Efficacy of axillary-to-femoral vein bypass in relieving venous hypertension in dialysis patients with symptomatic central vein occlusion

Objective Central vein stenosis or occlusion remains an unfortunate complication associated with the use of dialysis catheters. In patients with a functioning arteriovenous fistula, central vein stenosis can lead to debilitating arm, breast, or neck swelling. Treatment typically involves central vein angioplasty or stenting, or both, but restenosis and reocclusion rates remain high. Presented here are the initial results of a unique series of patients with a mature arteriovenous access and symptomatic upper extremity venous hypertension who were treated with axillary vein-to-femoral vein bypass after endovascular therapy failed. Methods This was a retrospective analysis of 10 hemodialysis patients with a functioning right upper extremity access who underwent axillary vein-to-femoral vein bypass between December 2011 and April 2013. Results The 10 patients (seven men) were a median age of 58 years. All patients had documentation of prior central venous catheter placement and had undergone a previous endovascular procedure that was unsuccessful or technically unfeasible. The median hospital stay was 2 days (range, 1-3 days), and the median assisted-primary patency was 197 days (25th-75th percentile, 114-240 days). Three patients presented with recurrent arm swelling that was successfully managed in one patient with revision of the proximal anastomosis. Three additional patients presented with subsequent lower extremity swelling, with one patient benefitting from femoral vein angioplasty. Ultimately, six patients continued to use their original access, and two required placement of interval central venous catheters for hemodialysis. Conclusions In patients who have exhausted all endovascular options, axillary-to-femoral vein bypass may represent a safe and efficacious approach to alleviate extremity swelling while simultaneously salvaging a functional dialysis access.