Endovascular treatment of central venous stenoses in patients with dialysis shunts.
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OBJECTIVE: Evaluation of long-term results of percutaneous treatment of central vein stenoses or occlusions in patients with haemodialysis shunt. MATERIALS AND METHODS: In 26 patients with haemodialysis shunts and confirmed central vein stenosis or occlusion, 28 primary percutaneous transluminal angioplasties (PTA) and 5 repeated PTAs (re-PTA) were performed; in three patients a stent was implanted - primary in one patient and due to early restenosis after PTA in two patients. To maintain stent patency, 10 re-PTA were performed. RESULTS: The technical success rate of primary interventions was 96 % (100 % in stenoses and 50 % in occlusions). Primary post-PTA patency rate was 70 % at 3 months, 60 % at 6 months and 30 % at 12 months. CONCLUSION: PTA with possible stent implantation is a first-choice method in the treatment of stenoses and occlusions of the central venous system. Despite the relatively frequent re-interventions, endovascular treatment is capable to preserve long-term function of the dialysis shunt. (+info)
Life threatening chylous pleural and pericardial effusion in a patient with Behcet's syndrome.
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Chylothorax and chylopericardium secondary to thrombosis of the superior vena cava and the innominate and subclavian veins were diagnosed in a patient with Behcet's syndrome. Immunosuppressive treatment, diet, and underwater seal drainage led to a diminished volume of pleural fluid and pericardial fluid and to a diminished concentration of triglyceride in them; pleurodesis with tetracycline was then performed. (+info)
Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty.
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OBJECTIVE: Residual subclavian vein stenosis after thoracic outlet decompression in patients with venous thoracic outlet syndrome is often treated with postoperative percutaneous angioplasty (PTA). However, interval recurrent thrombosis before postoperative angioplasty is performed can be a vexing problem. Therefore we initiated a prospective trial at 2 referral institutions to evaluate the safety and efficacy of combined thoracic outlet decompression with intraoperative PTA performed in 1 stage. METHODS: Over 3 years 25 consecutive patients (16 women, 9 men; median age, 30 years) underwent treatment for venous thoracic outlet syndrome with a standard protocol at 2 institutions. Twenty-one patients (84%) underwent preoperative thrombolysis to treat axillosubclavian vein thrombosis. First-rib resection was performed through combined supraclavicular and infraclavicular incisions. Intraoperative venography and subclavian vein PTA were performed through a percutaneous basilic vein approach. Postoperative anticoagulation therapy was not used routinely. Venous duplex ultrasound scanning was performed postoperatively and at 1, 6, and 12 months. RESULTS: Intraoperative venography enabled identification of residual subclavian vein stenosis in 16 patients (64%), and all underwent intraoperative PTA with 100% technical success. Postoperative duplex scans documented subclavian vein patency in 23 patients (92%). Complications included subclavian vein recurrent thrombosis in 2 patients (8%), and both underwent percutaneous mechanical thrombectomy, with restoration of patency in 1 patient. One-year primary and secondary patency rates were 92% and 96%, respectively, at life-table analysis. CONCLUSIONS: Residual subclavian vein stenosis after operative thoracic outlet decompression is common in patients with venous thoracic outlet syndrome. Combination treatment with surgical thoracic outlet decompression and intraoperative PTA is a safe and effective means for identifying and treating residual subclavian vein stenosis. Moreover, intraoperative PTA may reduce the incidence of postoperative recurrent thrombosis and eliminate the need for venous stent placement or open venous repair. (+info)
Masson's intravascular hemangioma masquerading as effort thrombosis.
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An otherwise healthy 55-year-old white woman had acute onset of right arm swelling. No precipitating factors were identified. Venograms revealed an occluded subclavian vein, and catheter-directed thrombolysis was performed. After lysis a persistent residual intraluminal filling defect was identified, with persistent symptoms. Partial claviculectomy was performed, the mass was removed, and patch venoplasty carried out, with good outcome. Pathologic analysis demonstrated the mass to be a Masson's hemangioma, a papillary proliferation of thin-walled capillaries intimately associated with thrombus. Considered a benign intravascular lesion, the treatment of choice is complete excision. (+info)
Proper shoulder position for subclavian venipuncture: a prospective randomized clinical trial and anatomical perspectives using multislice computed tomography.
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BACKGROUND: Although the Trendelenburg position and shoulder bracing are recommended for safe subclavian venipuncture, the optimal shoulder position remains unclear. The current study observed spatial relations between the subclavian vein and surrounding structures using multislice computed tomography to determine optimal shoulder position for safe subclavian venipuncture and then conducted a small follow-up clinical trial to confirm these findings. METHODS: Thoracic multislice computed tomography was performed for seven adult volunteers at three shoulder positions: elevated (up); neutral; and lowered caudally (down). Overlap and distance between the clavicle and the subclavian vein and the diameter of the subclavian vein were measured. Anatomical relations between the subclavian artery and vein were also observed. The success rate for subclavian venipuncture was then compared between the up and down shoulder positions in 30 patients. RESULTS: In the multislice computed tomography study, the mean overlap ratios between clavicle and subclavian vein in the up, neutral, and down positions were 33.5, 36.9, and 40.0%, respectively. Overlap increased with lower shoulder position (up < neutral < down; P < 0.05). The mean distances between the clavicle and the subclavian vein in the up, neutral, and down positions were 6.8, 5.0, and 3.6 mm, respectively. Again, distance decreased with lower shoulder position (up < neutral < down; P < 0.05). The diameter of the subclavian vein did not differ among the three shoulder positions. The success rate for subclavian venipuncture was significantly higher in the down position compared with the up position (P = 0.003). CONCLUSIONS: Lowered shoulder position increases both overlap and proximity between the clavicle and the subclavian vein, producing a more constant relation between the clavicle and the subclavian vein, without affecting vein diameter. Proper use of a lowered shoulder position should thus increase the safety and reliability of subclavian venipuncture compared with other shoulder positions. (+info)
Clinical review: vascular access for fluid infusion in children.
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The current literature on venous access in infants and children for acute intravascular access in the routine situation and in emergency or intensive care settings is reviewed. The various techniques for facilitating venous cannulation, such as application of local warmth, transillumination techniques and epidermal nitroglycerine, are described. Preferred sites for central venous access in infants and children are the external and internal jugular veins, the subclavian and axillary veins, and the femoral vein. The femoral venous cannulation appears to be the most safe and reliable technique in children of all ages, with a high success and low complication rates. Evidence from the reviewed literature strongly supports the use of real-time ultrasound techniques for venous cannulation in infants and children. Additionally, in emergency situations the intraosseous access has almost completely replaced saphenous cutdown procedures in children and has decreased the need for immediate central venous access. (+info)
Stridor and Horner's syndrome, weeks after attempted right subclavian vein cannulation.
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A 23-year-old woman presented with renal failure resulting from polycystic kidney disease (PKD) aggravated by tubulo-interstitial nephritis. Emergency haemodialysis was planned, and cannulation of the right subclavian vein was attempted, but failed. During this procedure, inadvertent arterial puncture occurred. Transient mild ischaemia of the right arm, and a transient Horner's syndrome were noted. Seven weeks later she presented with severe stridor with impending respiratory failure necessitating emergency intubation; the right-sided Horner's syndrome had recurred. CT imaging showed a large pseudo-aneurysm of the brachiocephalic artery resulting in severe compression of the trachea. Using a prosthetic graft, the operation for the pseudo-aneurysm was successful; there were mild neurological sequelae. Although her family history was negative, autosomal dominant PKD should be considered, and we discuss the possible role of a pre-existing PKD-associated aneurysm. (+info)
Ultrasound-guided insertion of subclavian venous access ports.
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INTRODUCTION: Central venous cannulation is an integral part of venous access port (portacath) placement for intravenous chemotherapy. NICE guidelines have suggested that CVC should be performed under ultrasound guidance. The technique of ultrasound-guided subclavian cannulation is reviewed and our experience presented. PATIENTS AND METHODS: Retrospective analysis of data on patients undergoing ultrasound-guided portacath placement for the failure rate and the incidence of complications. RESULTS: We were successful in cannulating the subclavian vein in 44 of 55 patients. There was one arterial puncture and no haemothorax or pneumothorax with the technique (complication rate 1.8%). CONCLUSION: An ultrasound-guided approach should be the standard technique for central venous cannulation in portacath placement. (+info)