Cephalic to jugular vein bypass surgery of subclavian vein stenosis for arteriovenous fistula salvage in maintenance hemodialysis patients

Introduction

An AVF is created by connecting a peripheral artery to a superficial vein to form an abnormal vascular pathway. It is a lifeline for patients undergoing long-term maintenance hemodialysis (MHD) for chronic kidney disease. Central venous occlusion (CVO) or upper extremity edema is a common complication that can result from narrowing or thrombosis of the central vein on the same side as the AVF, causing AVF dysfunction.^{1 –3} Risk factors for central venous stenosis (CVS) include central venous catheterization, vascular intimal hyperplasia caused by high-flow AVF shear stress, and the implantation of a cardiac pacemaker. These risk factors are becoming increasingly common among patients undergoing MHD, leading to an increased risk for CVO. If there is no effective clinical treatment and the patient has no alternative vascular options to create an AVF, they may have to rely on a dialysis catheter to maintain vascular access, which is associated with increased complications.

For complications, such as AVF dysfunction, loss of function, or upper extremity edema caused by CVS, the most recent consensus from Chinese experts on blood dialysis vascular access or the latest guidelines from the Kidney Disease Outcomes Quality Initiative (K/DOQI) in the United States recommend percutaneous transluminal angioplasty (PTA) or stent implantation (PSI) for treatment. ⁴ However, if re-stenosis occurs or if the surgery is ineffective, the only option is to close the AVF, making it impossible to create a new AVF on the same arm. Patients with limited vascular access may not be able to undergo hemodialysis.

Graft bypass surgery involves the use of a graft to bypass the stenotic or occluded central vein and can be regarded as the reconstruction of the AVF outflow tract. From a hemodynamic perspective, graft bypass surgery is in essence to restore the pressure gradient of the AVF, permitting the AVF outflow to smoothly return to the right atrium. This helps to restore AVF function and relieve the symptoms of arm swelling.^{5 –9} As part of the outflow tract, the graft can be connected to various vessels (internal/external jugular vein, brachiocephalic vein, superior vena cava, and right atrium). We performed cephalic-jugular graft bypass surgery in five patients with subclavian vein stenosis on the same side as the AVF. Our findings regarding surgical efficacy and perioperative evaluation are reported.

Methods

Between June 2020 and June 2022, 309 adult patients undergoing in-center MHD at the dialysis unit of Zhongda Hospital Southeast University (Jiangsu, China) were screened for enrollment. The eligibility criteria were as follows: MHD patient with an upper extremity AVF; upper extremity AVF failure or upper extremity swelling on the same side of the AVF resulting from ipsilateral subclavian vein stenosis; patency of the internal jugular vein/external jugular vein, brachiocephalic vein, and superior vena cava on the same or opposite side of the AVF; failed to undergo PTA to resolve the subclavian vein stenosis; and ability to provide informed consent. This study was approved by the Ethics Committee of Zhongda Hospital Southeast University, and adhered to the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. All participants provided written informed consent.

Five patients with upper extremity AVF and ipsilateral subclavian vein stenosis, who were undergoing MHD, were included (Table 1). Patients presented with either AVF failure or upper extremity swelling.

OPEN IN VIEWER

Table 1.

Clinical characteristics of included subjects.

Case	Age (years)	Gender	Vascular access	Clinical manifestation	Time of occurrence after AVF surgery (months)	Location of stenosis	Configuration of bypass	Duration of patency (months)
1	71	Male	Left brachio-cephalic AVF	Acute thrombosis	48	Left cephalic vein of the upper arm (including cephalic arch), distal subclavian vein and axillary vein	Cephalic vein near the anastomosis site of fistula to ipsilateral external jugular vein	19
2	73	Male	Left brachio-cephalic AVF	Acute thrombosis	77	Left subclavian vein	Cephalic vein near the anastomosis site of fistula to ipsilateral internal jugular vein	19
3	80	Female	Left radial-cephalic AVF	Left upper extremity edema	65	Left subclavian vein	Cephalic vein in middle of the upper arm to ipsilateral internal jugular vein	6
4	83	Male	Left radial-cephalic AVF	Left upper extremity edema	6	Left subclavian vein (by pacemaker)	Cephalic vein in shoulder to the contralateral external jugular vein	5
5	40	Male	Left brachio-cephalic AVF	Acute thrombosis	18	Left cephalic vein of the upper arm (including cephalic arch), distal subclavian vein and axillary vein	Cephalic vein in middle of the upper arm to ipsilateral internal jugular vein	5

Results

Case 1

A 71-year-old man with chronic nephritis, had been undergoing MHD for the past decade. The patient initially had a left radio-cephalic AVF and a history of temporary hemodialysis catheter insertion into the right internal jugular vein. Four years previously, a left brachio-cephalic AVF was created due to AVF occlusion. There was no CVS on the same side before AVF surgery. Nineteen months previously, the patient presented for treatment due to sudden AVF occlusion. Computed tomography angiography (CTA) revealed stenosis of the left cephalic vein of the upper arm, and stenosis from the distal subclavian vein to the axillary vein on the left side, whereas no obstructions were found in the internal jugular, external jugular, or brachiocephalic veins, or superior vena cava on the left side (Figure 1(a) and (b)).

OPEN IN VIEWER

Figure 1.

(a and b) Preoperative CTA for Patient 1 revealed stenosis (arrowhead) from distal subclavian vein (arrow) to axillary vein on the left side.

Case 2

A 73-year-old man with chronic nephritis and type 2 diabetes mellitus had undergone peritoneal dialysis for 10 years. He started hemodialysis 8 years previously, with an AVF created using the left elbow brachial artery and cephalic vein. No CVS was detected on the same side before AVF surgery. The patient had sought treatment 19 months previously for sudden AVF occlusion. Vascular ultrasonography revealed stenosis and thrombosis of the left subclavian vein. CTA confirmed stenosis in the left subclavian vein, while the left internal jugular, and brachiocephalic veins, and superior vena cava were patent (Figure 2(a) and (b)).

OPEN IN VIEWER

Figure 2.

(a and b) Preoperative CTA for Patient 2 revealed stenosis (arrowhead) in the distal left subclavian vein (arrow).

Case 4

An 83-year-old man with obstructive kidney disease due to prostate cancer underwent MHD for 5 years. Five years previously, he underwent insertion of a tunneled cuffed catheter into his right internal jugular vein and, 2 years later, a left radial-cephalic AVF was created. Thirteen years previously, a pacemaker was implanted through his left subclavian vein. Nine months previously, he had experienced swelling and pain in his left upper limb. Ultrasound examination of the blood vessels indicated that the left subclavian vein was obstructed, with no blood flow signal. CTA confirmed stenosis of the left subclavian and brachiocephalic veins, whereas the external jugular, and brachiocephalic veins, and superior vena cava on the right side were patent (Figure 3(a) and (b)).

OPEN IN VIEWER

Figure 3.

(a and b) Preoperative CTA for Patient 4 revealed stenosis (arrowhead) in the distal left subclavian vein (arrow), with the pacemaker lead extending from the left subclavian vein to the heart.

Case 5

A 40-year-old man with chronic nephritis had been undergoing hemodialysis for 2 years. He had a brachial-cubital median AVF in his left elbow and had not previously undergone hemodialysis catheter insertion. Six months previously, he was admitted to hospital for sudden blockage of the AVF in his left upper limb. CTA revealed stenosis of the left cephalic vein of the upper arm, and stenosis from the distal subclavian vein to the axillary vein on the left side. However, no obstructions were observed in the internal jugular, and brachiocephalic veins, or superior vena cava on the left side (Figure 4(a) and (b)).

OPEN IN VIEWER

Figure 4.

(a and b) Preoperative CTA for Patient 5 revealed stenosis (arrowhead) from distal subclavian vein (arrow) to axillary vein on the left side.

All five patients underwent graft bypass surgery using a 6 mm inner diameter polytetrafluorethylene (PTFE) graft under brachial plexus block anesthesia with 5% ropivacaine. Among these, two patients (case 1 and case 2) underwent graft bypass surgery, connecting the cephalic vein near the fistula to the ipsilateral jugular vein through a subcutaneous tunnel in the shoulder region. Two patients (case 3 and case 5) underwent a similar surgery, from the mid-upper arm cephalic vein to the ipsilateral jugular vein, via a subcutaneous tunnel in the shoulder region. Additionally, one patient (case 4) underwent graft bypass surgery, and the graft was bridged from one side’s cephalic vein in the shoulder area to the contralateral jugular vein via a subclavian and anterior-cervical subcutaneous tunnel, due to occlusion of the same-side subclavian or brachiocephalic veins caused by pacemaker placement (Table 1). All PTFE grafts were anastomosed to the veins using the end-to-side technique. The length of the implanted PTFE graft was 40–60 cm. All patients were routinely administered cefoperazone for 5 days to prevent infection after surgery.

After graft bypass surgery, blood flow in the vascular access quickly returned to normal, providing immediate relief from symptoms such as pain from swollen hands and acute thrombosis.

Our graft bypass surgery technique can be considered reconstruction of the outflow tract of the AVF. Two types of outflow tract reconstructions were performed using our techniques.

For type I, the graft is bridged between the cephalic vein near the anastomosis site of the fistula and the jugular vein, and the former outflow tract of the AVF is completely abandoned. In this situation (case 1 and case 2), a non-tunneled catheter was temporally used for hemodialysis before the graft could be used for cannulation. For type II, the graft bridged between the cephalic vein in the shoulder or upper arm and the jugular vein, and the distal part of the former outflow tract of the AVF was preserved. In this situation (cases 3, 4, and 5), a preserved outflow tract was used for cannulation after bypass surgery. Two to 4 weeks after surgery, the graft can be used for hemodialysis.

During this period, no complications including wound infections, non-healing wounds, steal syndrome, heart failure due to high-flow AVF, or deaths related to surgery were observed. The primary patency rate of the bridge graft at 5–19 months after surgery was 100%, with no need for further intervention, and the function of vascular access fulfilled the requirements for hemodialysis.

Discussion

In the present series of five cases, patients developed CVS symptoms 18–36 months after AVF creation, with severe manifestations necessitating urgent medical attention. Closing or abandoning the AVF may appear to be the easiest option; however, this means losing valuable vascular access and making it exceedingly difficult to perform vascular access surgery on the same arm. Interventional treatment (PTA or PSI) can quickly relieve patient symptoms; however, the relief is short-lived and recurrence rates are high.

Various surgical techniques have proven to be effective in treating CVO and maintaining AVF function. These approaches typically involve the use of autologous veins or PTFE grafts to bypass the occluded central vein. Depending on the location of the lesions in the central veins, the outflow tract of the vascular access can be connected to various vessels, such as the ipsilateral internal jugular, external jugular, or brachiocephalic veins, superior vena cava, right atrium, basilic vein, femoral vein, or transposed internal jugular vein.^{5 –9} Surgical trauma in accessing the chest cavity is significant. For most patients, it is easier and more practical to use either the internal or the external jugular vein as an outflow tract for the circuit. In the present case, we opted to use the contralateral external jugular vein as the outflow tract when the ipsilateral jugular vein was occluded, which was effective.

Graft bypass surgery for subclavian vein stenosis involves shunt creation using vascular anastomosis. It connects cephalic or basilic vein of the upper arm to the internal or external jugular vein through a subcutaneous tunnel using a graft. This redirects the AVF outflow through the narrowed subclavian vein, enabling it to flow into the superior vena cava and return to the heart. A PTFE graft with an inner diameter of 6 mm was used. Only two small skin incisions are necessary at the anastomosis sites with the veins. An additional incision is made to bury the midsection of the graft. This surgical procedure causes minimal trauma, has few complications, and maintains the jugular vein intact for establishing potential future vascular access. There are several advantages to using PTFE grafts: they are not limited by blood vessel length; are easy to obtain; permit smooth creation of subcutaneous tunnels, making them an ideal choice for patients without suitable autologous veins; and reduce patient trauma. The drawbacks of using PTFE grafts include higher infection rates and lower patency rates than AVFs. However, we followed up our five patients for 5–19 months and found that the patency rate of the repaired vascular access reached 100% without requiring interventions. This success may be attributed to the fact that the internal or external jugular vein is close to the central venous system. These veins have a larger diameter than superficial veins in the upper limbs, thus facilitating smoother flow and preventing stenosis at the venous anastomosis site of the loop. Stenosis at this site is a significant contributing factor in conventional arteriovenous grafts failure.

Another type of surgery for the transposition of the jugular vein involves separating the internal jugular vein high in the neck, ligating the distal end of the internal jugular vein, and anastomosing the proximal end of the internal jugular vein to either the distal end of the subclavian vein or the axillary vein through a subcutaneous tunnel. This surgery involves only one vascular anastomosis, which simplifies the procedure, although it has drawbacks. More specifically, it alters jugular vein anatomy and cannot be used for future vascular access, and a relatively large incision is needed to free-up sufficient jugular vein length. Surgery relies on the assumption that the opposite internal jugular vein is unobstructed and can adequately handle blood flow returning from the head. Otherwise, various postoperative complications may result from occult venous return in the head. One of our patients had severe stenosis of both the left subclavian and brachiocephalic veins caused by a cardiac pacemaker, making surgery for left internal jugular vein transposition impossible.

The Hemodialysis Reliable Outflow (HeRO) device is another option for bypassing central venous stenosis or occlusion. It is suitable for patients with occluded supracardiac outflow veins (especially superior vena cava occlusion) and is often considered the last resort for hemodialysis patients with exhausted vascular access.^{10 –12} However, this innovative device is currently not available in our country.

Currently, the effectiveness of AVF repair using graft bypass surgery is based on data from retrospective observational studies. Chandler et al. ⁷ included 12 patients who underwent bypass surgery, with an average follow-up of 16 months. The patency rate was 100% after 1 month and 80% after 1 year. Bhatia et al. ¹³ compared the patency rates of surgical bypass with those of PTA and PSI, and found no statistically significant differences in 1-year patency rates. In another retrospective study of hemodialysis patients with CVS, graft bypass surgery had a higher primary patency rate than PTA. ¹⁴ These studies indicated that the long-term patency rate of graft bypass surgery is not inferior to the assisted patency rates of PTA and PSI.

Overall, graft bypass surgery yielded a primary patency rate of 80%–100% at 1 year. PTA procedures have a secondary patency rate comparable with graft bypass surgery but require multiple interventions. ¹⁴ Moreover, PTA treatment may result in the advancement of vascular stenosis in asymptomatic patients with CVS.

The number of patients undergoing MHD is increasing, along with a gradual increase in the number of CVO cases. Effective management of CVO is essential. Based on the existing literature and our experience, we recommend repairing AVF access in patients with CVO as much as possible to improve long-term survival. For patients with non-severe CVS, PTA should be performed as early as possible. If PTA fails or the central vein is completely occluded and cannot undergo PTA, bypass surgery should be performed (Figure 5). Graft bypass surgery can effectively repair vascular access and preserve AVF function.

OPEN IN VIEWER

Figure 5.

The suggested workflow for repairing an upper limb AVF complicated by ipsilateral central venous stenosis.

During follow-up, we used ultrasound to examine vascular patency, to minimize radiation exposure and the financial burden on patients.

Limitations

Our findings were limited by the small sample size and a single-center design of our study. More cases and prolonged follow-up are needed to confirm the effectiveness of this surgery.

Conclusion

Graft bypass surgery was highly effective for patients with subclavian vein stenosis. It demonstrated a high patency rate and was associated with few complications, and eliminated the need for repeated intervention. This procedure not only relieves upper limb infections and necrosis caused by upper extremity edema but also restores the AVF function, enabling patients undergoing MHD to continue hemodialysis. This protects the patient’s vascular resources and reduces economic burden and radiation damage associated with repeated interventional surgery.