CENTRAL VENOUS OCCLUSION

RECANALIZATION USING A RF POWERWIRE

Resident: Nicole A. Lamparello, MD
Fellow: Sujoy Menon, MD
Attending: Todd E. Markowitz, MD
Program/Dept(s): NYU Langone Medical
Center and Mount Sinai Beth Israel

CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation
Right upper extremity pain and swelling.
History of Present Illness
49-year-old man with end-stage renal disease on hemodialysis with right
upper extremity radiocephalic AV fistula complicated by subclavian vein
and brachiocephalic vein occlusion status post unsuccessful central
recanalization.

The patient is referred for follow-up AV fistulography and attempted central

outflow vein recanalization and stent placement.

RELEVANT HISTORY
Past Medical and Surgical History
DM
ESRD with right upper extremity fistula
HTN
CAD
Family & Social History: Noncontributory
Allergies: NKDA

DIAGNOSTIC WORKUP
Physical Exam
Moderate right upper extremity swelling.

Strong pulsatile thrill within the outflow cephalic vein

DIAGNOSIS
Central venous occulsion (CVO)

DIAGNOTIC WORK UP
Images A and B: Right upper extremity AV
Fistulogram reveals complete occlusion of the right
brachiocephalic and right subclavian veins with
collateral formation in the right neck. Contrast
injection through the right internal jugular vein also
demonstrated occlusion of at the level of the
clavicle with central venous drainage via a
prominent supraclavicular clavicle draining into the
left brachiocephalic vein. No direct connection to
the patent portion of the right subclavian vein was
identified.

INTERVENTION: OBTAINING ACCESS

A

Image A: Through the

right upper extremity
access, a peripheral
subclavian vein was
accesses and the right
internal mammary vein
was selected.

Image B: Right common femoral

vein access was obtained and a
wire was advanced centrally into
the right superior vena cava.
Superior venacavogram
demonstrated wide patency of the
central left brachiocephalic vein
and the superior vena cava. Right
brachiocephalic vein was occluded.

INTERVENTION: RF POWERWIRE
RECANNULATION

Image A: From below, a loop was deployed

within the peripheral SVC at its confluence
with the left brachiocephalic vein.
Image B: A SOS 2 selective catheter was
advanced over a wire from the RUE access
and positioned with its distal tip in the
proximal right internal mammary vein aiming
medially. A RF PowerWire was advanced
through the SOS 2 selective catheter into the
right internal mammary vein aiming at the
indwelling loop snare within the SVC.

QUESTION
1). By what mechanism does the RF PowerWire guidewire cross occluded
blood vessels?
A: RF guidewire uses vibrations to cause vessel plaque to dissolve.

B: RF guidewire is unable to cross tight regions of stenosis.

C: Stiff shaft and tip punctures a small channel through vessel occlusion.
D: Radiopaque tip delivers RF energy to vaporize a channel through
occlusions with minimal trauma to surrounding tissue.

CORRECT!
1). By what mechanism does the RF PowerWire guidewire cross occluded blood
vessels?
A: RF guidewire uses vibrations to cause vessel plaque to dissolve.
B: RF guidewire is unable to cross tight regions of stenosis.
C: Stiff shaft and tip punctures a small channel through vessel occlusion.
D: Radiopaque tip delivers RF energy to vaporize a channel through
occlusions with minimal trauma to surrounding tissue.
Uses RF energy to facilitate crossing totally occluded peripheral vessels that are
difficult to cross with a standard recanalization crossing techniques.
Flexible, shaft with a stiff proximal end.
Radiopaque tip delivers RF energy to vaporize a channel through occlusions with
minimal trauma to surrounding tissue.
CONTINUE WITH CASE

Sorry, Thats Incorrect.

1). By what mechanism does the RF PowerWire guidewire cross occluded
blood vessels?
A: RF guidewire uses vibrations to cause vessel plaque to dissolve.

B: RF guidewire is unable to cross tight regions of stenosis.

C: Stiff shaft and tip punctures a small channel through vessel occlusion.
D: Radiopaque tip delivers RF energy to vaporize a channel through
occlusions with minimal trauma to surrounding tissue.

CONTINUE WITH CASE

INTERVENTION: BALLOON ANGIOPLASTY

OF RECANALIZATION TRACK
Images A and B: Serial dilatation of
the recanalized tract between the
right internal mammary vein and the
superior vena cava was performed
with angioplasty balloon. Contrast
injection demonstrated brisk central
venous flow from the right subclavian
vein, through the proximal internal
mammary vein into the superior vena
cava.

INTERVENTION: STENT PLACEMENT

Images A and B: A self-expanding SMART nitinol stent was advanced over the wire and positioned within
the recanalized tract. The stent was deployed and postdilated with angioplasty balloon.

SUMMARY: SUCCESSFUL CVO

RECANALIZATION USING RF POWERWIRE

A
Image A: Pre-intervention fistulogram demonstrating
chronic occlusion of the subclavian vein and
brachiocephalic vein with filling of multiple
supraclavicular collateral veins.

Image B: Successful right-sided central

B
recanalization utilizing RF wire with placement of a
self expanding nitinol stent within the recanalized
tract. Supraclavicular collaterals no longer identified.

CLINICAL FOLLOW UP
Patient reported complete resolution of symptoms.
Physical examination revealed no swelling of right upper
extremity.
Arteriovenous shunt functioning well.

REFERENCES & FURTHER READING

Baerlocher MO, Asch MR, Myers A. Successful recanalization of a longstanding complete left subclavian vein occlusion by radiofrequency
perforation with use of a radiofrequency guide wire. J Vasc Interv Radiol. 2006 Oct;17(10):1703-6.
Di lorio BR, Mondillo, Bortone S, et al. Fourteen years of hemodialysis with a central venous catheter: mechanical long-term complications. J Vasc
Access. 2006 Apr-Jun;7(2):60-5.

Guimaraes M, Schonholz C, Hannegan C, et al. Radiofrequency wire for the recanalization of central vein occlusions that have failed conventional
endovascular techniques. J Vasc Interv Radiol. 2012 Aug;23(8):1016-21.
Mansour M, Kamper L, Altenburg A, et al. Radiological central vein treatment in vascular access. J Vasc Access. 2008 Apr-Jun;9(2):85-101.
Nael K, Kee ST, Solomon H, et al. Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients: a single
institutional experience in 69 consecutive patients. J Vasc Interv Radiol. 2009 Jan;20(1):46-51.

Oguzkurt L, Lercan F, Torun D, et al. Impact of short-term hemodialysis catheters on the central veins: a catheter venographic study. Eur J Radiol.
2004 Dec;52(3):293-9.
Przywara S, Iizecki M, Terlecki P, et al.. New method of forced implantation of permanent catheters for hemodialysis into critically stenosed or
occluded central veins.. Pol Przegl Chir. 2014 Dec 18;86(9):405-9.
Surlan M and Popovic P. The role of interventional radiology in management of patients with end-stage renal disease. Eur J Radiol. 2003
May;46(2):96-114.
Vogel PM and Parise C. SMART stent for salvage of hemodialysis access grafts. J Vasc Interv Radiol. 2004 Oct;15(10):1051-60.