Application of Intravascular Ultrasound in End-Stage Renal Patients with Central Venous Occlusive Disease
RossMcFall, MD; TonyLu, M.D.Houston Methodist Hospital, Houston, Texas
Central venous occlusive disease is frequently observed in patients with end-stage renal disease. Venography remains the gold standard for diagnosis, but intravascular ultrasound is a potentially beneficial adjunct that may positively influence intervention.
Central venous stenosis and occlusive disease (CVOD) is an increasingly frequent finding on venography. In the end-stage renal disease (ESRD) population, the majority of whom are initiated on catheter-based hemodialysis, the incidence ranges from 20% to 40%, depending on the series.1,2 These patients may have adapted to their ? 50% intraluminal narrowing but more commonly exhibit an array of symptoms such as ipsilateral edema, pain, and access malfunction.3 The number, location, and duration of central venous catheters are all important factors in the development of CVOD.4-6 Moreover, the well-documented concurrent prevalence of chronic indwelling pacemaker and defibrillator wires in this population can further exacerbate CVOD symptoms.7 Although the precise mechanism of CVOD is unclear, a likely etiology is a combination of direct trauma, inflammation, and chronic endothelial injury.2,8,9
INTRAVASCULAR ULTRASOUND VERSUS VENOGRAPHY
Intravascular ultrasound (IVUS) uses a 10 MHz to 40 MHz catheter-mounted probe to provide cross-sectional imaging within the vessel. This modality is commonly used for coronary interventions to assist with sizing, stent deployment, and assessments after percutaneous coronary interventions.10-12 Recently, the Venogram vs IVUS for Diagnosing Iliac Vein Obstruction (VIDIO) trial demonstrated that IVUS showed a greater number of stenotic lesions and intraluminal diameter reductions in the iliofemoral system compared to traditional venography.13 Several studies have looked at using IVUS to assess CVOD in dialysis access patients, but consensus is lacking (Table 1).
Single-plane contrast venography and digital subtraction angiography (DSA) are the classic standard for evaluating CVOD, and the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) guidelines recommend an endovascular-first approach to addressing COVD lesions.14 However, the accuracy of venography is limited in standard anterior-posterior projections, and multiplanar venographic studies are not common. Neglén and Raju found that single-plane venography significantly underestimates the degree of stenosis in the iliofemoral system, and our unpublished institutional experience supports a similar assertion in hemodialysis patients with suspected CVOD (Figure 1).15 In the iliocaval system, stenosis is associated with decreased cross-sectional area and altered flow dynamics, but these outcomes have yet to be explored in the ESRD population.16-18 We would expect a similar result, although it has been observed that vessel shape has a significant impact on cross-sectional area. Kabnick et al. showed that elliptical vessels had decreased cross-sectional areas compared to circular vessels with the same perimeter.19
Initial reports focused on using IVUS as an alternative modality for diagnosing CVOD. In 2008, Matthews and Thomas described using IVUS in an ESRD patient with severe left upper extremity edema and discomfort.20 The patient had a known anaphylactic reaction to iodinated contrast despite multiple pretreatment attempts. IVUS identified a focal area of stenosis confirmed with pullback pressures and amendable to balloon angioplasty.21,22 Carbon dioxide angiography had previously been the preferred modality for patients with severe reactions to iodinated contrast, but use in the thoracic cavity is relatively contraindicated due to concerns for air trapping and hemodynamic compromise.23
Tsai et al. later reported using IVUS in another ESRD patient with extremity edema to diagnose left brachiocephalic vein compression by the innominate artery.24 These findings were confirmed intraoperatively with venography prior to angioplasty and stenting. Pullback pressures and IVUS were able to identify residual stenosis missed on completion venography. Lin et al. reported similar findings in their series of 94 ESRD patients, wherein they observed that pullback pressure gradients were better predictors of long-term patency than venography; pressure gradients ? 5 mm Hg correlated with better outcomes.22 We do not routinely measure pressure gradients for CVOD in our practice but have anecdotally found that patients with gradients > 3 mm Hg may have significant stenoses. This echoes the experiences in the coronary and iliofemoral systems where IVUS was instrumental in guiding therapy.10,25
More recently, Graaf et al. compared DSA to intravascular ultrasound in a series of 12 patients with CVOD.26 IVUS showed residual areas of > 50% stenosis after angioplasty in six patients, whereas venography only identified those conditions in three patients. IVUS additionally identified trabeculae within the central vasculature that could not be visualized with standard venography. Although the authors could not establish the impact of these trabeculae, they postulated that such features may one day serve as additional criteria to guide intervention. Similarly, they note that the hyperechogenicity within the walls of stenotic vessels may represent fibrinous changes consistent with venous stenosis.
The growing body of data suggests that IVUS is a potentially useful adjunct in the diagnosis and management of CVOD in patients with ESRD. Although we cannot advocate for its routine use at this time, additional investigation in this patient population may lead to stronger recommendations.
- Central venous stenosis and occlusive disease (CVOD) is frequently observed in end-stage renal disease (ESRD) patients.
- Intravascular ultrasound (IVUS) may be better suited than traditional venography to identify intraluminal narrowing and pre-/post-intervention outcomes.
- Additional study is warranted to better characterize the value of IVUS in the ESRD patient population.
- Lumsden AB, MacDonald MJ, Isiklar H, et al. Central venous stenosis in the hemodialysis patient: incidence and efficacy of endovascular treatment. Cardiovasc Surg. 1997 Oct;5(5):504-9.
- Glanz S, Gordon DH, Lipkowitz GS, Butt KM, Hong J, Sclafani SJ. Axillary and subclavian vein stenosis: percutaneous angioplasty. Radiology. 1988 Aug;168(2):371-3.
- MacRae JM, Ahmed A, Johnson N, Levin A, Kiaii M. Central vein stenosis: a common problem in patients on hemodialysis. ASAIO J. 2005 Jan-Feb;51(1):77-81.
- Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterisation vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant. 1991;6(10):722-4.
- Barrett N, Spencer S, McIvor J, Brown EA. Subclavian stenosis: a major complication of subclavian dialysis catheters. Nephrol Dial Transplant. 1988;3(4):423-5.
- Taal MW, Chesterton LJ, McIntyre CW. Venography at insertion of tunnelled internal jugular vein dialysis catheters reveals significant occult stenosis. Nephrol Dial Transplant. 2004 Jun;19(6):1542-5.
- Sticherling C, Chough SP, Baker RL, et al. Prevalence of central venous occlusion in patients with chronic defibrillator leads. Am Heart J. 2001 May;141(5):813-6.
- Weiss MF, Scivittaro V, Anderson JM. Oxidative stress and increased expression of growth factors in lesions of failed hemodialysis access. Am J Kidney Dis. 2001 May;37(5):970-80.
- Palabrica T, Lobb R, Furie BC, et al. Leukocyte accumulation promoting fibrin deposition is mediated in vivo by P-selectin on adherent platelets. Nature. 1992 Oct 29;359(6398):848-51.
- Witzenbichler B, Maehara A, Weisz G, et al. Relationship between intravascular ultrasound guidance and clinical outcomes after drug-eluting stents: the assessment of dual antiplatelet therapy with drug-eluting stents (ADAPT-DES) study. Circulation. 2014 Jan 28;129(4):463-70.
- Roy P, Steinberg DH, Sushinsky SJ, et al. The potential clinical utility of intravascular ultrasound guidance in patients undergoing percutaneous coronary intervention with drug-eluting stents. Eur Heart J. 2008 Aug;29(15):1851-7.
- Ahn JM, Kang SJ, Yoon SH, et al. Meta-analysis of outcomes after intravascular ultrasound-guided versus angiography-guided drug-eluting stent implantation in 26,503 patients enrolled in three randomized trials and 14 observational studies. Am J Cardiol. 2014 Apr 15;113(8):1338-47.
- Gagne PJ, Tahara RW, Fastabend CP, et al. Venography versus intravascular ultrasound for diagnosing and treating iliofemoral vein obstruction. J Vasc Surg Venous Lymphat Disord. 2017 Sep;5(5):678-87.
- National Kidney Foundation [Internet]. New York: National Kidney Foundation, Inc.; c2017. NKF KDOQI Guidelines; 2017 [cited 2018 May 18]. Available from: http://www.kidney.org/professionals/guidelines.
- Neglén P, Oglesbee M, Olivier J, Raju S. Stenting of chronically obstructed inferior vena cava filters. J Vasc Surg. 2011 Jul;54(1):153-61.
- Neglén P, Hollis KC, Olivier J, Raju S. Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result. J Vasc Surg. 2007 Nov;46(5):979-90.
- Raju S, Kirk O, Davis M, Olivier J. Hemodynamics of “critical” venous stenosis and stent treatment. J Vasc Surg Venous Lymphat Disord. 2014 Jan;2(1):52-9.
- Raju S. Ten lessons learned in iliac venous stenting. Endovasc Today. 2016 Jul;15(7):40-44.
- Kabnick LS, Recinella D, Shifflette M, Ouriel K. Importance of Stent Shape and Area on Clinical Outcome After Iliofemoral Venous Stenting. J Vasc Surg Venous Lymphat Disord. 2018 Mar 1;6(2):283-4.
- Matthews R, Thomas J. Intravascular ultrasound-guided central vein angioplasty and stenting without the use of radiographic contrast agents. J Clin Ultrasound. 2008 May;36(4):254-6.
- Labropoulos N, Borge M, Pierce K, Pappas PJ. Criteria for defining significant central vein stenosis with duplex ultrasound. J Vasc Surg. 2007 Jul;46(1):101-7.
- Lin YS, Yang CH, Chu CM, et al. The role of postintervention pullback pressure gradient in percutaneous transluminal angioplasty for central vein stenosis in dialysis patients. Cardiovasc Intervent Radiol. 2013 Oct;36(5):1296-305.
- Medscape [Internet]. New York: WebMD LLC; c1994-2018. Carbon dioxide angiography: overview, techniques, clinical applications; 2016 Feb 4 [cited 2018 May 18]. Available from: https://emedicine.medscape.com/article/423121-overview#a1.
- Tsai SC, Wu TY, Huang HL. Vein compression syndrome unmasked by intravascular ultrasound guided central vein stenting. VASA Z Gefasskrankheiten. 2015 Jan;44(1):65-9.
- Forauer AR, Gemmete JJ, Dasika NL, Cho KJ, Williams DM. Intravascular ultrasound in the diagnosis and treatment of iliac vein compression (May-Thurner) syndrome. J Vasc Interv Radiol. 2002 May;13(5):523-7.
- de Graaf R, van Laanen J, Peppelenbosch N, van Loon M, Tordoir J. The value of intravascular ultrasound in the treatment of central venous obstructions in hemodialysis patients. J Vasc Access. 2016 Mar;17 Suppl 1:S12-15.