Assistant Professor of Radiology MedStar Washington Hospital Center
Taedo J. Choi, MD: No financial relationships to disclose
Kaitlin A. Carrato, MD: No financial relationships to disclose
Nora E. Tabori, MD: Varian: Speaking and Teaching (Ongoing)
Gajan Sivananthan, MD: No financial relationships to disclose
Purpose: End-stage renal disease patients often rely on long-term hemodialysis catheters in last-resort locations due to central venous occlusions. The purpose of this study is to define the Balloon-targeted Extra-anatomic Sharp recanalizaTion (BEST) technique to re-establish supraclavicular vascular access in patients with central venous occlusions and describe our experience using this technique.
Materials and Methods: A retrospective review was performed of 5 patients with central venous occlusions who underwent sharp recanalization using the BEST technique from May 2018 to August 2022. Four patients had femoral and 1 patient had transhepatic tunneled dialysis catheters. Conventional sharp recanalization techniques were unsuccessful. Extra-anatomic traversal from the level of occlusion in the superior vena cava or right brachiocephalic vein to right upper mediastinum or neck was performed using the tip or back-end of a stiff guidewire, or 21G needle through a transfemoral sheath and catheter wedged at the level of occlusion. Once a guidewire was passed into the soft tissue of the upper mediastinum or neck, an angioplasty balloon was advanced over the guidewire into the extravascular space and inflated to function as a target for percutaneous access. A 21G needle was advanced percutaneously to puncture the inflated balloon using ultrasound or fluoroscopic triangulation to avoid critical structures. An exchange length 0.018” guidewire was advanced through into punctured balloon and externalized through the femoral or transhepatic access. Tunneled or non-tunneled catheters were placed using standard techniques through the re-established supraclavicular vascular access.
Results: The procedure was successful in all 5 cases (100%) in re-establishing supraclavicular vascular access. Four of the 5 patients (80%) underwent Hemodialysis Reliable Outflow (HeRo) graft placement using the re-established supraclavicular vascular access. Two of the patients were outpatients who were admitted for 1 and 2 days with same admission HeRo-graft placement. Estimated blood loss was less than 30 mL. One patient had bacteremia presumed secondary to catheter related infection. This patient was treated with antibiotics (SIR classification D). Another patient had hemoptysis post procedure which self-resolved and felt to be unrelated to the procedure.
Conclusion: The BEST technique can be utilized to re-establish supraclavicular vascular access in cases where standard sharp recanalization techniques are not successful or possible.