Radiofrequency wire ‘power wire’ recanalization of calcified chronically occluded inferior vena cava

The patient is a 55-yo-female with past medical history of end stage renal failure on hemodialysis with chronic SVC and IVC occlusions from prior hemodialysis accesses. She also had a history of chronic pancreatitis, coronary artery disease. She presented with recurrent massive episodes of hematemesis. Upper GI endoscopy 3showed varices only in the upper esophagus but none in the lower esophagus. The patient did not have liver disease. Cross sectional imaging at that time revealed extensive IVC occlusion (Fig. 1) and multiple dilated collaterals in the soft tissues especially around the area of the upper esophagus. Hence at the present hospital admission, after hemodynamically stabilizing the patient, interventional radiology (IR) was consulted for palliative central venous recanalization in hopes of reducing pressure in the aforementioned systemic venous collaterals. Since the patient also had a poorly functioning right groin hemodialysis arteriovenous (AV) graft with exhausted upper & lower extremity access sites and SVC obstruction, it was elected to recanalize the IVC first. It was hoped that this would not only decompress the esophageal varices through collaterals, but also improve function of the existing groin access. Multiple initial attempts to recanalize the occluded IVC using traditional techniques, including sharp recanalization with a variety of hydrophilic wires, catheters, triaxial systems and intravascular needles were unsuccessful. Initial planning venography from right common femoral access showed a completely occluded abdominal IVC and multiple abdominal-pelvic collaterals reconstituting flow through a dilated azygos system (Fig. 2). Five days later, patient was again brought to IR suite with an intention to recanalize occluded long segment of IVC with the use of RF wire ‘Power wire’ (Bayliss Medical). General anesthesia was administered. Under ultrasound guidance, 10 Fr and 5 Fr vascular sheaths were inserted into the right common femoral vein (CFV) and right common femoral artery (CFA) respectively. Then 4 Fr VCF-1 flush catheter was positioned in the abdominal aorta through CFA sheath to serve as a marker for the abdominal aorta. Venography redemonstrated abdominal IVC occlusion starting from confluence of the common iliac veins to intrahepatic IVC, innumerable abdominal-pelvic collaterals and dilated azygos/ hemiazygous system. Though not well demonstrated on cross sectional imaging or venography, it was assumed that the cavo-atrial junction could be patent and it could be accessed via transhepatic venous access. Using percutaneous transhepatic approach, a 23 cm long 6 Fr vascular sheath was placed in the proximal part of the right hepatic vein. Hepatic venogram confirmed the patency of all three hepatic veins and patency of a short segment of the cavo-atrial junction. Through intrahepatic vascular sheath, a 25 mm GooseNeck snare was positioned at the cavo-atrial junction. The snare served as a target for recanalization procedure. Following this, a 7 Fr steerable sheath was inserted through the right CFV sheath. Through steerable sheath, a co-axial system of catheters was assembled to guide the RF wire towards the snare in the cavo-atrial junction. The length of the occlusion was estimated to be greater than 10 cm. With great care, the RF wire and the coaxial system were advanced at 1–2 mm increments, always noting the relation of the RF wire to the aortic flush catheter in multiple oblique images. The RF wire generator was set to create short 300 milliseconds duration RF delivery. When the Power wire was approaching the proximal part of the intrahepatic IVC obstruction, the 25 mm snare was replaced with a 5 mm snare for more precise targeting. The 5 mm snare was positioned through an IMA catheter advanced through the intrahepatic vascular sheath so that it could be directed towards the approaching RF wire. The 5 mm snare captured the RF wire. Both the snare and RF wire were advanced into the right atrium. At this point IVC obstruction had been traversed. The RF wire was exchanged for a Lunderquist wire and catheters were removed. The IVC occlusion was dilated with 4 mm × 200 mm and 8 mm × 200 mm Mustang balloons. Because of the length of the IVC occlusion traversal, and potential for IVC injury, it was elected to use covered stent grafts except at the confluence of the hepatic veins. It was thought that bare metal self expanding stent across the origins of hepatic veins would reduce the risk of hepatic venous thrombosis. Hence initially a 14 mm × 120 mm bare metal self expanding E. Luminexx stent was deployed. Within this stent, three Gore Viabahn balloon expandable stent grafts (5 mm × 39 mm, 5 mm × 59 mm, 7 mm × 39 mm) were deployed except at the confluence of the hepatic veins. Acknowledging that the atretic renal veins would be covered it was decided to use stent grafts to seal any potential vascular injury. All the stents were then post dilated with a 14 mm × 40 mm balloon. Repeat venography demonstrated brisk flow through the recanalized IVC and a marked decrease in the number and sizes of intra-abdominal pelvic collaterals (Fig. 3). A 28 cm hemodialysis catheter was placed through the right hepatic vein access to obtain hemostasis at this access. Hemostasis at other groin access sites were obtained with manual pressure. There were no hematomas and pedal pulses remained unchanged. The patient was observed in the intensive care unit overnight.

One month later, the patient returned for follow up venography, which demonstrated widely patent stented IVC and removal of the transhepatic permcath (Fig. 4). Nephrology service noted improved hemodialysis and significant improvement in patient’s volume status. Hematemesis did not recur. Six months post-procedure, patient remained asymptomatic and had functioning right femoral arteriovenous hemodialysis graft.