Recanalization of chronic superior vena cava occlusion using a transseptal needle in a dialysis patient

Chronic superior vena cava (SVC) occlusion is a challenging complication in hemodialysis patients, particularly when conventional endovascular approaches fail. We describe the successful use of a manually straightened transseptal needle for sharp recanalization in a symptomatic dialysis patient with extensive collateralization and exhausted access options. Prior attempts using re-entry devices and back-ends of stiff guidewires had been unsuccessful. Under biplanar fluoroscopy, the transseptal needle was advanced transfemorally to cross the occlusion, allowing passage of a 0.018″ guidewire and subsequent snaring through a left axillary loop graft. A VBX 11 × 39 mm balloon-expandable stent-graft was deployed and post-dilated to 14 mm. Clinical symptoms, including facial and upper limb edema with prominent thoracic collateral veins, resolved by the following morning. No complications occurred, and patency remains stable at 9 months. This case highlights the utility of transseptal needles as a readily available sharp recanalization tool in expert centers, especially when other strategies have failed.