JVA

J Vasc Access 2017; 18 (2): 173-176

DOI: 10.5301/jva.5000625

ISSN 1129-7298 TECHNIQUES IN VASCULAR ACCESS

Balloon-assisted venous access salvage through a

thrombosed arteriovenous graft
Chen Pong Wong, Karthikeyan Damodharan, Thijs A.J. Urlings, Sivanathan Chandramohan

Department of Diagnostic Radiology, Singapore General Hospital, Singapore - Singapore

ABSTRACT
Introduction: Maintaining vascular access by means of radiological intervention has become the mainstay of
management of patients with central venous stenoses and occlusions (CVO), which can be challenging. We pres-
ent a case of balloon-assisted percutaneous puncture of an occluded left subclavian vein, through a thrombosed
arteriovenous graft, for a tunneled dialysis catheter insertion.
Methods: A thrombosed left arm arteriovenous graft was accessed, and the occluded left subclavian vein was
traversed with 0.018 platform. An 8 mm 0.018 low platform balloon was inflated in the left subclavian vein as a
target for percutaneous puncture to gain direct access into the occluded segment of the vein. This access was
then used for routine placement of a tunneled left subclavian dialysis catheter.
Results: Successful placement of a tunneled dialysis catheter into an occluded left subclavian vein using a
balloon- assisted puncture technique, through a thrombosed left-arm arteriovenous graft.
Conclusions: Thrombosed arteriovenous grafts are potential access sites into the central veins. Balloon-
assisted punctures allow vascular access salvage into otherwise occluded segments of a central vein; in our
case, it allowed access into an occluded left subclavian vein for dialysis catheter placement.
Keywords: Balloon-assisted percutaneous puncture, Central vein occlusion, Thrombosed arteriovenous graft,
Left subclavian vein, Vascular access, Hemodialysis

Introduction patients with CVO. Novel techniques are required to tackle

Central venous stenoses and occlusions (CVO) remain a
common and recurrent problem in patients with hemodial-
ysis-dependent end-stage renal disease, which affects pa-
tients with arteriovenous fistulas or grafts as well as those
with in-dwelling central venous dialysis catheters. Incidences
of CVO have been quoted to be as high as 30% in the hemo-
dialysis patient population (1), although the true incidence
is not known. The etiology of CVO appears multifactorial
vein injury, inflammation, hemodynamics and uremia but it
is believed that placement of prior central venous catheters
contributes significantly to its pathogenesis, chiefly through
catheter-induced trauma to the venous endothelium and sec-
ondary inflammation within the vessel wall during catheter
insertion (2-4).
Maintaining vascular access by means of radiological
intervention has become the mainstay of management of
Accepted: September 10, 2016
Published online: November 22, 2016
Corresponding author:
Chen Pong Wong
Singapore General Hospital
Outram Road
169608, Singapore
chenpong.wong@mohh.com.sg
the complexities presented by different patients with vary-
ing extents of CVO. We present a case of balloon-assisted
percutaneous puncture of an occluded left subclavian vein,
through a thrombosed arteriovenous graft, for a tunneled
dialysis catheter insertion.
Methods and results
Our institutional review board exemption was obtained
prior to the preparation of this manuscript.
A 62-year-old obese female with vascular access difficul-
ties was referred to us for the placement of a tunneled dialy-
sis catheter. She had multiple central venous dialysis catheter
insertions from 2011 to 2016 due to malfunctioning arterio-
venous fistulas and grafts, likely contributing to her extensive
CVO. Both internal and external jugular veins were occluded
bilaterally, as were the subclavian veins.
All the native veins in the arms were occluded from their
previous use for access. Therefore, the thrombosed left bra-
chio-brachial arteriovenous graft was accessed with a 21G Mi-
cropuncture needle (Cook Medical, USA) under ultrasound
guidance. A 2.6 F CXI Support Catheter (Cook Medical, USA)
and a 0.018-inch V-18 guide wire (Boston Scientific, USA)
were negotiated through the chronically occluded graft and left
subclavian vein (Fig. 1A), and advanced centrally into the distal
patent subclavian/proximal brachiocephalic vein. Venogram
confirmed the intravenous location and showed moderate left

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174 Balloon-assisted venous access salvage via a thrombosed arteriovenous graft
brachiocephalic stenosis (Fig. 1B). The V-18 guide wire was
subsequently manipulated through the stenosis and advanced
into the inferior vena cava (IVC). An 8 mm 4 cm Sterling
balloon catheter (Boston Scientific, USA) was advanced over
the wire to perform venoplasty of the left brachiocephalic
venous stenosis. Subsequently, the same balloon was in-
flated in the thrombosed proximal left subclavian vein. A
percutaneous direct puncture of this balloon was performed
Fig. 1 - Access of occluded left sub-
clavian vein via the occluded left arm
arteriovenous graft. (A) 0.018-inch
V-18 guidewire in the left subcla-
vian vein placed through the left
brachio-brachial arteriovenous graft.
Please note a Gore Viabahn stent
graft which was placed previously at
the venous-graft anastomotic steno-
sis. (B) Contrast injection through a
2.6 F CXI Support Catheter showing
an occluded left subclavian vein.
Fig. 2 - Image-guided balloon-assist-
ed access of the occluded left sub-
clavian vein. (A) The 8 mm x 4 cm
Sterling balloon being targeted by
the 21G AccuStick needle under
fluoroscopic guidance. (B) Tip of
0.018-inch guidewire coiling in the
punctured balloon.
with a 21G AccuStick needle (Boston Scientific, USA) under
fluoroscopic guidance (Fig. 2A), after confirming that the left
subclavian artery was deep to the thrombosed left subcla-
vian vein with ultrasound. Due to the patients body habitus
and thick subcutaneous adipose layer, an ultrasound-guided
puncture of the balloon could not be performed as the bal-
loon was too deep and poorly visualized on ultrasound. Con-
trast release from the balloon confirmed successful puncture.
2016 Wichtig Publishing
Wong et al
Fig. 3 - Wire access through the occluded vein in to the SVC. Arrow
showing the 0.018-inch guidewire tracking into the superior vena
cava through the balloon-assisted left subclavian vein puncture.
A 0.018-inch guidewire from the AccuStick set was then in-
serted into the punctured balloon (Fig. 2B). This was advanced
together with the punctured balloon and was manipulated
simultaneously into the superior vena cava (SVC) (Fig. 3). The
balloon catheter was then advanced independently to disen-
gage the wire. The balloon catheter was finally removed and
hemostasis at the left arteriovenous graft (AVG) puncture site
was achieved with manual compression.
Subsequently, a 6F AccuStick dilator/sheath was in-
serted over the wire at the left subclavian puncture site and
exchanged for a 0.035-inch Amplatz Super Stiff guide wire
(Boston Scientific, USA) which was then advanced into the
IVC. Following this, a 14.5 F (35 cm cuff to tip) HemoStar
tunneled dialysis catheter (Bard Peripheral Vascular, USA),
was then inserted through the left subclavian access (Fig. 4).
This left subclavian dialysis access was used as a temporiz-
ing measure for regular hemodialysis until the placement of
a Tenckhoff catheter for long-term peritoneal dialysis in the
patient a month later.
Discussion
The balloon puncture technique allows for vascular ac-
cess into central veins that are otherwise occluded, without
the need for full recanalization of the occluded segments.
Similar techniques have been described in literature. Uflacker
et al (5) described a balloon puncture technique from a pat-
ent right internal jugular access, where the balloon was in-
flated and targeted in the thrombosed/stenosed segment
located caudal to the first access. Gupta et al (6) used a pat-
ent right axillary vein access to target an inflated balloon in
the right brachiocephalic trunk that was abutting the throm-
bosed right subclavian vein segment. Our technique differs
from the two aforementioned reports in that (i) we acquired
access through a completely thrombosed arteriovenous graft
and (ii) the balloon that was targeted was inflated in the oc-
cluded left subclavian vein. The balloon puncture in our case
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175
Fig. 4 - Final tunneled dialysis catheter placement through the left
subclavian puncture.
was technically challenging due, in part, to the deeper ana-
tomical location of the subclavian vein compared to the in-
ternal jugular vein, as well as due to the body habitus of an
obese patient.
Thrombosed arteriovenous fistulae/grafts may serve as
potential access sites for small platform balloon catheters.
In our case, the combination of a 0.018-inch wire and a
braided 2.6 F catheter made it possible to access the more
central veins which were patent. In our experience, low pro-
file balloons are the mainstay in this type of recanalization
as they can track through chronically occluded segments
which may not be possible with the standard platform
(0.035-inch).
Various other techniques of crossing central venous oc-
clusions have been described in literature. Sivananthan et al
(7), used radiofrequency (RF) wires to cross these occlusions.
However, the vessel perforation rates were as high as 31%,
and RF wires are expensive. Davis et al (8) had used an in-
side out central venous access technique using the Surfacer
Inside-Out access catheter system (Bluegrass Vascular Tech-
nologies, USA). Above-mentioned techniques involve us-
ing dedicated devices but our technique uses only standard
wires, catheters and balloons.
This report demonstrates that peripheral vascular access
could be attempted in thombosed/occluded arteriovenous
grafts, and further illustrates the usefulness of balloon punc-
ture technique for vascular access salvage in CVO.
Disclosures
Financial support: No grants or funding have been received for this
study.
Conflict of interest: None of the authors has financial interest related
to this study to disclose.
176 Balloon-assisted venous access salvage via a thrombosed arteriovenous graft
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