Percutaneous Costoclavicular Bypass for Thoracic Outlet Syndrome and Cephalic Arch Occlusion in Hemodialysis Patients.

Purpose: To report results of percutaneous costoclavicular bypass for symptomatic thoracic outlet or cephalic arch occlusion in patients with arteriovenous fistula.

Materials And Methods: A retrospective review of percutaneous costoclavicular bypass patients between 2014 and 2018 was performed. Stent grafts were placed subcutaneously over the clavicle from the fistula outflow (axillary or cephalic vein) into a jugular vein or collateral. The procedures were performed in patients who had exhausted or were not candidates for balloon dilation or intravascular stent placement.

Results: Technical success was 100% (9/9) with resolution of symptoms in all patients. Indications were arm swelling in 67% (6/9), fistula dysfunction in 22% (2/7), and 1 enlarging aneurysm. The fistula outflow was cephalic in 67% (6/9) and axillary in 33% (3/9). The return vessel was external jugular in 78% (7/9) and internal jugular in 22% (2/9). Two overlapping Viabahn stent grafts were used in 88% of cases (7/8) and 3 stent grafts in 1 case. In the initial case, 2 Gore hybrid grafts were used. Stent graft diameter ranged from 9 mm to 13 mm. Mean follow-up was 852 ± 339 days (range, 488-1483 days). At 12 months and 24 months, primary patency was 67% and 67%, and secondary patency was 89% and 78%, respectively. Complications included late thrombosis and secondary infection. There were no anastomotic leaks or seromas associated with extravascular stent grafts.

Conclusions: The percutaneous costoclavicular bypass is a feasible option for thoracic outlet and cephalic arch occlusion in symptomatic dialysis patients.