Neo-Innominate Vein Creation Using Left Internal Jugular Vein in a Complex Dialysis-Dependent Pediatric Patient

Introduction
With a growing prevalence of end-stage renal disease in the pediatric population, maintaining vascular access has become increasingly complex (1). Central venous catheters (CVCs) can provide immediate hemodialysis access, but can lead to central venous stenosis (2). Central venous stenosis can interfere with arteriovenous fistula (AVF) or arteriovenous graft (AVG) function and lead to venous stasis-related morbidity (3-5).

Patient Background
An 11-month-old boy diagnosed with atypical hemolytic uremic syndrome was initiated on dialysis via a CVC placed in the right internal jugular vein (RIJ). After various access complications, including CVC-related sepsis, AVG infection, AVG pseudoaneurysm, and peritonitis from peritoneal dialysis, a left upper extremity brachiobasilic AVF was placed. A left subclavian port-a-cath, previously in place for frequent lab draws, was attempted to be removed postoperatively, but this was unsuccessful. Follow-up imaging demonstrated complete occlusion of the left innominate vein and transcatheter dilation was unsuccessful. With limited dialysis access options remaining, the patient was taken for venous reconstruction to bypass the occluded left innominate vein.

Surgical Technique
At 15 months of age, the patient was taken to the operating room for creation of a neo-innominate vein by creating a left internal jugular vein (LIJ) to RIJ anastomosis. An incision was made anterior to the left sternocleidomastoid muscle approximately from 1 cm above the clavicle to the mandibular angle. Dissection down to the strap muscles was performed, and the omohyoid muscle medial to the carotid sheath was identified and divided to allow for tension free transposition of the LIJ. The carotid sheath was incised and the LIJ was isolated from the mandibular angle to below the clavicle. The incision was extended across the neck to just anterior to the right sternocleidomastoid muscle. The LIJ was transected at the mandibular angle and the distal LIJ stump was oversewn. The LIJ was tunneled underneath the intact left sternohyoid muscle and to the RIJ. The site of the LIJ-RIJ anastomosis was placed below the entry point of the RIJ CVC to avoid any potential stenosis caused by the catheter. A side-biting clamp was applied to the RIJ and the end-to-side anastomosis of the LIJ to the RIJ was done using 7-0 polypropylene. Intraoperative Doppler ultrasound demonstrated a good audible bruit at the anastomosis and the subcutaneous tissue and skin were closed. The patient was taken to the ICU in stable condition.

Follow-Up
The patient’s postoperative course was uneventful and he was discharged home on postoperative day four. The neo-innominate vein remains patent at five years after surgery, but requires balloon dilation of the veno-venous anastomosis during follow-up angiography every 3-6 months.

Conclusion
Vascular access for pediatric hemodialysis patients can be immensely challenging. When transcatheter interventions fail for central venous stenosis, surgery is the next-line treatment, and numerous vascular reconstructions have been described. LIJ transposition is a promising option because autologous vein use has been demonstrated to have higher patency rates compared to prosthetic grafts, only requires one anastomosis, decreases the risk of anastomotic bleeding and stenosis, and avoids the need for a sternotomy.

References

1. Arhuidese IJ, Wanogho J, Faateh M, Aji EA, Rideout DA, Malas MB. Hemodialysis and peritoneal dialysis access related outcomes in the pediatric and adolescent population. J Pediatr Surg. 2020 Jul;55(7):1392-1399.

2. Ashoor IF, Hughson EA, Somers MJG. Arteriovenous access monitoring with ultrasound dilution in a pediatric hemodialysis unit. Blood Purif. 2015;39:93-98.

3. Chand DH, Valentini RP, Kamil ES. Hemodialysis vascular access options in pediatrics: considerations for patients and practitioners. Pediatr Nephrol. 2009;24(6):1121–1128.

4. Rinat C, Ben-Shalom E, Becker-Cohen R, Feinstein S, Frishberg Y. Complications of central venous stenosis due to permanent central venous catheters in children on hemodialysis. Pediatr Nephrol. 2014;29(11):2235-2239.

5. Toomay S, Rectenwald J, Vazquez MA. How can the complications of central vein catheters be reduced? Semin Dial. 2016;29:201-203.