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Central vein stenosis associated with hemodialysis access

Gerald A Beathard, MD, PhD
Section Editors
David L Cull, MD
Steve J Schwab, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


A common problem in the management of patients undergoing hemodialysis is central vein stenosis (CVS) or occlusion. An important goal of all physicians who care for patients with severe renal dysfunction should be to preserve and protect the central veins, a task that is not easily accomplished. The development of this problem in the dialysis patient is a serious issue, and it has a greater impact compared with stenosis of a peripheral vein because the central veins represent the final common pathway for blood flow from the periphery to the heart. If central stenosis is allowed to progress, the arteriovenous hemodialysis vascular access may eventually be lost. In addition, the development of central vein obstruction obviates the possibility of creating a new vascular access on the affected side. An unfortunate consequence of the loss of central vein patency for the patient is diminished life expectancy.

Central vein stenosis associated specifically with hemodialysis access is reviewed here. General issues related to catheter-induced upper extremity venous thrombosis are reviewed separately. Thrombosis observed in patients with hemodialysis arteriovenous fistulas and grafts is reviewed separately. (See "Catheter-related upper extremity venous thrombosis" and "Hemodialysis arteriovenous graft dysfunction and failure".)


Although the precise mechanisms by which central vein stenosis (CVS) occurs are not known, current concepts in its pathophysiology follow the response to vessel injury model, emphasizing the process of trauma, inflammation, intimal hyperplasia, and a fibrotic response. It is very likely that the exact mechanism can vary depending on the situation and may be multifactorial in many cases. Regardless of the inciting cause, the end result is the same. There is an upregulation of proinflammatory transcription factors and profibrotic genes, which in turn causes smooth muscle proliferation and thickening of the venous intima. The resulting venous outflow obstruction causes venous hypertension and threatens fistula and arm function. Certain inferences can be drawn from factors that are associated with the pathophysiology of central vein stenosis.

Vein injury – Central vein stenosis in the dialysis patient is most commonly associated with the presence of an intraluminal foreign body, either a central venous catheter (CVC) or the leads associated with a cardiac implantable electronic device (CIED). These lie in direct contact with the wall of the central veins, and the constant movement of these associated with the dual processes of breathing and the cardiac cycle causes endothelial injury. Pathological examinations of central veins obtained at autopsy have shown that even short-term catheters are associated with foci of local intimal injury with endothelial denudation and adherent thrombus [1]. This injury appears to be aggravated if the route followed by the device is characterized by one or more curves, accounting for a higher incidence of central vein stenosis with subclavian or left internal jugular vein placement [2-4].

Inflammation – Data suggest that inflammation plays a role in CVS. The pathology associated with this lesion is characterized by neointimal hyperplasia [1]. This is a common response to vessel injury and is closely related to vessel injury and inflammation [5-7]. There is also an increased incidence of central vein stenosis in patients having had catheter-related infection [8,9]. Although not shown to be directly related to CVS, the mere presence of a CVC in the absence of infection has been shown to be associated with an increased level of systemic inflammation as indicated by increases in inflammatory markers [10].

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Literature review current through: Oct 2017. | This topic last updated: May 18, 2017.
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  1. Forauer AR, Theoharis C. Histologic changes in the human vein wall adjacent to indwelling central venous catheters. J Vasc Interv Radiol 2003; 14:1163.
  2. Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterisation vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant 1991; 6:722.
  3. Salgado OJ, Urdaneta B, Colmenares B, et al. Right versus left internal jugular vein catheterization for hemodialysis: complications and impact on ipsilateral access creation. Artif Organs 2004; 28:728.
  4. Schillinger F, Schillinger D, Montagnac R, Milcent T. [Central venous stenosis in hemodialysis: comparative angiographic study of subclavian and internal jugular access]. Nephrologie 1994; 15:129.
  5. Roy-Chaudhury P, Sukhatme VP, Cheung AK. Hemodialysis vascular access dysfunction: a cellular and molecular viewpoint. J Am Soc Nephrol 2006; 17:1112.
  6. Wasse H, Huang R, Naqvi N, et al. Inflammation, oxidation and venous neointimal hyperplasia precede vascular injury from AVF creation in CKD patients. J Vasc Access 2012; 13:168.
  7. Mezzano D, España F, Panes O, et al. Increased activation of protein C, but lower plasma levels of free, activated protein C in uraemic patients: relationship with systemic inflammation and haemostatic activation. Br J Haematol 2001; 113:905.
  8. Hernández D, Díaz F, Rufino M, et al. Subclavian vascular access stenosis in dialysis patients: natural history and risk factors. J Am Soc Nephrol 1998; 9:1507.
  9. Hernández D, Díaz F, Suria S, et al. Subclavian catheter-related infection is a major risk factor for the late development of subclavian vein stenosis. Nephrol Dial Transplant 1993; 8:227.
  10. Goldstein SL, Ikizler TA, Zappitelli M, et al. Non-infected hemodialysis catheters are associated with increased inflammation compared to arteriovenous fistulas. Kidney Int 2009; 76:1063.
  11. Agarwal AK, Patel BM, Haddad NJ. Central vein stenosis: a nephrologist's perspective. Semin Dial 2007; 20:53.
  12. Jennings WC, Miller GA, Coburn MZ, et al. Vascular access flow reduction for arteriovenous fistula salvage in symptomatic patients with central venous occlusion. J Vasc Access 2012; 13:157.
  13. Taal MW, Chesterton LJ, McIntyre CW. Venography at insertion of tunnelled internal jugular vein dialysis catheters reveals significant occult stenosis. Nephrol Dial Transplant 2004; 19:1542.
  14. Oguzkurt L, Tercan F, Yildirim S, Torun D. Central venous stenosis in haemodialysis patients without a previous history of catheter placement. Eur J Radiol 2005; 55:237.
  15. Beathard GA. Percutaneous transvenous angioplasty in the treatment of vascular access stenosis. Kidney Int 1992; 42:1390.
  16. Lee T, Somarathna M, Hura A, et al. Natural history of venous morphologic changes in dialysis access stenosis. J Vasc Access 2014; 15:298.
  17. Mezzano D, Pais EO, Aranda E, et al. Inflammation, not hyperhomocysteinemia, is related to oxidative stress and hemostatic and endothelial dysfunction in uremia. Kidney Int 2001; 60:1844.
  18. MacRae JM, Ahmed A, Johnson N, et al. Central vein stenosis: a common problem in patients on hemodialysis. ASAIO J 2005; 51:77.
  19. Lumsden AB, MacDonald MJ, Isiklar H, et al. Central venous stenosis in the hemodialysis patient: incidence and efficacy of endovascular treatment. Cardiovasc Surg 1997; 5:504.
  20. Glanz S, Gordon DH, Lipkowitz GS, et al. Axillary and subclavian vein stenosis: percutaneous angioplasty. Radiology 1988; 168:371.
  21. Beathard GA. Angioplasty for arteriovenous grafts and fistulae. Semin Nephrol 2002; 22:202.
  22. Schwab SJ, Quarles LD, Middleton JP, et al. Hemodialysis-associated subclavian vein stenosis. Kidney Int 1988; 33:1156.
  23. Shi Y, Zhu M, Cheng J, et al. Venous stenosis in chronic dialysis patients with a well-functioning arteriovenous fistula. Vascular 2016; 24:25.
  24. Osman OO, El-Magzoub AR, Elamin S. Prevalence and Risk Factors of Central Venous Stenosis among Prevalent Hemodialysis Patients, a Single Center Experience. Arab J Nephrol Transplant 2014; 7:45.
  25. Tourret J, Cluzel P, Tostivint I, et al. Central venous stenosis as a complication of ipsilateral haemodialysis fistula and pacemaker. Nephrol Dial Transplant 2005; 20:997.
  26. Korzets A, Chagnac A, Ori Y, et al. Subclavian vein stenosis, permanent cardiac pacemakers and the haemodialysed patient. Nephron 1991; 58:103.
  27. Deighan CJ, McLaughlin KJ, Simpson K, Jones JM. Unsuspected subclavian vein stenosis resulting from a permanent pacing wire. Nephrol Dial Transplant 1996; 11:2333.
  28. Sticherling C, Chough SP, Baker RL, et al. Prevalence of central venous occlusion in patients with chronic defibrillator leads. Am Heart J 2001; 141:813.
  29. Da Costa SS, Scalabrini Neto A, Costa R, et al. Incidence and risk factors of upper extremity deep vein lesions after permanent transvenous pacemaker implant: a 6-month follow-up prospective study. Pacing Clin Electrophysiol 2002; 25:1301.
  30. Teruya TH, Abou-Zamzam AM Jr, Limm W, et al. Symptomatic subclavian vein stenosis and occlusion in hemodialysis patients with transvenous pacemakers. Ann Vasc Surg 2003; 17:526.
  31. Lickfett L, Bitzen A, Arepally A, et al. Incidence of venous obstruction following insertion of an implantable cardioverter defibrillator. A study of systematic contrast venography on patients presenting for their first elective ICD generator replacement. Europace 2004; 6:25.
  32. Riezebos RK, Schroeder-Tanka J, de Voogt WG. Occlusion of the proximal subclavian vein complicating pacemaker lead implantation. Europace 2006; 8:42.
  33. Asif A, Carrillo R, Garisto JD, et al. Epicardial cardiac rhythm devices for dialysis patients: minimizing the risk of infection and preserving central veins. Semin Dial 2012; 25:88.
  34. Gonsalves CF, Eschelman DJ, Sullivan KL, et al. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol 2003; 26:123.
  35. Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol 2000; 11:1309.
  36. Saad TF, Vesely TM. Venous access for patients with chronic kidney disease. J Vasc Interv Radiol 2004; 15:1041.
  37. Fistula First Position Paper 2008.
  38. Sasadeusz KJ, Trerotola SO, Shah H, et al. Tunneled jugular small-bore central catheters as an alternative to peripherally inserted central catheters for intermediate-term venous access in patients with hemodialysis and chronic renal insufficiency. Radiology 1999; 213:303.
  39. Oguzkurt L, Tercan F, Torun D, et al. Impact of short-term hemodialysis catheters on the central veins: a catheter venographic study. Eur J Radiol 2004; 52:293.
  40. Konner K, Vorwerk D. Permanent pacemaker wires causing subclavian vein stenosis in presence of AV fistula--is it ever wrong to try angioplasty and stenting? Nephrol Dial Transplant 1997; 12:1735.
  41. Suliman A, Greenberg JI, Angle N. Surgical bypass of symptomatic central venous obstruction for arteriovenous fistula salvage in hemodialysis patients. Ann Vasc Surg 2008; 22:203.
  42. Herzog CA, Mangrum JM, Passman R. Sudden cardiac death and dialysis patients. Semin Dial 2008; 21:300.
  43. Haghjoo M, Nikoo MH, Fazelifar AF, et al. Predictors of venous obstruction following pacemaker or implantable cardioverter-defibrillator implantation: a contrast venographic study on 100 patients admitted for generator change, lead revision, or device upgrade. Europace 2007; 9:328.
  44. Drew DA, Meyer KB, Weiner DE. Transvenous cardiac device wires and vascular access in hemodialysis patients. Am J Kidney Dis 2011; 58:494.
  45. Lin G, Nishimura RA, Connolly HM, et al. Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads. J Am Coll Cardiol 2005; 45:1672.
  46. Carrillo RG, Garisto JD, Salman L, Asif A. Arteriovenous dialysis access-associated transvenous pacemaker infection. Clin Nephrol 2011; 75:174.
  47. Carrillo RG, Garisto JD, Salman L, et al. Contamination of transvenous pacemaker leads due to tunneled hemodialysis catheter infection: a report of 2 cases. Am J Kidney Dis 2010; 55:1097.
  48. http://esrdncc.org/wp-content/uploads/2014/07/Epicardial-First_FINAL_08-11.pdf (Accessed on March 26, 2015).
  49. Lopera G, Beathard GA, Exaire J, Carrillo R. Cardiac implantable electronic devices in end-stage renal disease patients: preservation of central venous circulation. J Interv Card Electrophysiol 2012; 34:101.
  50. Gabor S, Prenner G, Wasler A, et al. A simplified technique for implantation of left ventricular epicardial leads for biventricular re-synchronization using video-assisted thoracoscopy (VATS). Eur J Cardiothorac Surg 2005; 28:797.
  51. Mair H, Jansens JL, Lattouf OM, et al. Epicardial lead implantation techniques for biventricular pacing via left lateral mini-thoracotomy, video-assisted thoracoscopy, and robotic approach. Heart Surg Forum 2003; 6:412.
  52. Garikipati NV, Mittal S, Chaudhry F, et al. Comparison of endovascular versus epicardial lead placement for resynchronization therapy. Am J Cardiol 2014; 113:840.
  53. Amraoui S, Sohal M, Li A, et al. Comparison of delayed transvenous reimplantation and immediate surgical epicardial approach in pacing-dependent patients undergoing extraction of infected permanent pacemakers. Heart Rhythm 2015; 12:1209.
  54. Chao TF, Chen SJ, Ho SJ, et al. Vegetation in the superior vena cava: a complication of tunneled dialysis catheters. Kidney Int 2010; 77:836.
  55. Aitken E, Honour P, Johnson N, Kingsmore D. Is there an association between central vein stenosis and line infection in patients with tunnelled central venous catheters (TCVCs)? J Vasc Access 2015; 16 Suppl 9:S42.
  56. Itkin M, Kraus MJ, Trerotola SO. Extrinsic compression of the left innominate vein in hemodialysis patients. J Vasc Interv Radiol 2004; 15:51.
  57. Glass C, Dugan M, Gillespie D, et al. Costoclavicular venous decompression in patients with threatened arteriovenous hemodialysis access. Ann Vasc Surg 2011; 25:640.
  58. Illig KA, Gabbard W, Calero A, et al. Aggressive Costoclavicular Junction Decompression in Patients with Threatened AV Access. Ann Vasc Surg 2015; 29:698.
  59. Asif A, Salman L, Carrillo RG, et al. Patency rates for angioplasty in the treatment of pacemaker-induced central venous stenosis in hemodialysis patients: results of a multi-center study. Semin Dial 2009; 22:671.
  60. Kundu S. Review of central venous disease in hemodialysis patients. J Vasc Interv Radiol 2010; 21:963.
  61. Agarwal AK, Khabiri H, Haddad NJ. Complications of Vascular Access: Superior Vena Cava Syndrome. Am J Kidney Dis 2017; 69:309.
  62. Wright RS, Quinones-Baldrich WJ, Anders AJ, Danovitch GM. Pleural effusion associated with ipsilateral breast and arm edema as a complication of subclavian vein catheterization and arteriovenous fistula formation for hemodialysis. Chest 1994; 106:950.
  63. Herzig DW, Stemer AB, Bell RS, et al. Neurological sequelae from brachiocephalic vein stenosis. J Neurosurg 2013; 118:1058.
  64. Kiernan M, Bhogal M, Wong K, et al. Sight-threatening intraocular pressure due to an upper arm dialysis fistula. Lancet 2015; 386:101.
  65. Ribeiro P, Patel S, Qazi RA. Case report: Unilateral conduction hearing loss due to central venous occlusion. J Vasc Access 2016; 17:e37.
  66. Prasad V, Baghai S, Gandhi D, et al. Cerebral Infarction due to Central Vein Occlusion in a Hemodialysis Patient. J Neuroimaging 2015; 25:494.
  67. Nishijima H, Tomiyama M, Haga R, et al. Venous cerebral infarction in a patient with peripheral hemodialysis shunt and occlusion of the left brachiocephalic vein. J Stroke Cerebrovasc Dis 2011; 20:381.
  68. Loudin M, Anderson S, Schlansky B. Bleeding 'downhill' esophageal varices associated with benign superior vena cava obstruction: case report and literature review. BMC Gastroenterol 2016; 16:134.
  69. Bent CL, Sahni VA, Matson MB. The radiological management of the thrombosed arteriovenous dialysis fistula. Clin Radiol 2011; 66:1.
  70. Gooding GA, Hightower DR, Moore EH, et al. Obstruction of the superior vena cava or subclavian veins: sonographic diagnosis. Radiology 1986; 159:663.
  71. Grassi CJ, Polak JF. Axillary and subclavian venous thrombosis: follow-up evaluation with color Doppler flow US and venography. Radiology 1990; 175:651.
  72. Robbin ML, Oser RF, Allon M, et al. Hemodialysis access graft stenosis: US detection. Radiology 1998; 208:655.
  73. Bakhshoude B, Ravari H, Kazemzadeh GH, Rad MP. Diagnostic value of computerized tomography venography in detecting stenosis and occlusion of subclavian vein and superior vena in chronic renal failure patients. Electron Physician 2016; 8:2781.
  74. Paksoy Y, Gormus N, Tercan MA. Three-dimensional contrast-enhanced magnetic resonance angiography (3-D CE-MRA) in the evaluation of hemodialysis access complications, and the condition of central veins in patients who are candidates for hemodialysis access. J Nephrol 2004; 17:57.
  75. Besarab A, Sullivan KL, Ross RP, Moritz MJ. Utility of intra-access pressure monitoring in detecting and correcting venous outlet stenoses prior to thrombosis. Kidney Int 1995; 47:1364.
  76. Beathard G. Percutaneous angioplasty for the treatment of venous stenosis: A nephrologist's view. Semin Dial 1995; 8:166.
  77. Schwab SJ, Raymond JR, Saeed M, et al. Prevention of hemodialysis fistula thrombosis. Early detection of venous stenoses. Kidney Int 1989; 36:707.
  78. Tuka V, Slavikova M, Krupickova Z, et al. Short-term outcomes of borderline stenoses in vascular accesses with PTFE grafts. Nephrol Dial Transplant 2009; 24:3193.
  79. Levit RD, Cohen RM, Kwak A, et al. Asymptomatic central venous stenosis in hemodialysis patients. Radiology 2006; 238:1051.
  80. Trerotola S, McLean G, Burke D, Meranze S. Treatment of subclavian venous stenoses by percutaneous transluminal angioplasty. J Vac Interv Radiol 1986; 1:15.
  81. Beathard GA. The treatment of vascular access graft dysfunction: a nephrologist's view and experience. Adv Ren Replace Ther 1994; 1:131.
  82. Kovalik EC, Newman GE, Suhocki P, et al. Correction of central venous stenoses: use of angioplasty and vascular Wallstents. Kidney Int 1994; 45:1177.
  83. Quinn SF, Schuman ES, Demlow TA, et al. Percutaneous transluminal angioplasty versus endovascular stent placement in the treatment of venous stenoses in patients undergoing hemodialysis: intermediate results. J Vasc Interv Radiol 1995; 6:851.
  84. Dammers R, de Haan MW, Planken NR, et al. Central vein obstruction in hemodialysis patients: results of radiological and surgical intervention. Eur J Vasc Endovasc Surg 2003; 26:317.
  85. Surowiec SM, Fegley AJ, Tanski WJ, et al. Endovascular management of central venous stenoses in the hemodialysis patient: results of percutaneous therapy. Vasc Endovascular Surg 2004; 38:349.
  86. Bakken AM, Protack CD, Saad WE, et al. Long-term outcomes of primary angioplasty and primary stenting of central venous stenosis in hemodialysis patients. J Vasc Surg 2007; 45:776.
  87. Ozyer U, Harman A, Yildirim E, et al. Long-term results of angioplasty and stent placement for treatment of central venous obstruction in 126 hemodialysis patients: a 10-year single-center experience. AJR Am J Roentgenol 2009; 193:1672.
  88. Masková J, Komárková J, Kivánek J, et al. Endovascular treatment of central vein stenoses and/or occlusions in hemodialysis patients. Cardiovasc Intervent Radiol 2003; 26:27.
  89. Maya ID, Saddekni S, Allon M. Treatment of refractory central vein stenosis in hemodialysis patients with stents. Semin Dial 2007; 20:78.
  90. Aytekin C, Boyvat F, Yağmurdur MC, et al. Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients. Eur J Radiol 2004; 49:81.
  91. NKF-K/DOQI Practice Guideline 6.1.
  92. Günther RW, Vorwerk D, Bohndorf K, et al. Venous stenoses in dialysis shunts: treatment with self-expanding metallic stents. Radiology 1989; 170:401.
  93. Chen CY, Liang HL, Pan HB, et al. Metallic stenting for treatment of central venous obstruction in hemodialysis patients. J Chin Med Assoc 2003; 66:166.
  94. Oderich GS, Treiman GS, Schneider P, Bhirangi K. Stent placement for treatment of central and peripheral venous obstruction: a long-term multi-institutional experience. J Vasc Surg 2000; 32:760.
  95. Vogel PM, Parise C. SMART stent for salvage of hemodialysis access grafts. J Vasc Interv Radiol 2004; 15:1051.
  96. Haage P, Vorwerk D, Piroth W, et al. Treatment of hemodialysis-related central venous stenosis or occlusion: results of primary Wallstent placement and follow-up in 50 patients. Radiology 1999; 212:175.
  97. Vesely TM, Hovsepian DM, Pilgram TK, et al. Upper extremity central venous obstruction in hemodialysis patients: treatment with Wallstents. Radiology 1997; 204:343.
  98. Gray RJ, Horton KM, Dolmatch BL, et al. Use of Wallstents for hemodialysis access-related venous stenoses and occlusions untreatable with balloon angioplasty. Radiology 1995; 195:479.
  99. Vorwerk D, Guenther RW, Mann H, et al. Venous stenosis and occlusion in hemodialysis shunts: follow-up results of stent placement in 65 patients. Radiology 1995; 195:140.
  100. Jones RG, Willis AP, Jones C, et al. Long-term results of stent-graft placement to treat central venous stenosis and occlusion in hemodialysis patients with arteriovenous fistulas. J Vasc Interv Radiol 2011; 22:1240.
  101. Mickley V, Görich J, Rilinger N, et al. Stenting of central venous stenoses in hemodialysis patients: long-term results. Kidney Int 1997; 51:277.
  102. Rajan DK, Saluja JS. Use of nitinol stents following recanalization of central venous occlusions in hemodialysis patients. Cardiovasc Intervent Radiol 2007; 30:662.
  103. Smayra T, Otal P, Chabbert V, et al. Long-term results of endovascular stent placement in the superior caval venous system. Cardiovasc Intervent Radiol 2001; 24:388.
  104. de Graaf R, van Laanen J, Sailer A, Tordoir J. Long segment recanalization and dedicated central venous stenting in an ultimate attempt to restore vascular access central vein outflow. J Vasc Access 2014; 15 Suppl 7:S109.
  105. Kim YC, Won JY, Choi SY, et al. Percutaneous treatment of central venous stenosis in hemodialysis patients: long-term outcomes. Cardiovasc Intervent Radiol 2009; 32:271.
  106. Rajan DK, Chennepragada SM, Lok CE, et al. Patency of endovascular treatment for central venous stenosis: is there a difference between dialysis fistulas and grafts? J Vasc Interv Radiol 2007; 18:353.
  107. Gertler JP. Decompression of the occluded subclavian vein in the patient with ipsilateral threatened access by transposition of the internal jugular vein. ASAIO J 1995; 41:896.
  108. El-Sabrout RA, Duncan JM. Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment option. J Vasc Surg 1999; 29:472.
  109. Glass C, Maevsky V, Massey T, Illig K. Subclavian vein to right atrial appendage bypass without sternotomy to maintain arteriovenous access in patients with complete central vein occlusion, a new approach. Ann Vasc Surg 2009; 23:465.