|Case of the Week - Patient Summary 12481|
Peer Reviewed and Certified -
|Demographics: 73 y.o. man|
|History & Chief complaint:|
| 73 year old man with ESRD presents with severe left arm swelling following regular dialysis.
When questioned he reports that the size of his arm has increased significantly over the preceding 2 weeks.
|Physical exam and Laboratory:|
| A pulse, rather than a thrill, is felt in the region of the left arm fistula. The patients left arm is edematous. The left hand is warm and the radial pulse can be palpated.
|Summary of Findings:|
|Chronic left brachiocephalic vein stenosis
Sub-acute complete occlusion
Angioplasty and stenting of the occlusion
|Central venous stenosis or central venous occlusion can be due to a number of disparate primary pathologies:
Chronic local venous hypertension in the arm of a dialysis patient, Paget Schroder syndrome in an athlete using anabolic steroids, fibrosis due to indwelling pacemaker leads, and superior vena cava syndrome due to cancer are some of the more common of these processes.
Lymphedema (subsequent to axiallary node dissection or other etiology)
| Stent Placement for Recurrent Central Venous Occlusion
|Confirmed by: Diagnostic and Interventional Radiology|
|Treatment and Followup:|
|AV fistulas for dialysis should be monitored for:
1. Venous pressure >140 mm Hg at a dialyzer flow of 200 ml/min
2. Dialyzer blood flow of >200 to ml/min
3. Difficulties in fistula access
A fistulagram should be performed if any of these criteria are met.
Peter J Bosman, Frans T J Boereboom, Bert C Eikelboom, Hein A Koomans and Peter J Blankestijn. Graft flow as a predictor of thrombosis in hemodialysis grafts. Kidney International (1998) 54, 1726–1730
|Patient Specific Discussion: (Also Read the Disease Discussion)|
|Venous stent patency rate are lower than arterial stent patency rates. Stents are not commonly placed for central venous stenosis or occlusion.
In this case, recurrent severe symptoms were present that were refractory to multiple venoplasty procedures, necessitating stent placement as a last resort to preserve patency of the fistula
|Central venous stenosis or occlusion may complicate access in hemodialysis patients in the setting of multiple prior catherizations. When patients have an upper extremity fistula or shunt, central stenosis can manifest as increased venous pressures, recirculation or post-dialysis arm swelling.
Percutaneous venoplasty is the preferred method for correction of central venous stenoses with surgical revision held in reserve for difficult cases.
Covered and uncovered stents have also been used in the setting of central venous stenosis when angioplasty results are suboptimal (>50% immediate or elastic stenosis) or stenosis with arm swelling recurs within 3 months. Initial case series and retrospective studies demonstrated only mild improved patency at 12 months versus angioplasty alone (2). More recently, authors have published results suggesting that newer stent design and material construction may led to improved patency rates (1). Randomized, controlled trials will be necessary to provide interventionalists stronger practice guidelines.