ISRA May 2022

Inside Out Central Venous Access (IOCVA) for Dialysis Access Failure

Itamar Tamir Ibrahim Shaheen Alexander Klimov Allan Bloom
Medical Imaging, Interventional and Vascular Radiology Unit, Hadassah University Medical Center, Israel

Background: Retrograde transfemoral inside-out central venous access (IOCVA) is a technically challenging procedure which has been used in patients with central venous occlusion (CVO) for various indications. Due to the frequency of CVO in the hemodialysis population, IOCVA provides an alternative to contralateral, femoral or alternate vein cannulation for achieving effective dialysis access.

Purpose: To report our results/outcomes of IOCVA in a population of patients with failed hemodialysis access due to CVO.

Materials and Methods: A retrospective search of the interventional radiology logbooks and electronic patient record was performed to identify thirteen hemodialysis dependent patients (7 female, 6 male) mean age 53, range 20-75 years undergoing IOCVA between January 2016 and October 2020. All the patients had a failed dialysis access due to type 3 or 4 central venous occlusions. Procedures were performed via a transfemoral vein approach, in the interventional radiology suite with conscious intravenous sedation and vital signs monitoring, using a purpose- built combination of standard disposable devices. Either Tunneled Dialysis Catheters (TDC) or Hemodialysis Reliable Outflow (HeRO) grafts were inserted from a transfemoral vein approach for dialysis access.

Results: IOCVA was technically successful in 100% with no immediate procedural complications. Eight patients had a TDC insertion, five had a HeRO graft (two underwent delayed exchange from TDC to HeRO graft).

Median follow up was 12.3 months, range 1 - 41 months. One patient was lost to follow up. One patient died from septic shock six days after the HeRO graft placement. Three patients died from sepsis unrelated to the procedure.

The average time the device has been utilized for dialysis until first exchange/removal was 3.3 months (1-12 months).

Conclusion: IOCVA appears to be a safe alternative to femoral or other venous access and may prolong adequate hemodialysis in this vulnerable population.