Alternative Strategies for Central Venous Stenosis and Occlusion in Patients Requiring Haemodialysis Access.

Dear Editor, The use of tunnelled dialysis catheters (TDCs) in patients awaiting permanent dialysis access creation has resulted in a rise in the prevalence of central venous stenosis and occlusion (CVSO) in up to 50% of cases.1,2 CVSO is a difficult problem to manage. The mainstay of treatment for CVSO includes percutaneous transluminal angioplasty (PTA) and stenting. These are, however, prone to recurrence, with primary patency rates of not more than 50% at 1 year.3-6 Potential long-term complications of CVSO include venous hypertension leading to recirculation and failure of vascular access, symptomatic limb swelling, and superior vena cava syndrome. Alternative vascular access techniques such as lower extremity arteriovenous grafts (AVGs) have high infection rates (27%), limited patency and are associated with other morbidities such as lower limb ischaemia.7,8 Two novel hybrid surgical options have been described in literature, but are rarely used in the local setting. The Haemodialysis Reliable Outflow (HeRO) graft circumvents the site of central obstruction, while the GORE® hybrid vascular graft allows deployment of an integrated stent to treat the stenotic central vein. Multicentre studies on the HeRO graft have shown superior patency (88% vs 37%) and infection rates (0.14 vs 2.3 infection/1000 days) when compared with TDC, and similar patency rates with conventional AVG (90% vs 65%).9,10 We introduce the first 2 local patients receiving the aforementioned vascular grafts and discuss these alternative options for patients with CVSO.