VTOS in the patient requiring chronic hemodialysis access

Abstract

Central venous obstruction (CVO) is the most common cause of failure of Arteriovenous fistulae (AVF) and grafts (AVG) placed for dialysis access. In essentially all reports, including international consensus statements for management of such patients, all CVOs are lumped together, implicitly assuming that all should be treated first with endovascular means. We point out that while stenosis in veins surrounded by soft tissue are appropriate for endoluminal intervention, those that occur at the costoclavicular junction are identical in pathophysiology to and should be treated in a fashion similar to those in patients with "conventional" venous thoracic outlet syndrome. By aggressive use of thoracic outlet decompression in patients with dialysis access dysfunction caused by costoclavicular stenosis we have achieved fistula salvage in approximately two-thirds of patients who would otherwise have required ligation. This lesion should be considered "dialysis-dependent venous TOS" and treated aggressively.