Fig. 7

4 y/o M with end stage renal disease requiring hemodialysis access and complete occlusion of the bilateral internal jugular veins and bilateral brachiocephalic veins. Hemodialysis access was from the right groin but he developed thrombus in that vessel and there was concern he would lose his ability for transplant consideration; thus access from the neck was desired. a Wire and sheath access from the right groin into the patent portion of the SVC. Snare and sheath access from a collateral vessel in the neck. Wire is also noted on the left periphery of the image marking the subclavian vein into the azygous vein. b A 22G 65 cm Chiba needle (solid arrow) was passed from the right groin sheath into the snare (dashed arrow) from the right neck venous access. c Inner obturator of needle was removed and replaced with a 0.018″ hydrophilic wire. Wire (solid arrow) was advanced centrally and snare tightened on wire (dashed arrow) while needle was retracted. d Sheath was advanced through the occlusion (dashed arrow) and venogram performed. Demonstrated numerous collateral venous vessels (upper solid arrow) with patent azygous vein (lower solid arrow) but no opacification of the occluded SVC. e Stent complex: balloon mounted Palmaz stent (Cordis Baar, Switzerland) deployed at the level of the complete occlusion (two solid arrows marking the cranial and caudal extent of the stent) and a self-expanding, Zilver 14 mm stent (Cook Bloomington, IN) deployed within the Palmaz stent. The stent complex connected the patent vessel lumens (two dashed arrows marking the cranial and caudal extent of the stent). Center of stent complex only ballooned to 10 mm due to size of patient native vasculature with intent of subsequent procedures to increase stent diameter as the patient grows. Dotted arrow marks the wire in the subclavian vein. f Final venogram status post recanalization, stenting, and balloon angioplasty. Contrast readily fills the right atrium with no extravasation present