TCTAP 2012, April 26, SEOUL, KOREA
The Importance of the Stent Selection on PTA for Left
B hi
Brachiocephalic
h li Venous
V
Lesions
L i
with
i h Chronic
Ch
i
Hemodialysis Patients: Choice of Self-expandable
and
dB
Balloon-expandable
ll
d bl St
Stent.
t
Department of Cardiology,
Kanazawa Cardiovascular Hospital
Yuki Horita, MD, PhD
Masanobu Namura, Masatoshi Ikeda, Hidenobu Terai,
Inoki Isao, Kanji Sakata, Naoto Tama, Toshimitsu Takagi
【B k
【Background(1)】
d(1)】
Th upper arm swelling
The
lli and
d venous hypertension
h
t
i on
artreriovanous fistula site, and insufficiency of hemodialysis condition are induced by the central venous
stenosis or totally occlusion(CTO) with chronic hemodialysis patients
patients. The percutaneous transluminal
angioplasty(PTA) for these central venous lesions has
been first choice of the treatment.
＊J
＊Japanese
S
Society
i t ffor Di
Dialysis
l i Therapy
Th
Guidelines
G id li
J Jpn Soc Dial Ther 38: 1532-1539, 2005
European
p
Best Practice Guideline(EBPG)
NDT 22(Supple 2): ii88-117, 2007
We reported,
The volume overload after PTA for central venous
stenosis or occluded lesions in chronic hemodialysis
patients resulted in increased RA and RV diameter
patients,
diameter.
These changes were transient and completely recovered
by
y the following
g day.
y
PTA for central venous lesions in patients with
normal ejection fraction can be performed without
clinical cardiac problems.
YH
Horita,
i et al:
l Serial
S i l cardiac
di influence
i fl
off volume
l
overload
l d
induced by interventional therapy for central venous stenosis or
occlusion in chronic hemodialysis patients.
J Cardiology, 57, 316-324, 2011
【Background(2)】
The stenosis or occlusion of left brachiocephalic vein
(
(innominate
vein)) with hemodialysis patients are
induced by
(1) Organic lesions of intimal hyperplasia
(2) Functional or anatomical oppression between
aortic arch, right brachiocepalic artery and sternum
It is necessary to choose the self-expandable or balloonexpandable
d bl stents
t t according
di g tto th
the etiology
ti l g off th
these
lesions, when we implant the stent for left brachiocephalic lesions.
lesions
【Purpose】
We presented the 4 cases implanted the stents
for left brachiocephalic lesions with
ith chronic
hemodialysis patients, and explain the selection
of self
self-expandable
expandable and balloon-expandable
balloon expandable stents.
stents
■Case-1, Long lesion: 85y.o. Male.
This patient was introduced to hemodislysis by chronic
glomerulonephritis. His AV-fitula was produced on his
left upper arm and he was introduced to our hospital
by the upper arm swelling and increasing of the returnpressure on routine
ti h
hemodialysis.
di l i
VR image
64 row-MDCT: venous phase
MIP image
Severe stenosis and
occlusion of left
brachiocephalic vein.
Occluded
portion
ti
Lt subclavian vein
Bi-directional
angiography
Bi directional approach:
Bi-directional
Lt basilic vein & rt femoral approach
Long lesion
0.035inch-Radifocus GW
0.014inch-GW
& IVUS check
IVUS findings presented the severe
stenosis by the intimal hyperplasia.
Ballooning(2 5mm)
Ballooning(2.5mm)
Balloonig(4 0mm)
Balloonig(4.0mm)
To avoid the risk of venous perforation following the initial
dilatation by the large-sized balloon, we performed the lesion
dilatation by the small-sized balloons.
Final angiography
SMART stenting
(10×60mm)
Post-ballooning(7.0mm)
The occluded lesion was completely dilated by
the self-expandable stent.
■Case-2, Short lesion: 47y.o. Male
This patient was introduced to hemodialysis by nephrosclerosis before 8 years. His AV-fistula was produced in his
l f forearm
left
f
and
d hi
his left
l f upper-arm swelling
lli has
h been
b
gradually increased since 4 years before. He was introduced
to our hospital for performing the PTA of left brachiocephalic
occluded lesion.
Bi-directional approach
Impossible passage of 0.035-Radifocus GW
The 0.018-inch
0.018 inch Treasure GW inserted from
rt. femoral vein could be crossed the lesion.
After predilatation by the 2.0mm-balloon, the
intimal hyperplasia
yp p
of the occluded lesion was
confirmed by IVUS.
The lesion was dilated by
the 4.0mm-balloon.
Express stent
(8.0×17mm)
Positioning
6 atm. deliveryy
The bilateral edge of delivered stent was additionally
dilated such as dog
dog-bone
bone configuration by the 10mm
10mm-sized
sized
balloon with low pressure(3 atm.) to avoid the dislocation of
the delivered stent.
Final angiography
Th occluded
The
l d d llesion
i was completely
l t l dilated
dil t d by
b th
the
balloon-expandable stent and the pressure gradient
was significantly decreased.
Pressure gradient: 28mmHg⇒0mmHg
■Case-3, Short lesion: 73y.o. Female
The basal disease of this patient was hypertension and
nephrosclerosis with chronic hemodialysis. He has received
the routine hemodialysis
y
since 20 y
years before. His access
was produced in his left forearm.
His left upper arm swelling and return-pressure on
routine hemodialysis have been gradually increased since
1.5 years before. He was introduced to our hospital.
Rt brachiocephalic vein
Severe stenosis of
Lt brachiocephalic vein
Left venous approach
on left AV-fistula
The angiography was performed by the 4F-catheter
advanced in the subclavian vein from AV-fistula
in lt. forearm.
The 0.014 Dejavu GW was crossed
the lesion and IVUS was performed.
IVUS fi di
IVUS-findings
The lesion presented severe stenosis and the lesion was
compressed from the outside without intimal hyperplasia.
5.0mm-POBA
Dilatation with
ith 4atm
4atm.
The lesion was recoiled and
impossible to dilate by the balloon.
5F-sheath was exchanged to
6F-sheath
6F
sheath. Self
Self-expandable
expandable stent
(Lumminexx:12×30mm) was
delivered.
Post-dilatation by 10.0mmballoon with 6 atm.
The lesion was not dilated enough by the self-expandable
stent(Luminexx)
(
i
) and
d the
h delivered
d li
d stent was slightly
li h l
dislocated. So, we implanted the balloon-expandable stent
(Express: 9x25mm) into the Luminexx stent to fasten and
dilate completely.
Implantation of Express with 8 atm.
We exchanged the 6F
6F-sheath
sheath to 8F
8F-sheath,
sheath, and
the stent-edge was dilated such as dog-bone configuration
by the 12mm-Balloon.
Fi l angiography
Final
i
h
The Luminexx & Express stent
were compressed by the rt. brachiocephalic artery
on the MDCT-findings at following day.
■Case-4, Short lesion: 46y.o. Male
This patient with hemodialysis by diabetic nephropathy
before 10 years, was introduced to our hospital for stenting.
His AV-fitula was produced on his left forearm and his
upper arm swelling and the return-pressure on routine
hemodialysis was gradually increased since 1 year before.
He was treated the balloon angioplasty for left brachio
brachiocephalic venous stenosis in other hospital, but the result
was incomplete dilatation, and he had the severe aortic
valve insufficiency.
Left brachocephalic stenosis
IVUS findings of the left brachiocephalic vein
4.0mm
C
Compression
i
Express(9.0×25mm) 10atm. Delivery
(Direct-stenting)
Post dilatation at bilateral stent edge
by12mm-balloon with 4 atm.
Final angiography
Stent-edge
Stent
edge were dilated
such as dog-bone configuration
Mean pressure gradient: 11mmHg⇒1mmHg
IVUS
MDCT at following
g day
y of PTA
4.0mm
Post-PTA
This lesion implanted stent was compressed
by the bifurcation of aorta and right brachiocaphalic artery.
【
【Conclusion】
】
The stenosis or chronic totally occluded lesions caused
by the organic stenosis in left brachiocephalic vein with
chronic hemodialysis patients, can be dilated by the
self or balloon-expandable stent.
B the
But
h llesions
i
caused
db
by the
h anatomical
i l oppression
i
of aorta, right brachiocephalic artery and sternum have
t be
to
b ttreated
t db
by th
the b
balloon-expandable
ll
d bl stents.
t t
The IVUS and MDCT are useful to evaluate the cause
of left brachiocephalic venous lesions in pre and postPTA.