Surgical Management of Hemodialysis- Related Central Venous Occlusive Disease: A Treatment Algorithm Javier E. Anaya-Ayala, Patricia H. Bellows, Nyla Ismail, Zulfiqar F. Cheema, Joseph J. Naoum, Jean Bismuth, Alan B. Lumsden, Michael J. Reardon, Mark G. Davies, and Eric K. Peden, Houston, Texas Background: Creation and preservation of dialysis access in patients with central venous occlusive disease (CVOD) is a complex problem. The surgical approach and decision-making process remains poorly defined. We evaluated our experience in the surgical management of hemodialysis-related CVOD. Surgical technique, demographics, complications, reinterventions, access function rates, and factors influencing morbidity and mortality were examined. Methods: From January 2006 to May 2010, we performed a total of 1,703 dialysis access-related procedures, 1,021 arteriovenous fistulas (AVFs), 335 arteriovenous grafts (AVGs), and 314 access revisions including endovascular salvage procedures. Seventeen patients (10 women [58%] with a mean age of 44 ± 27 years) with CVOD who were not suitable for peritoneal dialysis or kidney transplant underwent 20 complex vascular access procedures. The indications were need for access creation in 14 cases (70%) and preservation in the remaining 6 (30%). Polytetra- fluoroethylene (PTFE) was used for all surgical bypass grafts (BPG). All patients had previously undergone multiple access surgeries and had failed percutaneous interventions for CVOD. Results: The surgical planning centered on finding venous outflow for an arteriovenous (AV) access; central venous reconstructions were necessary in 10 (50%) cases (seven [35%] in the thoracic central venous system and three [15%] in infradiaphragmatic vessels) and extrac- avitary venous BPG in two (10%) cases. Non-venous access options included axillary arterial- arterial chest wall BPG in five (25%) cases and brachial artery to right atrium BPG in three (15%). Technical success was achieved in all cases (100%). Mean follow-up was 14.1 months, both BPG and AV access patency rates were 66% at 6 months and overall average AV access function time was 9.2 months. Of these, 85% of patients were discharged home and following 19 (95%) cases they returned or improved their baseline functional status. One death occurred from multiorgan failure during the 30-day postoperative period. Four additional patients died within 3 years of the procedure secondary to nonsurgical-related comorbidities. Conclusion: The need for complex vascular accesses will continue as the number of patients with end-stage renal disease increases. CVOD is an access surgical challenge and with this article we propose a decision-making algorithm. INTRODUCTION The ever increasing population of people with end- stage renal disease (ESRD) and the improved life expectancy of patients on dialyses have resulted in more cases where vascular access creation, preser- vation, and long-term use have become fundamen- tally necessary. 1 Central venous occlusive disease (CVOD) creates a complex problem for patients who have exhausted all conventional sites and Presented at the 20th Annual Winter Meeting of the Peripheral Vascular Surgery Society, Vail, CO, January 29-31, 2010. Dialysis Access Program, Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, The Methodist Hospital, Houston, TX. The Methodist Hospital Research Institute, The Methodist Hospital, Houston, TX. Correspondence to: Eric K. Peden, MD, Department of Cardiovas- cular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, 6550 Fannin Street, Suite 1401, Houston, TX 77030, USA, E-mail: EKPeden@tmhs.org Ann Vasc Surg 2011; 25: 108-119 DOI: 10.1016/j.avsg.2010.11.002 Ó Annals of Vascular Surgery Inc. 108