflux into the left internal jugular vein, but the location of the stenosis was unclear. As the left upper limb edema and poor skin coloration worsened, PTA wase scheduled. Angiography confirmed occlusion of the the left subclavian vein extending to the innominate vein, with collateral flow. An initial PTA attempt, using both a retrograde approach from the left cephalic vein and an antegrade approach from the right femoral vein with a single-plane system, failed to pass the guidewire through the occluded segment. One week later, a second PTA attempt was performed utilizing a biplane angiography system. While confirming the proper direction of the guidewire, it successfully traversed the occlusion site using a 60g tip-load guidewire. IVUS was then used to confirm the guidewire position within the true vessel lumen. Subsequent balloon dilatation successfully relieved the occlusion, leading to the improvement of the patient's upper limb edema and poor coloration.
Intervention is the first-line treatment for venous hypertension caused by CVS, yet navigating chronically occluded lesions can be challenging. In our case, the initial failure to pass the guidewire led us to consider alternative, more invasive options such as AVF closure with contralateral reconstruction or surgical bypass around the occlusion. Considering disadvantages of greater invasiveness and the need for AVF reconstruction, we opted for a repeat PTA. The successful and safe reopening of the occlusion on the second attempt was attributed to the synergic support of the biplane angiography system and IVUS guidance.
The combined use of biplane angiography systems and IVUS significantly enhances the safety and success rate of PTA, particularly for chronic central venous occlusion where guidewire passage is challenging.
