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The Inside Out Technique is Safe and Effective in Thoracic Central Venous Obstruction
Roberto G. Aru, Emad A. Chishti, Sayee S. Alagusundaramoorthy, John C. Gurley, Eric D. Endean
University of Kentucky, Lexington, KY

Introduction: Thoracic central venous obstruction (TCVO) presents a challenging scenario for patients requiring central venous access. The inside-out technique for crossing occluded veins has been described to avoid femoral catheters and to preserve the left-sided thoracic venous vasculature, but case series are limited by number of patients. The purpose of this study was to evaluate the use of the inside-out technique at a single tertiary academic center together with its efficacy and outcome, paying close attention to the severity of TCVO using the Society of Interventional Radiology (SIR) TCVO classification (Figure). Methods: Patients who underwent central venous access using the inside-out technique were identified between August 2007 and May 2021. Patient demographics, indication for the procedure, procedural details, SIR TCVO classification, outcomes, and procedure-related complications were recorded. Statistical analysis was performed using analysis of variance (ANOVA). Results: A total of 338 inside-out procedures were done in 221 patients. Forty-nine patients had the procedure done multiple times (25 twice, 11 three times, 13 more than three times). There were 109 (49.3%) men and 112 (50.6%) women with an average age of 54.714.8 years. Indications for the procedure included dialysis access 233 (64.0%), infusion of parenteral nutrition, antibiotics, chemotherapy, or other medication 81 (22.3%), cardiac access 39 (10.7%), other 10 (3.0%), and more than one indication in 26 patients. Type 1 SIR TCVO was present in 147 (43.5%), followed by Type 4 in 142 (42.0%), Type 2 in 36 (10.7%), Type 3 in 6 (1.8%), and unable to determine in 7 (2.0%). The access site was the right femoral vein 322 (95.3%), left femoral vein 14 (4.1%) or transhepatic 2 (0.6%). The exit site location was right supraclavicular 274 (81.3%), right sub-clavicular 52 (15.4%), left supraclavicular 3 (0.9%), left sub-clavicular 6 (1.8%), and not defined 2 (0.6%). Comparisons based on SIR TCVO type are depicted in the table. Average follow-up was 4.175.8 months. Removal of the catheter was documented in 166 with indications for removal including bacteremia in 43 (25.9%), catheter malfunction in 34 (20.5%), catheter infection in 27 (16.3%), new hemodialysis access in 19 (11.5%), no longer needed in 19 (11.5%), patient removal of catheter in 13 (7.8%), and replacement of a temporary line with a tunneled device in 11 (6.6%). There were no complications associated with removal. Average device duration was 4.65.9 months with no difference in duration between SIR TCVO types. Conclusions: For a variety of indications, the inside-out technique is safe and effective for establishing central venous access in patients with TCVO and can be done repeatedly. More complex obstructive patterns are associated with longer fluoroscopy times and greater contrast volume. Long-term durability is primarily limited by infectious complications.

Figure. Types of SIR TCVO. Abbreviations: IJ (internal jugular vein), SC (subclavian vein), and SVC (superior vena cava).

Table. ANOVA results for contrast volume, radiation dose, and fluoroscopy time based on SIR TCVO type. Types 3 and 4 were grouped as SVC occlusion given small sample size of type 3 (n=6).

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