Comparative outcomes of treated symptomatic versus non-treated asymptomatic high-grade central vein stenoses in the outflow of predominantly dialysis fistulas

Abstract

Withholding treatment in asymptomatic/pauci-symptomatic CVS in dialysis fistulas yielded significantly better short- and long-term central vein patency than treatment of symptomatic cases without detrimental effects on overall dialysis circuit.

Central Venous Stenosis Is More Often Symptomatic in Hemodialysis Patients with Grafts Compared with Fistulas

“…All the stenoses in that study were in the SCV, which is not surprising given the near-universal use of that vein at that time and the limitations of ultrasound in evaluating the BCV. Although not all of the 51% CVS in this study was significant as determined by symptoms, even asymptomatic CVS has been shown to progress; in one study, 40% of minimally symptomatic or asymptomatic CVS progressed to being symptomatic over a 4-year period of observation (7). The message is clear: CVS remains very prevalent.…”

“…It is estimated that 25%-40% of patients with end-stage renal disease receiving hemodialysis have CVS (1), and this estimated prevalence has changed little since before the widespread transition from subclavian to jugular access for hemodialysis catheters (2). As a result of this high incidence, the focus in the literature has been on what can be done to treat CVS effectively and whether or not it is beneficial to treat CVS in asymptomatic patients (3)(4)(5)(6)(7)(8)(9).…”

“…The focus of the Centers for Medicare and Medicaid Services Fistula First Breakthrough Initiative (FFBI) has also been prevention, such as through avoidance of transvenous cardiac rhythm devices, in addition to reinforcing existing K/DOQI recommendations regarding avoiding subclavian catheterization and ideally avoiding catheters altogether (Fistula First Catheter Last [FFCL]). Among the main reasons that the emphasis in K/DOQI and FFBI has been on prevention are the relatively poor results associated with treatment of CVS, whether using percutaneous transluminal angioplasty (PTA), stents and stent grafts, or surgery (3)(4)(5)(6)(7)(8)(9).…”

Effect of Central Venous Angioplasty on Hemodialysis Access Circuit Flow: Prospective Study of 25 Symptomatic Patients

“…Subclavian stenosis typically causes edema of the ipsilateral arm and/or breast, whereas brachiocephalic stenosis often causes ipsilateral neck or facial edema (3,5,6). Incidentally discovered asymptomatic CVS should not be treated because treating asymptomatic CVS can elicit more severe stenosis; only about 40% of asymptomatic CVSs worsen after 4 years (20)(21)(22).…”

Briefly Noted

“…High‐grade, incidental, asymptomatic, central vein stenosis in 53 patients (detected during access outflow angiograms) remained asymptomatic after 4 years in 60% without intervention (15). Among the 103 central vein stenoses overall, only 37% were associated with previous central vein catheterization.…”