Hemodialysis Vascular Access with Central Venous Disease

Vascular access (VA) for hemodialysis (HD) is the lifeline of a patient. Arteriovenous fistula (AVF) is the gold standard of VA, but there are challenging situations when providing long-term VA becomes challenging, in the presence of central vein stenosis (CVS), which is common in patients on hemodialysis, but its exact prevalence is not known. It would be ideal to have proper venous mapping with imaging modality to be able to plan central venous access. This prior venous mapping will help to plan the target vein and delineate venous path to be able to place HD catheter in the best position or resolve the VA-related problems. However, digital subtraction angiography remains the gold standard of the procedure, during which the target vein is accessed via ultrasound guidance, and subsequent passage of wire is done under fluoroscopic guidance. Venous angiography and, if indicated, angioplasty are performed. For complete chronically occluded thrombotic veins, recanalization needs to be attempted. Stenting is reserved for a select group of patients. There are advances in endovascular techniques to deal with CVS, and it needs a multidisciplinary team approach to tackle the complex issues of VA-related central venous disease (CVD).