Symptomatic Central Venous Stenosis in a Hemodialysis Patient Leading to Loss of Arteriovenous Access: A Case Report and Literature Review
We report the case of a 58-year-old male African-American patient who became dialysis dependent in 1990 after he had developed end-stage renal disease due to focal segmental glomerulosclerosis. He had received hemodialysis via a left-radial-artery-to-brachial-vein Gore-Tex graft for several years before he was noted to have poor arteriovenous access blood flow. Venography showed graft stenosis and an accompanying thrombus. Despite efforts to restore patency, the graft could not be salvaged. A tunneled left subclavian hemodialysis catheter was placed in order to continue maintenance hemodialysis. He subsequently underwent creation of a left brachiocephalic arteriovenous fistula that provided reliable vascular access for hemodialysis during several months. The patient eventually underwent a successful cadaveric kidney transplant and was emancipated from hemodialysis. Months later, he developed a remarkable enlargement of the arteriovenous fistula (fig. ) and dilated jugular veins (fig. ). Venography revealed 50% stenosis of the left brachiocephalic vein accompanied by dilatation of the ipsilateral cephalic and subclavian veins (fig. ). Retrograde flow was noted in the left internal jugular vein. After successful dilatation of the left brachiocephalic vein stenosis by balloon angioplasty, venography showed restoration of the blood flow in the central venous circulation and disappearance of the previously noted retrograde flow in the left internal jugular vein (fig. ). However, as the access arm remained massively enlarged, venography was repeated a few weeks later, revealing moderate-to-severe stenosis of the left cephalic as well as subclavian veins. Successful balloon angioplasties of both lesions were performed. Despite several interventions, the striking enlargement of the venous system persisted, and surgical ligation of the fistula was done to avert catastrophic complications.