Sharp central venous recanalization by means of a TIPS needle

The purpose of this study was to perform an alternative technique for recanalization of a chronic occlusion of the left brachiocephalic vein that could not be traversed with a guidewire. Restoration of a completely thrombosed left brachiocephalic vein was attempted in a 76-year-old male hemodialysis patient with massive upper inflow obstruction, massive edema of the face, neck, shoulder, and arm, and occlusion of the stented right brachiocephalic vein/superior vena cava. Vessel negotiation with several guidewires and multipurpose catheters proved unsuccessful. The procedure was also non-viable using a long, 21 G puncture needle. Puncture of the superior vena cava (SVC) at the distal circumference of the stent in the right brachiocephalic vein/superior vena cava, however, was feasible with a transjugular intrahepatic portosystemic shunt (TIPS) set under biplanar fluoroscopy using the distal end of the right brachiocephalic vein as a target, followed by balloon dilatation and partial extraction of thrombotic material of the left brachiocephalic vein with a wire basket. Finally, two overlapping stents were deployed to avoid early re-occlusion. Venography demonstrated complete vessel patency with free contrast media flow via the stents into the SVC, which was reconfirmed in follow-up examinations. Immediate clinical improvement was observed. Venous vascular recanalization of chronic venous occlusion by means of a TIPS needle is feasible as a last resort under certain precautions.