Use of the Surfacer® Inside-Out® Catheter Access System to Obtain Central Venous Access in Dialysis Patients With Thoracic Venous Obstructions: Single-Center Series

Abstract

Background: Thoracic central venous obstruction (TCVO) is a common condition which can impact the ability to achieve central venous access (CVA) in patients on hemodialysis. The Surfacer® Inside-Out® Catheter Access System is designed to enable repeated right-side central venous access in patients with TCVO. Methods: We retrospectively analyzed medical records of 10 dialysis patients who presented with TCVO and underwent the Inside-Out procedure with the Surfacer System to obtain CVA between 2017 and 2020. Patient demographics, hemodialysis vascular access history, and procedural data were identified and analyzed. The mean patient age was 62.4 ± 19.6 years (25.9-89.1 years) with 7 of the 10 patients being male. Eight patients (80.0%) were diagnosed with chronic kidney disease with time on hemodialysis ranging from 3 to 13 years. The remaining 2 required CVA to treat acute-on-chronic kidney injury due to septic shock. Patients in our series had a mean of 2.8 ± 1.6 previous catheters placed prior to the Surfacer procedure. Results: CVA was achieved in all 10 patients with 1 patient requiring a second attempt to achieve access due to the inability to initially traverse the iliac vein with the device, possibly due to a history of kidney transplantation. One multimorbid patient died shortly after the successful procedure, possibly due to cardiac decompensation. Mean total procedure time for the 7 patients having only dialysis catheter placement using the Surfacer device was 67.2 ± 19.1 minutes (49-103 minutes). The remaining 3 patients received a Hemodialysis Reliable Outflow (HeRO) graft in conjunction with the Inside-Out procedure. All vascular accesses functioned properly during the immediate time period following placement. No adverse events associated with the use of Surfacer device were encountered. Conclusions: Data presented from our patient series confirms the effectiveness of the Surfacer System to safely achieve CVA in dialysis patients with TCVOs with a history of multiple catheter placements.

Comparison of catheter patency between surgical inside-out technique and conventional femoral approach for tunneled cuffed catheter placement in patients with thoracic central venous occlusion

“…The patency and technical success rate of the inside-out technique has exceeded 82% and 97% to 100%, respectively. 8 , 10 , 11 , 12 , 13 , 14 , 15 Therefore, considering the high technical success rate and longer patency, our results have confirmed that the S-inside-out approach for patients with TCVO will provide better catheter function than the FVC technique.…”

“…Some series have reported procedure-related complications in one or two patients. 8 , 10 , 11 , 12 , 13 , 14 , 15 Hadziomerovic et al 10 reported that two of nine patients had developed pneumothorax using the inside-out technique for TCC insertion. Galas and Shahverdyan 14 reported a case series using a Surfacer commercial set (Bluegrass Vascular Technologies, San Antonio, TX) for inside-out TCC insertion in 10 patients, of whom 2 had developed pneumohemothorax during the procedure.…”

“… 8 , 10 , 11 , 12 , 13 , 14 , 15 Hadziomerovic et al 10 reported that two of nine patients had developed pneumothorax using the inside-out technique for TCC insertion. Galas and Shahverdyan 14 reported a case series using a Surfacer commercial set (Bluegrass Vascular Technologies, San Antonio, TX) for inside-out TCC insertion in 10 patients, of whom 2 had developed pneumohemothorax during the procedure. To avoid this complication, first, the anatomic criteria for a safe inside-out technique should include TCVO with ≥1 cm of patent SVC above the right atrium and no significant collateral vessels.…”

“…To avoid this complication, first, the anatomic criteria for a safe inside-out technique should include TCVO with ≥1 cm of patent SVC above the right atrium and no significant collateral vessels. 14 Second, during the procedure, the wire should kept in the medial and anterior direction during the passage of the wire in the mediastinum. 10 To visualize the wire passage, the C-arm position should be changed from an anteroposterior to a left anterior oblique 30° to 60° angle to visualize the wire direction.…”

“…Variations of the devices used in the inside-out technique have been described, including the end of a wire, 9 , 11 needle, 10 and commercial devices. 12 , 13 , 14 , 15 The various methods for accessing the wire out of the body at the supraclavicular area have included the percutaneous technique (needle and wire) 10 , 12 , 13 , 14 , 15 and the surgical technique. 9 , 11 The potential complications include pneumothorax and pneumohemothorax.…”