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Biliary complications after orthotopic liver transplant (OLT) remain one of the primary causes of morbidity and mortality in liver transplant recipients with an approximate incidence between 5% and 32%. Given the limited supply of hepatic grafts, one of the most feared outcomes as a result of biliary complications is acute and or chronic graft failure. Biliary complications include leaks, biliary stasis, and stone formation, sphincter of Oddi dysfunction, recurrence of biliary disease (primary sclerosing cholangitis and primary biliary cirrhosis), and biliary strictures/obstruction. Overwhelmingly, the most common complication in hepatic transplantation is biliary stricture formation accounting for more than 50%. Currently, the mainstay of therapy as it pertains to biliary strictures/obstruction includes endoscopic retrograde cholangiography–guided therapy, percutaneous transhepatic cholangiography–guided therapy, or surgical revision/retransplantation. We present a case of biliary obstruction in a patient with a second liver transplant complicated by Cocoon Syndrome managed via sharp recanalization of CBD occlusion and placement of an endoscopic biliary Viabil stent.

Sharp recanalization for short-segment intravascular occlusion, using an endovascular route, has been described for inferior vena cava (IVC) occlusion. Often, the technical challenge to the endovascular management of Budd-Chiari syndrome (BCS) is the recanalization of the occluded hepatic vein or suprahepatic IVC. Presented here, the challenge was the level of occlusion of the suprahepatic IVC, with the resultant separation of both the patent IVC segments in a horizontal plane, making it technically challenging for sharp recanalization. We describe the use of percutaneous transhepatic access into the suprahepatic IVC via the middle hepatic vein under ultrasound guidance with eventual sharp recanalization of the occluded segment of the IVC, in a woman with BCS. This novel approach has not been described in the literature and can serve as an important addition to guide complex suprahepatic IVC recanalization.

Symptomatic central venous stenosis and occlusion remains the gordian knot of vascular access. Advances in techniques, like sharp recanalization, allowed for improved success rates in crossing these difficult lesions. There is also increasing evidence of new devices in treating central venous stenosis and, at the same time, improving the time needed between interventions. High-pressure balloons, paclitaxel-coated balloons, bare metal stents and covered stents have been tested with an aim to offer additional treatment options, although obstacles still exist. In the current review, authors describe relevant techniques and options, provide the evidence and evaluate the actual implementation of these devices in this demanding field. [ABSTRACT FROM AUTHOR]

Background: Many cases of chronic thoracic central vein occlusion (CVO) fail to recanalize using the standard conventional guidewire technique. This study aims to present the outcomes of sharp recanalization with a transseptal needle in chronic thoracic CVO., Methods: This retrospective study involved 22 hemodialysis patients who developed clinical signs and symptoms of CVO, had unsuccessful conventional endovascular treatment using guidewire, and underwent sharp recanalization with a transseptal needle from January 2018 to December 2021. Demographic information of patients, technical success rate, and complications were kept. Post-intervention primary patency rate was examined using survival regression., Results: Thirteen men and nine women were enrolled with a median age of 50 years (range: 30-83 years). The most common site of thoracic CVO was the right brachiocephalic vein (21 patients). The average length of occlusion was 2.5 cm (range: 1-4.4 cm). Technical success rate was 90.9% (20 patients). Major complications occurred in three instances, including severe hemothorax and pulmonary edema. The median post-intervention primary patency between balloon angioplasty alone and primary stenting was 2.1 and 8.0 months ( p  = 0.015). Post-intervention primary patency rates at 6 and 12 months in the group receiving balloon angioplasty alone versus primary stenting were 33.3% and 0% versus 70.6% and 29.4% ( p  = 0.013)., Conclusion: Sharp recanalization with a transseptal needle is successful in chronic thoracic CVO cases that fail with conventional recanalization. Primary stenting in this CVO lesion shows a greater primary patency compared to balloon angioplasty alone., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Central venous obstructions that impedes catheter placement or results in catheter dysfunction is a significant problem for haemodialysis patients. Recanalization can be performed with an intent to restore central venous access, improve outflow from arteriovenous fistula or to relieve symptomatic venous obstructions. Sharp recanalization encompasses various interventional techniques using a sharp instrument to puncture through or bypass around a venous obstruction. In this paper we outline our experience performing CT guided sharp recanalization and review alternative sharp recanalization techniques that are specifically used to restore haemodialysis access in patients with thoracic central venous obstruction., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Resistant chronic total occlusion (CTO) lesions present an ongoing challenge for conventional endovascular interventions to restore functional hemodialysis (HD) access. This study endeavors to present a novel endovascular approach utilizing ultrasound (USG)-guided percutaneous sharp recanalization to cross the resistant occlusions and evaluates its effectiveness., Methods: This is a multi-center retrospective review of consecutive patients received USG guided sharp recanalization for the treatment of resistant CTO lesions of their HD access between 1st January 2019 and 31st July 2023. Data encompassing patient demographics, access and lesion characteristics, procedural specifics, associated complications, immediate clinical outcomes, and outcomes during follow-up were collected. The procedural technical and clinical success, Kaplan-Meier estimated target lesion (TLPP), access circuit primary patency (ACPP), and index access secondary patency (SP) were reported., Results: During the study period, 22 patients underwent USG-guided sharp recanalization procedures in the three participating centers with median follow-up of 14.5 months. Both the technical and clinical success were 100%. Only two patients experienced minor complications of localized hematoma over the access, with no instances of major complication. Kaplan-Meier estimated TLPP and ACPP at 3-, 6-, and 12 months were 90.9%, 68.2%, 56.8%, and 90.9%, 63.6%, 52.1% respectively. The SP rates were 100%, 95.5%, and 84.1% at 3-, 6-, and 12 months respectively., Conclusion: USG guided percutaneous sharp recanalization is an effective and safe endovascular approach to treat resistant CTO lesions of dysfunctional HD access., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

An excluded calyx is a rare, acquired urologic condition where there is discontinuity between a portion of the renal collecting system with the remainder of the collecting system. Re-establishment of reliable long-term communication between the excluded calyx and the remaining collecting system is crucial for preservation of renal function and possible relief of symptoms. In this manuscript, we discuss two such cases where a previously undescribed novel procedure is used for treatment of this uncommon condition, where percutaneous antegrade transcatheter techniques were used to establish long-term urinary drainage. The first case discusses an excluded calyx in a 17-year-old male who suffered left renal injury after a high speed motor vehicle accident, where the kidney was divided by the injury and subsequently required creation of a neoinfundibulum in order to maintain continuity of the collecting system. The second case involves a 39-year-old female who underwent resection of a renal cell carcinoma, later developing an excluded calyx where radiofrequency wire recanalization was performed and the neoinfundibular track underwent serial retrograde balloon dilation, resulting in a continuous collecting system. Both patients have done well for more than 2 years after neoinfundibulum creation, showing that this novel technique should be considered a viable and safe procedure in the treatment of this rare condition.

Objective: Our objective was to evaluate the feasibility of XperCT combined fluoroscopy to guide sharp recanalization for the treatment of chronic thoracic venous occlusive disease in hemodialysis patients., Methods: The records of hemodialysis patients with chronic thoracic venous occlusive disease who received endovascular sharp recanalization after conventional techniques failed were retrospectively reviewed. The sharp devices used for recanalization included the stiff end of a guidewire, Chiba biopsy needle, RUPS-100 set, and transseptal needle. The needle was advanced toward a target placed at the opposite end of the occlusion and was guided by fluoroscopy and/or XperCT. While the guidewire crossed the occlusion, endovascular procedures such as percutaneous angioplasty were performed for the treatment of the occlusion., Results: The analysis included 32 sharp thoracic vein recanalization procedures in 29 patients. Two attempts in one patient failed, and in one patient the first attempt failed but the second attempt was successful. In one patient, two separate successful procedures were performed, and the other 26 procedures in 26 patients were successful. The overall technical success rate of sharp recanalization was 90%. The mean number of puncture attempts in the combined group was less than that of the fluoroscopy-guided alone group (2 vs 5, p  < 0.05). The success rate of sharp recanalization in the combined group was higher (100% vs 86%), and the recanalization time (28.5 min vs 36 min, p  > 0.05) was no different. There was no statistical difference in procedure-related complications between the groups., Conclusion: XperCT can facilitate sharp recanalization for the treatment of chronic thoracic venous occlusive disease in hemodialysis patients., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Abstract Background Chronic venous occlusion is common particularly in cancer patient due to hypercoagulate state associated with venous compression. Treatment options include endovascular management with venoplasty and stenting. Recanalization can be challenging in patients with complete venous occlusion secondary to significant external compression by a mass. Case presentation We report a case of a 73-year-old man with a history of bladder and prostate cancer who presented with worsening right leg edema and pain due to deep venous thrombosis secondary to a retroperitoneal mass. Management was sharp recanalization, venoplasty and stenting. Conclusion Endovascular intervention of chronic venous occlusion is technically challenging and time consuming. Sharp venous recanalization is feasible and safe in patients who failed standard recanalization procedures. We present a case of cancer-related obstruction of the right iliac veins and acute thrombosis of the femoral vein with symptomatic lower limb swelling relieved by sharp recanalization through the tumor mass.

Introduction: Hemodialysis catheter‐related superior vena cava (SVC) occlusions can cause considerable morbidity for patients and be challenging to treat if refractory to conventional guide wire transversal. This pilot study assessed the feasibility and safety of sharp recanalization of SVC occlusion in hemodialysis patients. Methods: This study retrospectively enrolled hemodialysis patients treated in West China Hospital diagnosed with SVC occlusion who failed traditional guide wire transversal from January 2014 to November 2017. In brief, a guide wire from the femoral approach was advanced to the lower end of the obstructive lesion to act as a target, while the stiff end of hydrophilic wire was advanced though a jugular approach. Under fluoroscopic guidance in biplane imaging, the occlusive SVC lesion was penetrated with the stiff wire that was snared and pulled through. Graded dilation of the SVC and subsequent tunneled‐cuffed catheter implantation were performed. Demographic information and clinical outcomes were recorded and evaluated. Findings: Sixteen patients with a mean age of 62 ± 13 years (13 females and 3 males) who received SVC sharp recanalization were included in this study. The sharp recanalization procedure was successfully performed in 14 patients (87.5%). Two patients were complicated with SVC laceration and hemopericardium but remained asymptomatic and required no surgical repair. One patient suffered ventricular fibrillation during procedure. Despite the return of spontaneous circulation, the patient unfortunately died of gastrointestinal tract bleeding after 3 days in ICU. Follow‐up suggested the 6‐month catheter patency to be 92.85% and 12‐month catheter patency to be 58.33%. No long‐term procedure‐related complications were recorded. Discussion: Sharp recanalization might be a feasible strategy in managing SVC occlusion in hemodialysis patients. The potential life‐threatening complications (cardiac arrhythmia and SVC laceration) necessitate strict eligibility screening, skillful operation, and avoidance of over‐dilation of SVC. [ABSTRACT FROM AUTHOR]

A 50-year-old male with right upper quadrant symptoms and hepatic dysfunction was found to have multiple dilated hepatic veins (HVs) with intrahepatic collateralization and membranous occlusion of the intrahepatic inferior vena cava (IVC) consistent with primary Budd–Chiari syndrome. Venacavograms depicted drainage of the intrahepatic collaterals through a left-sided HV entering the IVC above the level of the occlusion. Sharp recanalization of the membranous IVC occlusion was performed with an occlusion balloon as a needle target under echocardiographic monitoring followed by balloon angioplasty with restoration of IVC patency. Clinical, laboratory, and venographic procedural success has been demonstrated to 9 months with minimal residual stenosis.

Background: Patients on hemodialysis are particularly vulnerable to central venous occlusion (CVO). Endovascular treatment has gained wide acceptance for the treatment of CVO. However, difficulties in crossing the occluded segment can be encountered during conventional endovascular management. Sharp recanalization has been adopted when conventional endovascular methods could not recanalize the obstructed region. This study aimed to assess the outcome of the sharp venous recanalization technique with angioplasty and stenting in the treatment of CVO in Egyptian patients undergoing hemodialysis., Methods: This retrospective study is based on data from a prospectively maintained department database of patients under regular hemodialysis who underwent the sharp venous recanalization technique for CVO. Routinely, the patients were followed up at 3, 6, and 12 months with a clinical examination. The primary outcomes were technical success and primary patency. Secondary outcomes included complication rates and clinical success., Results: This study included 40 patients. Thirty-six patients (90%) achieved technical and clinical success. Seven patients (17.5%) had immediate postoperative complications. Four cases had minor complications (10%) and three patients had major complications (7.5%): hemothorax in two patients (5.1%) and pneumothorax in one patient (2.6%). At the 1-year follow-up, reintervention was required in nine patients (22.5%), with primary patency rate of 77.5% and a secondary patency rate of 100%., Conclusions: Sharp recanalization offers a solution for patients undergoing hemodialysis who developed CVO and failed to be recanalized using the conventional endovascular method. It offered promising technical success, clinical improvement, and good primary patency rates., Competing Interests: Disclosures None., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: To present a unique case in which intravenous medications were administered intermittently through a peripherally inserted central catheter (PICC) line over 2 years in the presence of an occluded superior vena cava (SVC) due to impressive collateral development. However, SVC recanalization was ultimately needed to allow for long-term future access needs. Case Description: This is a 25-year-old female with cystic fibrosis with known chronic occlusion of the SVC requiring multiple ports and PICC lines to maintain venous access. Despite conservative measures, it eventually became impossible to pass the occlusion via guidewire to properly place a PICC line. Sharp recanalization of the SVC occlusion with port placement was scheduled and successfully performed. The SVC was stented due to severe residual stenosis following recanalization and balloon angioplasty. Results: Imaging revealed a significantly enlarged hemiazygos vein and numerous prominent collaterals throughout the mediastinum and chest wall, resulting in the majority of chest venous drainage entering the inferior vena cava. After recanalization, her SVC and port remained patent and functional. Conclusions: For patients with SVC occlusion requiring venous access, a PICC line with the tip placed near the confluence of the brachiocephalic veins may serve as a temporary method for venous access in the presence of extensive collateral flow. However, for long-term access, sharp recanalization of the occlusion should be considered to restore normal laminar blood flow patterns and allow for optimum central venous catheter tip placement at the cavoatrial junction. [ABSTRACT FROM AUTHOR]

Purpose: To report the technical success and complications following sharp recanalization of chronic venous occlusions.Materials and Methods: A total of 123 patients, including 75 (61.0%) men and 48 (39.0%) women, with mean age of 50.5 ± 17.5 years (range 19-90 years), underwent sharp recanalization of chronic venous occlusions. The etiologies of occlusion were chronic deep venous thrombosis (n = 43; 35.0%), prior central venous access (n = 39; 31.7%), indwelling cardiac leads (n = 21; 17.1%), and occluded venous stents (n = 20; 16.3%). The sites of venous occlusion included 59/123 (48.0%) thoracic central veins, 37 (30.1%) non-thoracic central veins, and 27 (22.0%) peripheral veins. Median length of occlusion was 3.2 ± 1.4 cm (range 1.3-10.9 cm).Results: Sharp recanalization was most commonly attempted with transseptal needles in 108/123 (87.8%), with a mean number of 1.2 ± 0.4 crossing devices per patient (range 1-4 devices). Targeting devices included a loop snare (n = 92; 74.8%), partially deployed Wallstent (n = 21; 17.1%), partially deployed Amplatzer vascular plug (n = 8; 6.5%), and an angioplasty balloon (n = 3; 2.4%). Technical success was achieved in 111 (90.2%) patients. There were 3 (2.4%) severe, 1 (0.8%) moderate, and 7 (5.7%) minor adverse events. Severe adverse events included 1 case each of pericardial tamponade, hemothorax, and inferior vena cava filter occlusion. 88 (71.5%) patients had venous stents placed; at the last follow-up examination, 68/86 (79.0%) stents were patent.Conclusion: Sharp recanalization has a high technical success and low rate of adverse events in the recanalization of chronic venous occlusions. [ABSTRACT FROM AUTHOR]

Resection of the inferior vena cava (IVC) is a rare surgical technique that is occasionally combined with nephrectomy in the setting of renal malignancy with intravascular tumor extension. While this may be fairly well tolerated in some patients due to extensive collateralization in the venous system, there is a clear potential for lower extremity venous insufficiency and deep vein thrombosis (DVT). This report describes a patient who underwent right nephrectomy and segmental IVC resection from the subhepatic space to the iliac confluence, which was complicated by profoundly symptomatic lower extremity DVT and gastrointestinal hemorrhage due to system-to-portal shunting. After performing sharp recanalization through the retroperitoneum, iliocaval reconstruction was accomplished utilizing covered stent-grafts, with complete resolution of symptoms.Level of Evidence Case Report, Level 5. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate success and safety of needle (sharp) recanalization as a method to re-establish access in patients with chronic central venous occlusions.Materials and Methods: Thirty-nine consecutive patients who underwent this procedure were retrospectively reviewed to establish success rate and associated complications. In all cases, a 21- or 22-gauge needle was used to restore connection between two chronically occluded segments after conventional wire and catheter techniques had failed. The needle was guided toward a target placed through a separate access by fluoroscopic guidance. When successful, the procedure was completed by placing a catheter, ballooning the segment, and/or stenting.Results: The procedure was successful in 37 of the 39 patients (95%). The vast majority of the treated lesions were in the SVC and/or right innominate vein. Occlusions ranged in length between 10 and 110 mm, and the average length of occluded venous segment was 40 mm in the treated group. There were four minor (SIR classification B) complications involving pain management after the procedure. There were two major (SIR classification D) complications both of which involved hemorrhage into the pericardium treated with covered stents (5.1%).Conclusions: Sharp recanalization is a viable procedure for patients who have exhausted standard wire and catheter techniques. The operator performing this procedure should be familiar with potential complications so that they can be addressed urgently if needed. [ABSTRACT FROM AUTHOR]

Introduction/purpose: Sharp recanalization of chronic venous occlusions is usually performed with targeting of wire-capture devices like loop snares or balloons. We describe sharp recanalization of chronic venous occlusions using self-expanding stents and vascular plugs.Material and Methods: We retrospectively reviewed all sharp venous recanalization procedures performed over an 11-month period and found Wallstent and Amplatzer vascular plug (AVP) targeting was performed in 16 patients. Patient demographics, occlusion site, targeting device, technical success of the targeting, and overall procedural success were recorded.Results: Technical success was achieved in twelve (86%) Wallstent and two (67%) AVP deployments. Procedural success was achieved in 15 (94%). Three minor complications occurred.Conclusion: Wallstent and AVP targeting may be a useful technique when performing sharp recanalization for chronic venous occlusions. These devices expand the target space and present the same cross section viewed from any angle and can directly capture and extract the wire, features helpful in regions with crowded vascular anatomy. [ABSTRACT FROM AUTHOR]

Patients with end-stage renal disease undergo renal transplant, peritoneal dialysis, or intermittent hemodialysis for renal replacement therapy. For hemodialysis, native fistulas or grafts are preferred but hemodialysis catheters are often necessary. Per KDOQI, the right jugular vein is the preferred vessel of access for these catheters. However, in patients with long-standing end-stage renal disease vein thrombosis, stenosis and occlusion occurs. In these patients with end-stage vascular access, unconventional routes of placement of dialysis catheters are needed. These methods include placing them by means of sharp recanalization, via a translumbar route directly into the inferior vena cava, and via transhepatic and transrenal routes. These difficult, but potentially lifesaving methods of gaining vascular access are reviewed in this article. [ABSTRACT FROM AUTHOR]

Central venous stenosis or occlusion is a common and vexing problem in patients undergoing hemodialysis. Typical presenting symptoms include arm swelling and prolonged bleeding after hemodialysis. Despite multiple treatment approaches, these stenoses tend to recur and progress over time. A thorough preprocedure evaluation, methodical procedural approach and awareness of potential complications are all essential to try to preserve vascular access and improve patients' quality of life. [ABSTRACT FROM AUTHOR]

Background: Central vein occlusion (CVO) is a serious problem in hemodialysis patients. There is an unsatisfactory result for refractory CVO by sharp recanalization alone. This study evaluated the efficacy and safety of blunt impingement followed by sharp recanalization for the treatment of CVO in hemodialysis patients., Methods: This study retrospectively examined hemodialysis patients with CVO who failed to recanalize using standard guidewire and catheter techniques in our department. In the first instance, all CVOs were recanalized using blunt impingement techniques, including a 6-Fr long sheath (Cook Incorporated, Bloomington, IN USA) and an 8-Fr sheath of Rosch-Uchida Transjugular Liver Access Set (RUPS-100; Cook Incorporated, Bloomington, IN, USA). If this was not successful, sharp recanalization devices were applied, including the stiff tip of a guidewire (Terumo, Tokyo, Japan), the RUPS-100, and the percutaneous transhepatic cholangial drainage (PTCD) needle (Cook Incorporated, USA). All patients were followed up at least 4 months postoperatively. The technical success rate, arteriovenous access patency rates, and operation-related complications were analyzed., Results: The procedural success rate was 100.0% (30 of 30). Thirty patients with CVO underwent blunt impingement with a technique success rate of 70.0% (21 of 30), and 9 patients received sharp recanalization after failed blunt impingement, with a technique success rate of 100.0% (9 of 9). The primary patency rates at 6 and 12 months postoperatively were 86.7% and 53.3%, respectively. The primary assisted patency rates were 93.3% and 63.3%, and the secondary patency rates were 93.3% and 70.0% at 6 and 12 months, respectively. One major procedure-related complication was detected, namely, a small injury of the superior vena cava (SVC) wall in a patient receiving recanalization via the stiff end of a guidewire, but this did not require further treatment., Conclusions: It is potentially effective and safe for interventionalists to use blunt impingement followed by sharp recanalization techniques to treat chronic CVO that is refractory to traversal using traditional catheter and guidewire techniques., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-22-3131/coif). The authors have no conflicts of interest to declare., (2022 Annals of Translational Medicine. All rights reserved.)

Background: The purpose of the present study was to evaluate the technical feasibility and safety of sharp recanalization for central venous occlusive disease (CVOD) in patients requiring hemodialysis., Methods: Patients with CVOD requiring hemodialysis who had undergone endovascular recanalization using sharp devices, including the stiff end of a guidewire, Chiba needle, or RUS-100 to cross occluded segments after conventional techniques had failed were included. The needle was guided toward a target placed at the opposite end of the occlusion. Although the guidewire was passed though the occlusion, subsequent procedures such as percutaneous transluminal angioplasty could be performed., Results: A total of 27 sharp recanalization procedures in 25 patients were performed. Two attempts failed, 1 patient had undergone two separate successful procedures, and 23 procedures in 23 patients were successful. The overall technique success was 92.6%. The stiff end of a guidewire was the first choice for all the procedures, and recanalization was achieved in 18 patients (66.7%). A Chiba biopsy needle was used in six procedures (22.2%), with 100% technical success. A RUPS-100 set was used in two procedures (7.4%), with one aborted because of concern for complications. The occlusion was subsequently crossed using a Chiba needle. Four minor adverse events (two of mediastinal hematoma and two of chest pain) had occurred, and two major adverse events (pericardial tamponade and acute pleural effusion in one patient [4%], treated with the guidewire stiff-end technique, who recovered after drainage) had occurred., Conclusions: Sharp recanalization is safe and feasible with high technical success for CVOD in patients requiring hemodialysis who cannot be recanalized using conventional techniques., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

A patient with central venous occlusion at the junction of the superior vena cava and right atrium underwent endovascular revascularization. The leakage of contrast agents was detected during sharp recanalization that was then managed with covered stent deployment. The initial symptom of facial swelling disappeared and the vital signs were stable after treatment. Regrettably, the patient suffered from the clinical features of cardiac tamponade on the third day post-treatment, which was confirmed by computed tomography. Finally, a pericardial effusion was drained, leading to dramatic improvement in the cardiovascular status of the patient.

Highlight Hirata and colleagues report on a difficult case of biliary strictures and extensive bile leak near the hepatic hilum after hepatectomy for metastatic cancer. Treatment with sharp recanalization and the rendezvous technique was effective to establish bridging between the common bile duct and intrahepatic bile duct in this case., (© 2021 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

We present the case of a 53-year-old woman with a history of maintenance hemodialysis through arteriovenous fistula, CUFF catheter (cuffed tunneled catheter) and artificial vascular graft successively. Some signs of superior vena cava syndrome have presented including chronic edema in the face and left arm and varicose veins. Both CT (computed tomography) and angiography showed narrowing and occlusion in multiple veins, especially the right innominate vein, superior vena cava, inferior vena cava, left jugular vein, and bilateral common iliac veins. The first attempt at recanalization of the AVG (arteriovenous graft) failed due to severe occlusion of central venous. Finally, the patient was treated with a minimally invasive surgical approach involving percutaneous direct superior vena cava puncture driven by a single bend and vascular snare that were placed in the right atrium via hepatic vein percutaneous direct puncture under a double C arm angiographic device. The initial attempt failed with RUPS 100 (Cook, Chicago, USA) and was complicated by pericardial tamponade. The second attempt succeeded and the catheter was placed without hindrance and edema or varicose veins and its patency has remained for over 18 months following the intervention. It is the first successful case of sharp recanalization in combined superior and inferior vena cava syndromes with long-segment occlusion. This creative approach to providing vascular access offers a novel way to address refractory lesions in central veins.

Background: Although the internal jugular vein (IJV) is the most widely used puncture site in hemodialysis catheter insertion and central vein angioplasty, the external jugular vein (EJV) offers an alternative vascular access point in cases when the IJV is inaccessible. The present study aims to observe the efficacy and safety of sharp recanalization of the brachiocephalic vein occlusion through the EJV in hemodialysis patients., Methods: This retrospective study enrolled a cohort of hemodialysis patients who received sharp recanalization of occlusive brachiocephalic vein through the EJV at a university-affiliated hospital between January 2017 and January 2019. The demographic information and clinical outcome data of the patients were collected and analyzed., Results: A total of 16 hemodialysis patients who received right brachiocephalic vein sharp recanalization through the EJV were analyzed. The technical success rate was 100%. Twelve patients (12/16, 75%), whose EJV-subclavian vein angle (E-S angle) was 60-80 degrees, were successfully recanalized on the first attempt. With the other 4 patients (4/16, 25%), whose E-S angle approached 90 degrees, the brachiocephalic vein was recanalized on the second attempt by elevating the ipsilateral shoulder, therefore decreasing the E-S angle to align the course of the EJV with the brachiocephalic vein. Three minor complications were recorded, including 1 patient with blood continuously oozing from the EJV at the puncture site and 2 patients with mild chest pain. After an average of 10 months of follow-up, the clinical patent rate was 81.25% with no procedure-related complications reported., Conclusions: Sharp recanalization through the EJV could be an effective and safe alternative treatment for right brachiocephalic vein occlusion in hemodialysis patients if performed by an experienced practitioner. Measuring the angle formed by the EJV and the subclavian vein might provide helpful information for selecting patients., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-3015). The authors have no conflicts of interest to declare., (2020 Annals of Translational Medicine. All rights reserved.)

Rationale & Objective: Left-sided internal jugular and all subclavian central venous catheters (CVCs) cause thoracic central vein occlusions (TCVOs) more often than right-sided internal jugular catheters. To enable right-sided CVC placement in patients with TCVO, an inside-out access (IOA) approach was established at 3 vascular access centers in Europe involving use of a novel IOA device advanced from the right femoral vein. In the current analysis, we assessed the eligibility and success rate of this IOA approach in a cohort of patients with TCVO requiring a tunneled dialysis catheter., Study Design: Retrospective multicenter observational study., Setting & Participants: 36 patients with TCVO treated in Vienna, Austria; Oxford, England; or Cologne, Germany, who required hemodialysis access between July 2016 and June 2018., Exposure: Application of the IOA approach to gain vascular access., Outcome: The primary end point was the success rate of passing the TCVO to gain dialysis access using the IOA approach. Secondary end points were catheter patency at 3 months and procedure-related complications (early infections, bleeding, hematoma, and pericardial effusions)., Analytical Approach: Descriptive statistics to characterize eligibility, success rate, and complications of the IOA approach., Results: 36 patients with TCVO and history of multiple CVCs and arteriovenous fistulas were referred to the participating centers for vascular access. 32 (89%) patients were eligible for the IOA approach. 39 treatments were performed, with 7 patients undergoing the IOA procedure a second time more than 3 months after initial CVC placement. Dialysis access was established successfully in 38 of 39 (97%) implementations of the IOA procedure. Median intervention time was 43 minutes. No complications occurred., Limitations: No comparison to other methods to place CVCs and the observational study design., Conclusions: The IOA approach is a promising method to enable rapid access to the right jugular vein in the setting of pre-existing TCVO. Additional experience is needed to understand the generalizability of these observations., (Copyright © 2019 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)