Outcomes of Chronic Thoracic Central Venous Recanalization Using Radiofrequency Guidewire Technology in Patients with End-stage Renal Disease

Monday, March 6, 2023

4:03 PM – 4:21 PM

Location: Phoenix Convention Center, 221C

Presenting Author(s)

Sherif M. Moawad, MD

Resident Physician
University of Pennsylvania

Disclosure(s): No financial relationships to disclose

Author/Co-author(s)

Ansar Z. Vance, MD (he/him/his)

Attending Physician
Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
Ryan M. Cobb, MD (he/him/his)

Assistant Professor
Hospital of the University of Pennsylvania
MM

Mark P. Mantell, MD

Attending Physician
Department of Surgery, Division of Vascular Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
Rc

Raphael cohean, MD

Attending Physician
Division of Nephrology, Department of Medicine, Penn Presbyterian Medical Center, Philadelphia, PA
Timothy Clark, MD

Professor
University of Pennsylvania

Disclosure(s):

Sherif M. Moawad, MD: No financial relationships to disclose

Ansar Z. Vance, MD: No relevant disclosure to display

Ryan M. Cobb, MD: INARI MEDICAL, INC.: Consultant (Ongoing)

Timothy Clark, MD: No relevant disclosure to display

Purpose: To assess the outcome and safety of radiofrequency wire recanalization in patients with end-stage renal disease (ESRD) and refractory central venous occlusions.

Materials and Methods:

Retrospective review of ESRD patients who underwent radiofrequency wire recanalization (Powerwire, Baylis Medical) of symptomatic chronic thoracic central venous occlusion from January 2017 to August 2022 yielded 20 patients who underwent 21 procedures. All patients have undergone one or more prior unsuccessful attempts at crossing each occlusion using conventional catheter-based techniques. The mean age was 64 ± 9 years; all procedures were done under anesthesia monitoring with anticipation of potential initiation of massive transfusion protocol. Median RF pulse duration was 1 second using a straight-tip and/or 40-degree angled-tip 0.035-in radiofrequency guidewire supported by coaxial or triaxial directional catheter/sheath combinations. The technical success rate was defined by the ability to cross the central occlusion enabling endovascular treatment. Access circuit patency was evaluated based on follow-up imaging and symptomatic improvement.

Results: Radiofrequency recanalization was successful in 18/21 procedures (81%) with all patients (100%) reporting resolution of arm ± facial swelling. All cases were crossed from an outside-in approach except for one utilizing a snare and through-and-through guidewire technique. Three major complications occurred (14%): two hemothoraces (both requiring chest tube placement and blood transfusion) and one hemopericardium (requiring percutaneous pericardial drain placement). All patients (except 1 who underwent tunneled dialysis catheter insertion to enable removal of a chronic femoral catheter) underwent placement of one or more ePTFE-covered stent grafts after successively escalated angioplasty balloon sizes during the same procedure. Medial stent diameter was 13 mm (range, 9-14 mm). Mean duration of hospital stay was 2 days ± 3 days. Mean procedure time was 158 ± 46 minutes with a mean fluoroscopy time of 31.7 ± 16.3 minutes. Primary unassisted patency of the stented cohort (19/20 patients) at 6 and 12 months was 94 ± 6% and 85 ± 10%, respectively.

Conclusion:

Radiofrequency wire recanalization of chronic central venous occlusions in symptomatic dialysis patients has a high rate of technical success enabling resolution of arm swelling and continued use of ipsilateral dialysis access. Major complications were not infrequent indicating this procedure should be performed in centers equipped to manage central venous perforations.