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Background
The delivery of adequate hemodialysis requires dependable access to the vascular system of end stage renal disease patients. Despite the recommendation that arteriovenous fistulae (AVF) be used preferentially over arteriovenous grafts (AVG) and central venous catheters (CVC), hemodialysis via arteriovenous fistulae remains the exception rather than the rule.¹ Currently, in the United States, up to 60% of incident patients and nearly 30% of prevalent patients are using a central venous catheters for hemodialysis.^2,3 Recurrent vascular access failure is a major cause of morbidity in patients receiving long-term hemodialysis, the economic burden of which is estimated at greater than one billion dollars per year.⁴

As end-stage renal disease duration and its associated catheter time increase, the traditional access sites eventually occlude. Alternative percutaneous access sites such as the translumbar, transhepatic, transrenal, and transazygous have been well described.^5–12 These innovative approaches have been associated with higher complication rates and comparatively shorter catheter life. The technique whereby occluded subclavian veins are percutaneously recanalized have been described.^13–16 We present a novel application of this technique to recanalize previously occluded internal jugular veins for hemodialysis catheter placement.

Case Reports

Case 1:
A 40-year-old woman with a history of end stage renal disease secondary to focal and segmental glomerulosclerosis, was referred from the emergency department to interventional nephrology for hemodialysis access after her tunneled femoral catheter “fell out” three days prior. She had had tunneled internal jugular (IJ) dialysis catheters bilaterally in the past as well as multiple femoral catheters and a peritoneal dialysis catheter.

Ultrasound was used to evaluate the internal jugular and femoral veins bilaterally. The only visible vessel was the left internal jugular. After local anaesthesia, a micropuncture needle was used to cannulate the left internal jugular. A guidewire was inserted into the lumen of the vein. A 4-French introducer/dilator combination was then inserted over the wire into the lumen of the vein. Contrast venogram revealed a 100% stenosis at the anastomosis of the subclavian vein, with the left internal jugular and multiple collaterals leading to the central vasculature (Figure 1A). The 4-Fr introducer was then exchanged for a 6-Fr 5-cm introducer over a hydrophilic guidewire. A hydrophilic catheter was then inserted over the wire into the left internal jugular via introducer and was manipulated under fluoroscopic guidance to the level of the stenosis. The wire and catheter were then advanced in turn under fluoroscopic guidance past the lesion into the central vasculature. The wire was left in place and the catheter was removed. A 4 x 4 angioplasty balloon was then inserted into the introducer and manipulated to the level of the right heart and inflated serially to the left internal jugular. This was repeated with a 6 x 4 angioplasty balloon (Figure 1B), creating a tract for the hemodialysis catheter to be placed. Post-intervention venogram revealed smooth flow of contrast from the left internal jugular to the right side of the heart with a patent superior vena cava (SVC) and subclavian vessels (Figure 1C). A tunneled hemodialysis catheter was then inserted using the traditional technique (Figure 1D).

Case 2:
A 55-year-old woman with a history of end-stage renal disease due to systemic lupus nephritis who received 3 kidney transplants, all complicated by rejection, was hospitalized for uremia. She had a previous history of left brachiocephalic AVF complicated by left subclavian vein stenosis, status post stent placement. She had tunneled right internal jugular dialysis catheters in the past. The patient was referred to interventional nephrology for evaluation and management of acute and chronic hemodialysis access.

Ultrasound was used to evaluate the internal jugular veins bilaterally. The femoral regions were not examined with ultrasound due to severe candidal infection of the groin. The left internal jugular was absent. The right internal jugular was generous in the upper part of the neck but tapered to a 0.5-cm lumen at the base of the neck. A micropuncture needle was used to cannulate the right internal jugular vein. A guidewire was inserted through the needle and resistance was encountered 4-cm from the insertion point. A 4-Fr dilator/introducer was then inserted over the wire into the lumen of the right internal jugular. Contrast venography revealed 100% stenosis at the insertion of the internal jugular into the right subclavian and multiple collaterals that led into the central vasculature (Figure 2A). A hydrophilic guidewire was inserted into the lumen of the introducer and the 4-Fr introducer was exchanged for a 6-Fr introducer. A hydrophilic catheter was then inserted over the wire to the level of the lesion and the wire and catheter were then advanced in turn under fluoroscopic guidance past the lesion into the central vasculature. The procedure was successful in entering the SVC from the subclavian vein, however, the persistent stenosis prevented further advancement of the catheter (Figure 2B). The catheter was then removed and a 4 x 4 angioplasty balloon was inserted over the wire and manipulated under fluoroscopic guidance proximal to the lesion where it was inflated while applying pressure to the shaft of the balloon. This process was repeated with a 6 x 4 angioplasty balloon. During balloon inflation a straight hydrophilic guidewire was inserted into the stenosis. The balloon was serially inflated along the course of the lesion. This procedure was successful in opening a tract for the guidewire into the superior vena cava (Figure 2C). A tunneled hemodialysis catheter was then inserted using the traditional technique.

Discussion
Hemodialysis access remains the “Achilles heel” of end-stage renal disease care. As end-stage renal disease patients are progressively depleted of potential access sites, vascular access becomes more challenging. Many advanced techniques have been described to acquire vascular access via alternative sites. We describe an advanced technique that restores the patency of the internal jugular vein, potentially affording the benefits associated with the traditional internal jugular approach to the challenging hemodialysis access patient.
Although infrequent, immediate complications such as pneumothorax, hemothorax, carotid artery puncture, and hemorrhage can and do occur with the traditional internal jugular approach; they are less frequent compared with advanced techniques.¹⁷ It is certainly possible that the technique to recanalize the internal jugular described herein will lead to a similar, if not a higher, complication rate. Thus, the immediate safety and efficacy of the internal jugular recanalization approach described here awaits more rigorous investigation. Internal jugular salvage should, therefore, be reserved for patients in whom an alternative approach does not exist.

Long-term complications are also less frequent with internal jugular hemodialysis catheters, compared to alternative approaches. For instance, although the femoral vein is the easiest vessel to access as a substitute for the internal jugular and subclavian veins, long-term femoral vein catheters are also associated with a higher risk of iliac vein stenosis.¹⁸ More so, infection rates are as high as 40–50%, and bacterial contamination is even higher if the catheter exit site is near the groin.¹⁹ Another consideration is the possible need for a femoral arteriovenous graft; this would be problematic after multiple femoral catheters.⁶ Finally, the patency rate of femoral catheters, as well as alternative site catheters, is much shorter than the traditional internal jugular approach.²⁰ In the cases described, we were able to achieve hemodialysis blood flows of greater than 300 ml/min several months after catheter placement. Although the long-term outcomes for the described technique of internal jugular salvage must attend more rigorous investigation, this seems to be the most promising potential benefit.