Over the past decade, endovascular techniques have supplanted open procedures because of the large decrease in procedural morbidity, ease of use, and ability of many specialists to perform these procedures. Today, endovascular interventions are the preferred method for diagnosis and treatment of central venous stenosis. The frustration with endovascular therapy is the poor durability of the repairs and need for frequent reinterventions, with some interventions compromising further surgical therapy.

Endovascular interventions can be performed in any facility with suitable fluoroscopic imaging and the ability to safely perform moderate sedation. General anesthesia is not necessary. The procedure starts through venous access, using the existing AV access. Venography is performed from the access anastomosis to the central veins draining to the right atrium. Guiding catheter placement into the central veins may be necessary to adequately visualize any significant stenosis or occlusions. Central stenosis in dialysis patients, unlike anatomic compression in other areas of the venous anatomy, is usually obvious. Confirmatory techniques such as intravascular ultrasounds or pull-through pressures are rarely needed.

Once a central stenosis is identified, the first-line treatment is percutaneous transluminal angioplasty (PTA) (Fig. 31.2). Large-size balloons (10–14 mm) are needed with inflation times of at least 2 min. Due to the fibrous nature of central venous stenosis, it often requires high-pressure, noncompliant balloons. The immediate success of initial PTA alone, without stenting, has been reported up to 70 %. Primary patency results drop down to a sobering 29 % at 1 year [8], and symptom relief at 1 year is equally poor [9]. Due to this poor durability, PTA requires frequent reinterventions to maintain patency. With frequent interventions, patency can be maintained in up to 86 % at 1 year [9].

Primary stenting also has a very poor performance, with primary patency at 1 year to be only 21 % [8]. The high failure rate of central venous stents is not fully understood, but it is clear that intimal hyperplasia is aggressive in the central veins. Stents are reserved for lesions that recur at intervals less than 3 months, perforations or residual stenosis greater than 50 %. Stents should be oversized by at least 30 % to prevent migration, and care should be taken to not cover critical venous branches (the internal jugular (IJ) or contralateral brachiocephalic vein). Stent placement should be avoided at the costoclavicular junction, where the subclavian vein enters the thoracic outlet. Technology in endovascular surgery is quickly changing, and it is important to recognize that many available studies have used first-generation stainless steel wall stents (Fig. 31.3). More recently, the use of covered stents in the central veins has gained popularity, in part, because small early studies have indicated decreases in intimal hyperplasia and stent failure [10–12]. Outcomes are promising with primary patency at 1 year of 67 % and assisted patency at 2 years of 75 % [12]. Evolving technology with drug-coated balloons and stents, targeted at halting intimal hyperplasia, may further change the endovascular management of central vein stenosis in the future.

Central venous occlusions are more challenging to treat than central venous stenosis. Crossing occlusions is often performed using hydrophilic wires with guiding catheters and usually requires support with long sheaths. Patience is required for these difficult lesions and establishing access from the arm, the ipsilateral neck (internal jugular), and the contralateral IJ as well. If unable to cross from the upper extremity, attempting to cross from the lower extremity is occasionally helpful. Once the total occlusion has been crossed, some authors advocate for mechanical or catheter-directed thrombolysis to unmask the true stenotic lesion and remove any thrombus. We find this is not typically necessary as the occlusions are normally chronic and more fibrous, and so we will treat with PTA and/or stent as highlighted above and have not experienced embolic complications from this technique.

It is important to highlight the potential complications associated with endovascular treatment. Access site complications are most common and include bleeding, cellulitis/AV access infections, and access thrombosis. Procedures should be performed under sterile conditions and the extremity adequately prepped. When accessing a prosthetic AV graft, it is our routine to give preoperative antibiotics covering common skin organisms. Complications specific to central vein stenosis/occlusion are potentially life threatening. Venous perforation, with high flow from a distal AV access, can lead to significant bleeding in the mediastinum and pleural or pericardial spaces. Early recognition is essential, and often times the bleeding can be controlled with local balloon inflation or deployment of a stent graft across the tear though open repair may be indicated and requires an emergent surgical consultation.