Thoracic central venous occlusion from the interventional radiology perspective

Central venous occlusion is a common condition in certain patient populations, with significant associated morbidity. Symptoms range from mild arm swelling to respiratory distress and can be particularly troublesome in the end stage renal disease population when related to dialysis access and function. Crossing completely occluded vessels is often the most challenging step and various techniques exist to accomplish this. Traditionally, blunt and sharp recanalization techniques are used to cross occluded vessels and are described in detail. Even with experienced providers there are lesions which prove to be too difficult and are refractory to traditional approaches. We discuss advanced techniques such as with radiofrequency guidewires as well as newer technologies which offer an alternative pathway to re-establishing access. These emerging methods have demonstrated procedural success in the majority of cases where traditional techniques were futile. Following recanalization, angioplasty with or without stenting is typically performed and restenosis is a commonly encountered complication. We discuss angioplasty and the emerging use of drug-eluting balloons in venous thrombosis. Subsequently, in regards to stenting we discuss the indications and multitude of available types including novel venous stents with their respective strengths and drawbacks. Potential feared complications such as venous rupture with balloon angioplasty and stent migration are discussed along with our recommendations to reduce their risk of occurrence and promptly manage them when they do unfortunately occur.