Aggressive Costoclavicular Junction Decompression in Patients with Threatened AV Access

Area of Science:

• Vascular Surgery
• Interventional Radiology
• Nephrology

Background:

• Stenoses at the costoclavicular junction (CCJ) frequently threaten arteriovenous (AV) access and resist endovascular treatment.
• Extrinsic compression on the vein at the CCJ is a primary cause of these stenoses.
• Surgical bony decompression is proposed as a necessary intervention for resolving CCJ stenoses.

Purpose of the Study:

• To evaluate the short- to medium-term outcomes of bony decompression for CCJ stenoses in patients with failing AV access.
• To assess the efficacy of this approach in salvaging threatened AV fistulae and preserving arm access.

Main Methods:

• A prospectively maintained database was reviewed to identify patients with threatened AV access due to CCJ stenoses.
• Surgical decompression (claviculectomy or first rib resection) was performed, followed by endovascular intervention as needed.
• Pre- and postoperative courses and long-term follow-up data were analyzed.

Main Results:

• Twenty-four patients underwent CCJ decompression between July 2012 and December 2013.
• First rib resection was the predominant decompression method (21 patients).
• One-year assisted primary patency was 85% for fistulae and 89% for central bypasses, with 85% of patients maintaining arm access at last follow-up. Dramatic symptom relief was observed in most patients.

Conclusions:

• Aggressive bony decompression of the CCJ is effective for high-risk patients with otherwise unsalvageable AV access.
• This approach achieves excellent symptom relief and facilitates long-term fistula and ipsilateral arm use.
• Endovascular intervention, when needed, complements surgical decompression for optimal outcomes.