Recanalisation of an axillary vein occlusion jailed by a migrated cephalic arch stent-graft using the TruePath chronic total occlusion drilling device
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Stent placement in the cephalic arch is being used with increasing frequency. Late complications of bare metal and stent grafts in dialysis access, in particular stent migration, are often under-reported and can lead to compromise of future dialysis circuits.
A 52-year-old man developed acute arm swelling 2 days after creation of a left arm brachio-basilic arteriovenous graft. The axillary vein was found to be jailed by a previously deployed cephalic arch stent graft which had migrated into the subclavian vein. There was failure to cross through the fabric of the stent graft using conventional chronic total occlusion wires and techniques. A TruePath device was used successfully to cross through the fabric of migrated cephalic arch stent graft and recanalise the short subclavian-axillary vein occlusion.
The adapted use of a drilling chronic total occlusion device to drill through the fabric of migrated stent graft was performed successfully to allow complete recanalisation of the occluded axillary vein.
KeywordsDialysis access Recanalisation Stent graft TruePath
Chronic Total Occlusion
Stent-graft (SG) placement for cephalic arch stenosis in dysfunctional dialysis access is an option for patients, and a recent systematic review suggests that it may be more durable in the short term compared to angioplasty alone (Miller et al. 2018; D’Cruz et al. 2019). Precise placement of SGs in the cephalic arch, particularly the terminal segment near or at the junction with the axillary vein, can be difficult. Due to the angle at which the cephalic arch joins the axillary vein, over or under stenting of the stenosis is not uncommon. Central migration of SGs may result in subclavian and axillary vein occlusions, compromising future dialysis access options in the ipsilateral arm and may cause symptoms of central venous occlusion. We report the novel use of a diamond tipped chronic total occlusion (CTO) drilling device, TruePath (Boston Scientific, MA, USA), to recanalise an occluded axillary-subclavian vein segment that had been jailed by a migrated cephalic arch SG.
In view of the limited access options, a further attempt was made using the TruePath CTO drilling device. Under ultrasound guidance, 6F and 4F sheaths were inserted into the left common femoral vein and the venous limb of the left AVG respectively. Venography revealed a 2 cm subclavian vein occlusion adjacent to the central end of the migrated SG (Fig. 2). Attempted retrograde crossing of the occluded segment was unsuccessful and complicated by self-limiting guidewire perforations.
Left arm swelling improved significantly over the 3 days. Unfortunately, late infection of the AVG developed and was explanted 28 days post intervention. New long-term AVG dialysis access was created in the left lower limb. Six months after left subclavian-axillary vein stenting, an opportune catheter angiogram via his left groin AVG demonstrated continued patency, and without recoil, of the stented segment (Fig. 6).
Cephalic arch stenosis affects up to 34% of dysfunctional brachiocephalic AVFs (Bennett et al. 2015). The use of stents, in particular SGs, to treat recurrent cephalic arch stenosis has been increasing due to low primary patency rates of balloon angioplasty and an increasing body of evidence demonstrating superior patency rates of stents (Miller et al. 2018; D’Cruz et al. 2019). Despite appropriate sizing and accurate deployment of the Fluency SG, central stent migration may result in jailing of the axillary vein. Relative mobility of the cephalic arch segment and external compressional forces from the claviculopectoral and deltopectoral fasciae may contribute to SG migration. The problem of stent migration in the cephalic arch is probably under-reported as these patients tend to be asymptomatic (Sequeira 2016).
Conventional techniques of crossing the occlusion were unsuccessful due to the SG fabric preventing wire passage. Due to vascular anatomy and potential inadvertent subclavian artery injury, sharp recanalisation employing a straight needle was deemed high risk. Bench-testing using a demonstration unit of the TruePath device and Fluency SG demonstrated controlled and easy traversal of the drilling tip of the device through the SG fabric. TruePath is guidewire-mounted mechanical recanalization device with a rotating distal diamond tip designed for true-lumen crossing of peripheral arterial occlusions. We adapted the previously reported balloon puncture technique, for placement of dialysis access catheters in occluded internal jugular veins (Too et al. 2016) for this case. Once recanalised, stenting was mandated in view of the aetiology of this occlusion. A Supera stent was chosen for its crush-resistance properties, superior flexibility and kink resistance.
The case report demonstrates the successful novel use of the TruePath device to drill through the fabric of a migrated cephalic arch stent graft which had jailed the axillary vein outflow causing acute arm swelling due to compromise of the axillary vein outflow. Migration of cephalic arch stent grafts are under-reported and can compromise future dialysis access options. The use of the TruePath device facilitated recanalization of the occluded axillary vein. The device and techniques used in this case can be utilised in similar situations, where conventional techniques would pose high risk of arterial injury or likely be futile.
All the authors mentioned in the manuscript have made a significant contribution to this manuscript and agreed for authorship, read and approved the manuscript. AP conceived the manuscript, edited the proof and contributed to logical interpretation and presentation of the results; AP prepared the manuscript SXJMC and ZKD supervised the manuscript; AP and ZKD provided clinical data; AP took part in the intervention.
The authors did not receive funds for this manuscript.
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Institutional Review Board approval is not needed for case reports at the authors institution.
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All authors read, agreed for authorship and approved the submission to CVIR Endovascular. Consent for publication was obtained for every individual person’s data included in the study.
The authors declare that they have no competing interests related to this paper. All the authors mentioned in the manuscript have made a significant contribution to this manuscript and agreed for authorship, read and approved the manuscript. Consent for publication was obtained for every individual person’s data included in the study.
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