Percutaneous Costoclavicular Bypass for Thoracic Outlet Syndrome and Cephalic Arch Occlusion in Hemodialysis Patients

 
Clinical Question
Report results of percutaneous costoclavicular bypass for symptomatic thoracic outlet or cephalic arch occlusion in patients with arteriovenous fistula.

Take-Away Point
Percutaneous costoclavicular bypass is a feasible option for thoracic outlet and cephalic arch occlusion in symptomatic dialysis patients.

Reference
Hull, J. and J. Snyder (2019). "Percutaneous Costoclavicular Bypass for Thoracic Outlet Syndrome and Cephalic Arch Occlusion in Hemodialysis Patients." J Vasc Interv Radiol 30(11): 1779-1784.

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Study Design
Retrospective chart review of patients undergoing percutaneous costoclavicular bypass.

Funding Source
No reported funding

Setting
Richmond Vascular Center, North Chesterfield, VA






Figure 1. Key steps of costoclavicular bypass.

Summary

Intravascular treatment of venous outflow stenosis in patients with thoracic outlet syndrome and cephalic arch pathology has been limited by external compression at the costoclavicular junction. Subcutaneous costoclavicular bypass is a minimally invasive alternative to surgical decompressive options such as first rib resection and claviculectomy.

A retrospective chart review of 9 patients undergoing percutaneous costoclavicular bypass was performed. Inclusion criteria comprised patients with ESRD, AV fistula, and symptomatic occlusion of the cephalic arch or subclavian vein with previous failure of standard therapies. One patient received a Gore Hybrid vascular graft, all other cases were performed using Viabahn stent grafts.

The percutaneous costoclavicular bypass was technically successful in 100% of cases. All patients had symptomatic improvement at 1 week. There were no immediate complications. At 12 months and 24 months, primary patency was 67% and 67%. Secondary patency was 89% and 78%. The Viabahn stent graft achieved a hemostatic seal in all cases and the stent grafts remained intact at follow up.

One patient demonstrated stent migration at the fistula outflow, which was treated with overlapping stent graft extension. Loss of costoclavicular bypass occurred in 3 patients. One stent graft was secondarily infected 5 months after placement and was subsequently excised. The Gore hybrid graft kinked and required over-stenting with bare metal and covered stents, leading to graft thrombosis and edge stenosis, and was abandoned after 3 years.

 

Commentary

Percutaneous costoclavicular bypass demonstrates early clinical success in this retrospective study. While this study is limited by the inclusion criteria and small patient population, the patency rates, high technical success rates, and high clinical success rates are promising. Notably, the authors did not report any stent compression, buckling, or deformity. The durability of the Viabahn stent graft opens the door for other potential percutaneous, subcutaneous bypass procedures. While percutaneous costoclavicular bypass shows early clinical success, further research is required to determine success in larger patient populations.

Post Author
Maxwell R. Cretcher, DO
Resident Physician, Integrated Interventional Radiology
Dotter Department of Interventional Radiology
Oregon Health & Science University