title: Bilateral central vein stenosis: options for dialysis access and renal replacement therapy when all upper extremity access possibilities have been lost.
abstract: OBJECTIVE
  Patients with bilateral central vein stenosis present a unique challenge: treatment options are limited, largely unproven and associated with reputedly poor outcomes. Our aim was to compare patency rates of different access and renal replacement treatment (RRT) modalities in patients with bilateral central vein stenosis/occlusion.
  
  
  METHODS
  Data on all patients presenting to a tertiary referral vascular access centre with end-stage vascular access (defined by bilateral central vein stenosis/occlusion with loss of upper limb access) over a 5-year period were included. 3, 6 and 12-month patencies of translumbar catheters (TLs), tunnelled femoral catheters (Fem), native long saphenous vein loops (SV), prosthetic mid-thigh loop grafts (ThGr), peritoneal dialysis (PD), and expedited donation after cardiac death (DCD) cadaveric renal transplants (Tx) via local allocation policies were compared using log-rank test. Kaplan-Meier survival analysis was used to estimate long-term access survival.
  
  
  RESULTS
  One hundred forty-six vascular access modalities were attempted in 62 patients (62 Fem, 25 TL, 15 SV, 25 ThGr, 8 PD, 11 Tx). Median follow-up was 876±57 days. Three, 6 and 12-month primary-assisted patencies for each modality were as follows: Fem: 75.4%, 60% and 28%; TL: 88%, 65% and 50%; SV: 87.5%, 60% and 44.6%; ThGr: 64%, 38% and 23.5%; PD: 62.5%, 62.5% and 50%; Tx: 72.7%, 72.7% and 72.7%. SV had better secondary patency at 900 days (76.9%) than ThGr (49.2%) or Fem (35.8%) (p<0.01). No patients died as a result of loss of access.
  
  
  CONCLUSIONS
  Patients with bilateral central vein stenosis often require more than one vascular access modality to achieve a "personal access solution." Native long saphenous vein loops provided the best long-term patency. Expedited renal transplantation with priority local allocation of DCD organs to patients with precarious vascular access provides a potential solution to this difficult problem.
authors.affiliation: 1 Department of Renal Surgery, Western Infirmary, Glasgow - UK.
authors.forename: Emma
authors.initials: E
authors.lastname: Aitken
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Jackson
authors.forename: Ram
authors.initials: R
authors.lastname: Kasthuri
authors.forename: David B
authors.initials: DB
authors.lastname: Kingsmore
mesh_terms: D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D002405:Catheterization, Central Venous / Q000009:adverse effects; D003251:Constriction, Pathologic; D016208:Databases, Factual; D006083:Graft Occlusion, Vascular / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000628:therapy*; D016030:Kidney Transplantation / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D010530:Peritoneal Dialysis / Q000009:adverse effects; D006435:Renal Dialysis / Q000009:adverse effects; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D012501:Saphenous Vein / Q000637:transplantation*; D012606:Scotland; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply*; D014654:Vascular Patency; D014850:Waiting Lists