Management of Venous Hypertension after Vascular Access in Haemodialysis Patient

Abstract

The Pathology of central venous stenosis related to hemodialysis is most often initiated by placement of an indwelling catheter. Injury to the venous wall leads to fibrotic reaction and thrombosis that may cause significant stenosis or complete occlusion of the central veins. CVS can be asymptomatic and detected on a diagnostic venogram or fistulogram before access placement for an immature fistula. Most occult CVS cases become clinically apparent after development of a functioning AV access in the ipsilateral extremity. Symptomatology secondary to CVS depends on the anatomic location of the stenosis or obstruction. CVS commonly presents with edema and/or venous hypertension of the corresponding extremity and/or breast. It can also presents with swelling, induration, hyperpigmentation, and even ulceration of the hand. Duplex is the preferred diagnostic method for early-onset edema following autogenous access placement because it avoids cannulation of the newly created access and potential damage of the thin-walled vein. Venogram or fistulogram is the study of choice in these patients owing to the insensitivity of duplex in evaluating the central veins. There are many lines of treatment of CVS including access sacrifice, endovascular treatments angioplasty, stenting and covered stent placement and venovenous bypass. Endovascular treatment angioplasty, stenting techniques offers a minimally invasive therapeutic option for these patients. The addition of intravascular stents to the angioplasty procedure led to better results. Intravascular stents reduced the elastic recoil of these hyperplastic venous lesions. BMSs are the second-generation technology and second line of treatment for CVS; they provide mechanical support to a site of stenosis that is resistant or unresponsive to PTA. Covered stents, also known as peripheral endografts, have been pro-posed as a new treatment option for CVS. The potential advantages of covered stents would include providing a relatively inert and stable intravascular matrix for endothelialization while providing the mechanical advantages of a BMS. This could potentially reduce the intimal hyperplastic response that causes restenosis after PTA or BMS placement. Surgical treatment of central venous stenosis has been associated with substantial morbidity and should be reserved for extraordinary circumstances. Endovascular intervention for hemodialysis-related CVS remains the present mainstay of treatment. As mentioned, these options include PTA and placement of BMSs or Covered stens.