Central venous occlusion in dialysis patients – Novel surgical management

Introduction: The progress in the management of maintenance hemodialysis and renal transplant has led to longer survival and also increased incidence of delayed complications. One of its dreadful complications is central venous occlusion which needs a satisfactory management. Materials and Methods: Bilateral subclavian vein occlusion, innominate vein occlusion, or superior vena cava occlusion remains the most dreadful scenario for central venous stenosis and central venous obstruction (CVO) in dialysis patients. In these patients who are refractory to endovascular options, surgery must be considered. We hereby describe our experience of managing these complications by a novel surgery of draining the area proximal to CVO to the right atrium by reinforced Polytetrafluoroethylene graft. Results: Three of our patient's symptom relief, salvage of arteriovenous fistula, and primary graft patency (mean – 20 months) were achieved satisfactorily. No postoperative mortality or no severe morbidity noted. Anticoagulation orally used up to 3 months of operation. One patient had graft occlusion and mild symptom recurrence. Conclusions: All the current endovascular options for CVO in dialysis patients are prone to recur. Extra-anatomic central venous bypass grafting draining into right atrial appendage is a novel management to relieve the complications. A satisfactory conduit with long-term patency and minimum thrombotic complications is still not available. Randomized control trials with long-term follow-up are needed to develop appropriate treatment algorithms.