Assistant Professor of Radiology MedStar Washington Hospital Center
Kaitlin A. Carrato, MD: No financial relationships to disclose
Taedo J. Choi, MD: No financial relationships to disclose
Nora E. Tabori, MD: Varian: Speaking and Teaching (Ongoing)
Gajan Sivananthan, MD: No financial relationships to disclose
Review conventional and advanced techniques for sharp recanalization
Learn how to perform Balloon-targeted Extra-anatomic Sharp recanalizaTion (BEST) to reestablish neck vascular access in patients who have an occluded right internal jugular vein
Background: Many patients with end-stage renal disease (ESRD) develop central occlusion and rely on last-resort hemodialysis (HD) access sites such as femoral, translumbar, or transhepatic catheters. Several commonly used sharp recanalization techniques have been described to reestablish neck vascular access. This is a pictorial review of these techniques and we also provide a description of BEST (Balloon-targeted Extra-anatomic Sharp recanalizaTion) technique to reestablish neck access in patients who no longer have a right internal jugular vein.
Clinical Findings/Procedure Details: Sharp recanalization procedures begin by obtaining access both proximal and distal to the occlusion and performing venography to determine the anatomy. Central venous occlusions can often be crossed using the front or back end of a guidewire to create a channel. Advanced techniques have also been described in cases that fail conventional techniques such as advancing a long Chiba needle or radiofrequency ablation wire via intravascular access and using an angioplasty balloon or snare as a target.
The BEST technique is an advanced technique in which the back end of a guidewire or more commonly a long Chiba needle is used to intentionally perforate the right brachiocephalic vein at the level of occlusion into the soft tissue of the mediastinum. The guidewire is then advanced into the neck soft tissues in patients who no longer have an IJ vein or IJ remnant. Once a guidewire is positioned, a balloon is advanced into the soft tissues of the neck at or above the level of the clavicle. Ultrasound or fluoroscopic triangulation is used to percutaneously puncture the balloon using a 21G needle. A guidewire is then advanced through the needle into the punctured balloon and fed through as the punctured balloon is withdrawn through the femoral access sheath. Cone beam CT can be used to confirm no vital structures were traversed before the tract is dilated. A dialysis catheter is then left in place at the newly obtained neck access site.
Conclusion and/or Teaching Points: There are several commonly used and advanced techniques described for sharp recanalization of occluded central veins. The BEST technique is an advanced technique for obtaining HD access in the neck in centrally occluded patients without an internal jugular vein.