Successful stent implantation in the internal jugular vein occlusion using Brockenbrough needle under intravascular ultrasound guidance leading to prevention of vision loss in a hemodialysis patient with neovascular glaucoma

Published:September 17, 2020DOI:https://doi.org/10.1016/j.jccase.2020.08.010

      Abstract

      Central venous occlusion (CVO) remains an unresolved issue in hemodialysis patients. We herein present an interesting case of a 42-year-old hemodialysis female patient with complete vision loss in the left eye, who was at high risk of losing vision in her right eye because of neovascular glaucoma (NVG). Computed tomography (CT) showed occlusion of the right internal jugular vein (IJV) just above the junction with the right innominate vein. From the configuration and location of the lesion, it was concluded the occlusion had been caused by venous valvular degeneration. Her NVG with progressive intraocular pressure (IOP) elevation was presumably attributed to the right IJV occlusion. The extra-rigid occlusive lesion was successfully penetrated by means of a Brockenbrough needle and subsequently implanted with a balloon-expandable stent. Intravascular ultrasound (IVUS) guidance allowed us to manipulate the Brockenbrough needle safely. After stent implantation, the right IOP declined dramatically, resulting in the preservation of her eyesight.
      <Learning objective: Neovascular glaucoma (NVG) is a devastating disease for the occurrence of which various factors are responsible. In this report, the occlusion of the right internal jugular vein was determined as the main cause of the elevated intraocular pressure, which had led to the deterioration of her NVG. Stent implantation provided an immediate reduction in intraocular pressure. The Brockenbrough needle was safely manipulated under intravascular ultrasound guidance.>

      Keywords

      Introduction

      Neovascular glaucoma (NVG), recognized as a severe form of secondary glaucoma, is characterized by fibrovascular tissue proliferation in the anterior chamber angle mainly because of diabetic retinopathy and central retinal vein occlusion (CRVO) [
      • Havens S.J.
      • Gulati V.
      Neovascular glaucoma.
      ].
      Central venous occlusion (CVO) is one of the most common complications that leads to significant morbidity and venous access dysfunction in hemodialysis patients. The principal causes of internal jugular vein (IJV) stenotic or occlusive lesions, where thrombosis is often found to be involved, include central venous catheterization, trauma, and surgical or radiation therapy [
      • Kundu S.
      Review of central venous disease in hemodialysis patients.
      ]. Although the management of CVO lesions, which mostly occur in the subclavian or brachiocephalic veins, has been well described, there are only few studies addressing the appropriate treatment of IJV occlusion in hemodialysis patients.
      In this report, we present a case of a patient who developed serious NVG presumably secondary to right IJV occlusion, which was successfully treated using a Brockenbrough needle (BB) followed by stent implantation under intravascular ultrasound (IVUS).

      Case report

      The patient was a 42-year-old hemodialysis female with a complex medical history. At the age of 30 years, an arteriovenous fistula (AVF) had been placed in her left forearm for the purpose of hemodialysis due to focal segmental glomerulonephritis. When she was 36 years old, she lost her vision in the left eye because of ipsilateral fundal hemorrhage. At the age of 38 years, she experienced venous pressure elevation secondary to right subclavian vein occlusion, which was managed by creating an arteriovenous graft (AVG, 6 mm in diameter) between the right proximal cephalic vein and the right IJV as she refused to undergo endovascular treatment. She had no history of central venous catheterization.
      Four years after receiving the AVG, she noticed a decline in her right eyesight along with the right-sided edematous face and arm. On ophthalmological examinations, she was found to have elevated intraocular pressure (IOP; greater than 30 mmHg) and was diagnosed with NVG. A computed tomography (CT) image showed the right IJV occlusion just above the innominate vein (Fig. 1). After discussion with relevant specialists, we concluded that the elevated IOP was probably associated with the deterioration of her vision. We decided to perform endovascular therapy to the right IJV occlusion after discussion with cardiovascular surgeons.
      Fig. 1
      Fig. 1Computed tomography (CT) image before endovascular treatment. (A, B) The right proximal internal jugular vein (IJV) is occluded. At the occlusion site, the thin membrane-like structure (arrow) separating the vessel is visualized without obvious thrombus. The arrowhead indicates the artificial graft between the right cephalic vein and the IJV.
      A 4F and a 6F sheath were inserted into the right forearm vein and right femoral vein, respectively. Right arm venography showed mild to moderate right IJV-AVG anastomotic stenosis and total occlusion in the right IJV just above the innominate vein (Fig. 2A). Femoral venography visualized a peculiar shape, which looked like a valve, at the occlusion site. The occlusive lesion appeared to be discrete with no observable sign of thrombus formation (Fig. 2B). Firstly, we attempted to pass a 0.014 soft guidewire (3 g tip-load) beyond the occlusion with microcatheter backup in a 6 Fr straight guiding catheter from the femoral vein. The lesion was so hard that we had to escalate guidewire stiffness up to 40g tip-load. This guidewire went up beyond the occlusion site; however, IVUS indicated that the wire was in the false lumen. Then, a stiff 0.018 guidewire was steered toward the true lumen during simultaneous IVUS observation in the false lumen (Fig. 2C). We also strived to pass various guidewires through the occlusion site from the right arm, but all to no avail because of poor back-up force; that is, all guidewires slipped on the surface of the occlusion site (Fig. 2D).
      Fig. 2
      Fig. 2Venography during endovascular procedure. (A, B) Right arm and femoral venograms show discrete total occlusion (arrow) in the right internal jugular vein (IJV) just above the innominate vein. (C) While the intravascular ultrasound (IVUS) is in the false lumen, a stiff 0.018 guidewire (arrow) is directed toward the true lumen. (D) An attempt from the right arm fails because of poor back-up force (arrow: the guidewire from the right arm, arrowhead: the occlusion site). (E) The IVUS from the right arm (arrow) is placed just above the occlusion. From the femoral vein, a Marine sheath (arrowhead) with a Brockenbrough needle (BB) is advanced to just below the occlusion, and the BB is manipulated carefully under IVUS guidance. (F) After puncture with the BB, injection with contrast media from the Marine sheath reveals the distal true lumen of the right IJV. (G) A balloon-expandable stent (arrow) is implanted. (H) The final venogram reveals excellent stent expansion (arrowhead) and sufficient antegrade blood flow (arrow: the artificial graft).
      After discussion with the cardiovascular surgeons, we decided to use a BB for making a hole through the occlusion. We advanced a 0.014 soft guidewire from the right forearm, with the IVUS probe positioned just above the occlusion site. Next, a Marine sheath was inserted from the femoral vein, and the BB was advanced toward just below the occlusion. We carefully manipulated the BB under IVUS guidance (Fig. 2E). Furthermore, using IVUS, we were able to confirm the tenting phenomenon of the vessel wall, which indicated the exact position where the BB was to penetrate (Fig. 3A). Then, we successfully passed the BB across the lesion into the distal true lumen, which was clearly visualized by IVUS (Fig. 3B). Afterward, we advanced the Marine sheath along the BB and injected contrast through the sheath to identify the distal true lumen of the right IJV (Fig. 2F). Femoral IVUS observation confirmed the guidewire passage route was correct (Fig. 3C). Then, we directly placed a balloon-expandable stent (Express LD 10/25 mm, Boston Scientific, Natick, MA, USA) (Fig. 2G). IVUS showed adequate stent expansion (Fig. 3D), and final venography revealed sufficient antegrade blood flow without extravasation (Fig. 2H).
      Fig. 3
      Fig. 3Intravascular ultrasound (IVUS) findings during the procedure. (A) Tenting phenomenon of the vessel wall is observed (arrow), which implies the accurate position to stick the Brockenbrough needle (BB). (B) The BB passing through the occlusion site into the distal true lumen (arrow) is clearly visualized. (C) IVUS observations from the femoral vein confirm the guidewire passage route is correct. The arrow indicates the IVUS catheter passing through the puncture site created by the BB. (D) A balloon-expandable stent is adequately expanded.
      As we expected, the IOP declined immediately after stent implantation and returned to normal (Fig. 4). Since then, no signs of NVG progression or visual impairment have been observed in her right eye.
      Fig. 4
      Fig. 4Serial changes of intraocular pressure (IOP) in the right eye. The IOP gradually elevated with the deterioration of her vision in the right eye. Just after the stent implantation in the right internal jugular vein (IJV) (arrow), the pressure dramatically dropped to the normal level.

      Discussion

      This case was unique in that the deterioration of NVG was associated with IOP elevation following IJV occlusion and a BB was used under IVUS guidance to cross the occlusion safely.
      NVG is a blinding, intractable disease that seems difficult to manage and often results in disastrous visual loss. The most common diseases responsible for the development of NVG are ischemic CRVO and diabetic retinopathy [
      • Hayreh S.S.
      Neovascular glaucoma.
      ]. Recently, anti-vascular endothelial growth factor monoclonal antibody has been introduced and has been expected to be a reliable therapy for this refractory disease [
      • Hu X.N.
      • Ni Y.
      • Luan J.
      • Ding Y.Z.
      A review on vasohibin and ocular neovascularization.
      ]. Yet, as shown in the present case without a clearly known cause of NVG, it is obvious that controlling high IOP is primarily crucial for the prevention of visual loss, regardless of whatever the exact cause of NVG may be.
      With respect to the pathogenesis of the IJV occlusive lesion, none of the major causes of IJV occlusion was present in the patient. For example, she had no history of previous central venous catheterization; moreover, CT and venography did not show obvious thrombus formation at the occlusion site. The occlusion configuration was discrete, looking like a venous valve [
      • Harmon Jr., J.V.
      • Edwards W.D.
      Venous valves in subclavian and internal jugular veins. Frequency, position, and structure in 100 autopsy cases.
      ]. Also, the IJV occlusion had developed 4 years after an unusual artificial bypass graft creation (the right cephalic vein to right IJV). Taken together, it seems logical to deduce that the increased turbulent flow because of the bypass graft might have caused venous valvular degeneration in the IJV, subsequently leading to total occlusion.
      In Japan, a BB is sometimes applied in endovascular therapy to penetrate a heavily calcified occlusive lesion because appropriate debulking devices have yet to be approved [
      • Miyashita Y.
      Penetration of calcified lesions in chronic total occlusion using a Brockenbrough needle.
      ]. In our case, before using a BB, we tried several guidewires including a very stiff one (tip-load 40 g). Although this lesion did not contain dense calcium, the degenerated valve itself was so hard that we ended up using a BB to cross the occlusion site. Since the most important point when using a BB during endovascular procedures is how to prevent vessel perforation, the IVUS system was utilized to show us the direction toward which the BB had to be steered by visualizing the tenting phenomenon of the vessel wall. As such, we were able to manipulate the BB with confidence under IVUS guidance in this procedure.
      CVO remains a major challenge in the management of hemodialysis patients. Treatment options include percutaneous balloon angioplasty and bare metal stents. However, all the available treatment options have had variable rates of patency, requiring repeated interventions. In addition, stent implantation does not always provide a more favorable outcome than does conventional balloon angioplasty [
      • Ozyer U.
      • Harman A.
      • Yildirim E.
      • Aytekin C.
      • Karakayali F.
      • Boyvat F.
      Long-term results of angioplasty and stent placement for treatment of central venous obstruction in 126 hemodialysis patients: a 10-year single-center experience.
      ]. We chose primary stenting with balloon-expandable stent because of the following reasons: the lesion was short without containing thrombus, and the rigid degenerative valve was not expected to respond well to the balloon. Regarding the type of stent, we chose balloon expandable stent rather than self-expanding stent in this case mainly because of the length of stent available. The minimum length of self-expanding stent available then was 40 mm, and it appeared to be longer for this short occlusion. We also expected to get a precise placement with balloon-expanding stent.

      Conclusions

      In conclusion, we dealt with a hemodialysis patient who was at high risk of losing her eyesight because of the NVG deterioration. IOP dramatically declined after stent implantation in her right IJV occlusive lesion, which subsequently resulted in the preservation of her vision. A Brockenbrough needle was safely manipulated under IVUS guidance and was helpful for crossing the very rigid occlusion site resulting presumably from a degenerative venous valve.

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