Safety and Effectiveness of Sharp Recanalization for Thoracic Central Venous Occlusion: A Systematic Review and Pooled Analysis
Ashraf, Nader et al.
JVIR. 2025;36(8):1254 - 1267.e5
Tell us about you, your team and your institution.
Behnam Shaygi, MD, MS
Nader Ashraf, MBBS: I am a graduate research assistant at Alfaisal University, Saudi Arabia, and upcoming radiology resident at the Cleveland Clinic. This work was led in collaboration with Behnam Shaygi, MD, MS, senior author and consultant interventional radiologist at London North West University Healthcare, United Kingdom, whose team inserts a high volume of dialysis and feeding catheters. We are a collaborative team of IRs, clinical researchers and medical students based in the UK, Saudi Arabia and France. Our shared clinical experience spans high-volume tertiary centers where central venous occlusions (CVOs) are a common and complex challenge. We have seen the growing reliance on sharp recanalization but also noticed how fragmented the published literature is, with most data buried in small series or single-center studies. This study is the product of collective curiosity, hands-on procedural experience and a drive to collect meaningful, evidence-based insights from scattered studies into something comprehensive and actionable.
Why did you pursue this topic?
NA: Sharp recanalization is a procedure often cautiously used when conventional techniques fail. As a result, the reports in literature are scarce and most available data have been retrospective or narrowly focused. We saw an opportunity to systematically evaluate sharp recanalization across the published literature, to better understand its effectiveness and critically evaluate its potential risks. In a field that thrives on precision and evidence, this felt like a necessary step to guide decision-making for a vulnerable patient population.
What are the key takeaways from your research?
NA and Behnam Shaygi, MD, MS: By pooling data from 28 studies and over 500 patients, our analysis shows that sharp recanalization is highly effective, with a pooled technical success rate of 93.2%, though likely overestimated due to publication bias. Using the Society of Interventional Radiology 2017 specialty-specific adverse-event classification, we found a pooled rate of adverse events of 15.9%. Most adverse events were mild (73.8%) and effectively managed, with 18.5% classified as severe or higher. While primary patency is moderate (around 60–65%), secondary patency exceeds 90%, which suggests that with appropriate surveillance and reintervention, long-term access can be maintained.
How might this research influence treatment, practice or clinical processes in interventional radiology?
Nadar Ashraf, MBBS
NA and BS: Our analysis can help clinicians better gauge the real-world risk-benefit profile of sharp recanalization for thoracic CVOs. It emphasizes that while sharp recanalization is an essential tool, it should be approached with full awareness of its risks and ideally, performed in settings equipped for immediate management of potential adverse events. It may also prompt institutions to develop internal protocols and training strategies that recognize the procedure’s complexity and risk profile. In that sense, our review does not just evaluate the procedure, but it also helps define its proper place within the IR toolkit.
Given the pooled technical‑success rate of 93% for sharp recanalization in thoracic CVOs, when should clinicians consider this technique over conventional endovascular approaches?
NA and BS: This number is encouraging but it comes from a pooled analysis, which aggregates data across varying patient populations and operator experiences/techniques. So, while sharp recanalization is clearly effective when needed, we would stress that it should remain a second-line approach. That said, the high success rate and salvage potential of sharp recanalization make it a crucial option, particularly for patients with no other viable vascular access. Clinicians should consider the anatomy, location of the occlusion, and patient comorbidities before making the call.
Your analysis showed a primary patency rate of 65% and an adverse event rate of 15.9%. Did any of these findings surprise you, and how should they inform choice of devices or procedural planning?
NA and BS: A 65 % primary patency is in line with expectations for a salvage technique used only after conventional recanalization has failed. This, however, has been shown to reach more than 90% after appropriate surveillance and reintervention.
The 15.9% adverse event rate sounds high at first glance, but more than 70% of these events were classified as mild and only 18.5% were severe, according to the SIR specialty-specific adverse-event classification. What surprised us most was the relatively high consistency in technical success across studies, despite the variability in technique and devices. However, the adverse events rate, especially the proportion of severe events, was a reminder that this is not a benign intervention. These data reinforce the importance of careful instrument selection, precise trajectory planning, and team readiness for severe adverse events.
Publication bias was detected for technical‑success and adverse‑event rates. What steps can researchers and journals take to strengthen future evidence and reduce bias in studies of sharp recanalization?
NA and BS: Publication bias is an ongoing challenge, especially with niche procedures where “success stories” are more likely to be reported. We encourage journals to support the publication of negative or null results and promote registries or prospective datasets that capture real-world procedural outcomes. Collaborative networks and standardized reporting protocols can also go a long way toward reducing bias and improving the granularity of the data.
Any next steps or plans for follow-up research?
NA and BS: Given the rarity and complexity of these cases, conducting a large-scale prospective trial may be difficult. A more practical and impactful next step would be the creation of a dedicated registry hosted by societies like SIR to systematically collect and compare real-world data. Much like the IVC filter and peripheral arterial embolization registries, this could offer invaluable insight into instrument performance, adverse-events profiles and long-term patency across institutions.
