doi: 10.5604/01.3001.0014.1734 PoL PRZEGL CHiR, 2020: 92, 1-2 AHEAd oF PRiNT
casestudy
1
Bilateral brachiocephalic vein stenosis in a chronic
hemodialysis patient with well-functioning
arteriovenous fistula – A rare entity
Maj Gen D V Singh, Vinod Kumar
Institute of Liver and Biliary Sciences, New Delphi, India
Article history: Received: 23.03.2019 Accepted: 04.06.2020 Published: 05.06.2020
AbstrAct: Introduction: Central vein stenosis has been reported in patients of end stage renal disease with subclavian vein being more commonly affected than brachiocephalic vein.
case report: We present a case of young female with bilateral brachiocephalic vein obstruction following arteriovenous fistula creation for hemodialysis.
Keywords: arteriovenous fistula, central veins, hemodialysis
AbbrevIAtIons
CKD – Chronic Kidney Disease CVS – Central Vein Stenosis
IntroductIon
Hemodialysis is frequently required in patients of stage V Chron- ic Kidney Disease (CKD) for which vascular access in the form of arteriovenous fistula or central vein catheterisation is created.
Complications associated with vascular access include stenosis, thrombosis, infection, distal limb ischemia, heart failure, pseu- doaneurysm and aneurysm. We report a case of a 17-year-old fe- male with bilateral brachiocephalic vein stenosis following crea- tion of left brachiobasilic fistula.
cAse report
A 17-year-old female with stage V CKD with left brachiobasilic arteriovenous fistula presented to us with progressive left upper limb swelling and pain for three days. A Doppler study was done which showed increased flow of 1.1 litres across the fistula with reduction in flow in radial and ulnar arteries which improved on occlusion of the fistula and patent ipsilateral axillary and subcla- vian vessels. In view of these findings, the fistula was closed under local anethesia. However, the patient did not get relieved of the symptoms and in addition to left upper limb swelling and pain, also ipsilateral hemi facial swelling occurred on post-operative day one of fistula closure. Angiography was performed in suspi- cion of central vein obstruction/stenosis which revealed bilateral brachiocephalic vein stenosis (Fig. 1.). Bilateral balloon dilation and venoplasty were carried out and the patient got relieved of the symptoms.
dIscussIon
Central Vein Stenosis (CVS) in patients on hemodialysis, although rare, is a known entity [1]. Subclavian vein stenosis has been
Fig. 1. DSA images (A) showing partial stenosis of the right brachiocephalic vein (black arrows) up to the superior vena cava and (B) showing near total occlusion of the left brachiocephalic vein (black arrows) with collaterals (black arrowheads). Image obtained post venoplasty and stent placement in both brachiocephalic veins (C) showing re-established flow in the central veins with good contrast opacification of both brachiocephalic veins and superior vena cava (Black arrows).
reported in dialysis patients especially in those with a previous history of central vein cannulation. Brachiocephalic vein stenosis also has been reported but much less commonly than subclavi- an vein stenosis [2]. As the patient had a prior history of left cen- tral veincannulation it was assumed that she might be harbour- ing latent brachiocephalic vein stenosis which manifested due to a high flow following fistula creation. Endothelial injury being a result of central vein cannulation appears to be the most plausi- ble explanation for CVS which got aggravated due to a high flow resulting from fistula creation [3]. Bommer et al. reported left
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brachiocephalic kinking and stenosis in a patient who had all cen- tral catheters placed on the right side, suggesting that this may be explained by the tip of a right-sided catheter becoming displaced to the left causing local damage to a vessel wall resulting in steno- sis [4]. This may be the possible explanation for complete block on the ipsilateral (left) side with stenosis of the contralateral bra- chiocephalic vein in our patient.
REFERENCES
1. Agarwal A.K., Patel B.M., Haddad N.J.: Central vein stenosis: A nephrologists’
perspective. Semin Dial, 2007; 20: 53–62.
2. Ashizawa A., Kimura G., Sanai T., Kawano Y. et al.: Omae Idiopathic left inno- minate vein stenosis manifested following the creation of arteriovenous fistula in uremia. Am J Nephrol., 1994; 14: 142–144.
3. Forauer A.R., Theoharis C.: Histologic changes in the human vein wall adja- cent to indwelling central venous catheters. J VascInterv Radiol, 2003; 14(9 Pt1): 1163–1168.
4. Bommer J., Ritz E.: The dialysed lady with one swollen cheek. Nephrol Dial Transplant., 1997; 12: 2188–2190.
Word cound: 731 Page count: 2 Tables: – Figures: 1 References: 4
10.5604/01.3001.0014.1734 Table of content: https://ppch.pl/resources/html/articlesList?issueId=0 Copyright © 2020 Fundacja Polski Przegląd Chirurgiczny. Published by Index Copernicus Sp. z o. o. All rights reserved.
The authors declare that they have no competing interests.
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Maj Gen D V Singh; Institute of Liver and Biliary Sciences, New Delphi, India; E-mail: dvs_neerusha@yahoo.co.in Singh D.V., Kumar V.: Bilateral brachiocephalic vein stenosis in a chronic hemodialysis patient with well-functioning arteriovenous fistula – A rare entity; Pol Przegl Chir 2020; 92: 1–2; DOI: 10.5604/01.3001.0014.1734 (Advanced online publication)
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Therefore, in all CKD stage V patients requiring vascular access for hemodialysis, central veins (including the brachiocephalic veins) should be checked before creation of a fistula.
A high index of suspicion of central vein stenosis should be main- tained when symptoms (pain and swelling) develop in a limb hav- ing an arteriovenous fistula.
