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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2013  |  Volume : 24  |  Issue : 2  |  Page : 326-329
Delayed compartment syndrome following brachiocephalic arteriovenous fistula formation in a hemodialysis patient


1 Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, North Rhine-Westphalia, Germany
2 Sheffield Kidney Institute, Sheffield Teaching Hospitals, Sheffield, United Kingdom

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Date of Web Publication26-Mar-2013
 

   Abstract 

Delayed compartment syndrome following the surgical creation of an arteriovenous fistula (AVF) for vascular access is rare. A 71-year-old male patient experienced left anterior forearm compartment syndrome caused by a brachiocephalic AVF. The fistula failed after five days. Immediate radiological de-clotting failed and the thrombosed fistula was de-clotted with the help of a Fogarty balloon. On Day 11, the patient developed symptoms and signs of acute anterior forearm compartment syndrome and underwent immediate surgical decompression of the superficial and deep flexor compartments, which resulted in an excellent outcome. Iatrogenic forearm compartment syndrome is a rare but potential complication after creation of AVF. The critical errors regarding compartment syndrome are failure to recognize or failure to act. This case report illustrates that swift diagnosis and immediate surgical intervention results in an excellent outcome and avoids the morbidity associated with this potentially devastating and debilitating process.

How to cite this article:
Al-Benna S, Elenin H. Delayed compartment syndrome following brachiocephalic arteriovenous fistula formation in a hemodialysis patient. Saudi J Kidney Dis Transpl 2013;24:326-9

How to cite this URL:
Al-Benna S, Elenin H. Delayed compartment syndrome following brachiocephalic arteriovenous fistula formation in a hemodialysis patient. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2019 Nov 14];24:326-9. Available from: http://www.sjkdt.org/text.asp?2013/24/2/326/109595

   Introduction Top


Forearm compartment syndrome is a limb-threatening surgical emergency and can lead to marked disability if not treated promptly. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] It can have several etiologies and can occur in any part of the body where the tissue has little or no capacity to expand. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] Trauma is unquestionably the most common cause. [1] Pathophy-siologically, any process that results in elevated pressure in a closed fascial compartment can cause a compartment syndrome. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] Acute compartment syndrome occurs when the tissue pressure within an enclosed space is elevated to the extent that there is decreased blood flow within the space, decreasing tissue oxygenation and impairing metabolic function. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] The final result without prompt treatment is cellular death.

We report a case of delayed iatrogenic compartment syndrome following the surgical creation of a left arteriovenous fistula (AVF) for vascular access. Although compartment syndrome is a rare complication of AVF creation, this case report illustrates that it can occur and emphasises that, with proper technique, attention to detail and serial monitoring of the involved limb, complications of the compartment syndrome can be avoided.


   Case Report Top


A 71-year-old retired Bengali male with end-stage renal disease secondary to chronic pyelonephritis was admitted for elective vascular access surgery. His past medical history included transurethral prostatectomy for benign prostatic hyperplasia and right radical nephrectomy for renal cell carcinoma (pT1a N0, M0, Fuhrman nuclear grade III).

A left brachiocephalic AVF was successfully constructed for hemodialysis. The end of the 4-mm diameter vein was anastomosed to the side of the 5-mm diameter artery with interrupted 7-0 polypropylene sutures (Prolene; Ethicon Inc., Hamburg, Germany).

On Day five, no thrill or pulsation was felt and no bruit was heard at the fistula site, and an immediate radiological declotting was attempted to restore function. The de-clotting was abandoned as it was only possible to feed the guide wire for 3 cm into the proximal venous limb. Consequently, on the same day, the patient underwent successful surgical de-clotting with no. three and no. four Fogarty balloon catheters and the AVF was considered functioning.

On Day 11, the patient complained of severe pain in the left forearm and hand. The pain was associated with paresthesia, numbness along the median and ulnar nerve territories of the left hand and with a tense anterior forearm compartment, but with a soft posterior one. Physical examination revealed a tense swollen forearm with the presence of epidermolysis and cyanosis in the anteromedial region of the forearm, decreased sensation of the hand, reduced capillary return in fingers and severe pain upon passive wrist flexion but minimal pain on wrist extension. A diagnosis of compartment syndrome was made.

The patient was immediately taken to the operating room for decompression surgery under general anesthesia with tourniquet control. Emergency anterior forearm compartment fasciotomy was performed via a single sinusoidal incision. Release included carpal tunnel, volar aspect of the forearm and distal aspect of the biceps and the original incision for the fistula. There was no bleeding or hematoma formation. The bulging muscle bellies in both superficial and deep flexor compartments were found to be viable, although there was significant edema in the subcutaneous tissues. Ulnar and median nerves were edematous and congested. Superficial and deep flexor compartment decompression was undertaken and the nerves underwent neurolysis. The volar forearm muscles expanded on release and the color improved by the end of the procedure. Good distal pulses were noted. The wound was left open and wet dressed for three days until it closed in a delayed fashion [Figure 1]. The limb was elevated post-operatively for three days. One month after the fasciotomy, the wound was fully healed and there was no sign of neuromuscular or vascular deficit of the patient's left forearm or hand.
Figure 1: Clinical photograph of the affected limb taken three days after surgical decompression showing that the muscle bellies are healthy with minimal edema and that the wound can be closed directly.

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   Discussion Top


Compartment syndrome is a limb-threatening surgical emergency. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] A rise in tissue pressure to a degree when interstitial pressure exceeds the perfusion pressure can lead to neurovascular pathology and, consequently, to tissue hypoxia and eventual cell lysis. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] The key factor in all cases of compartment syndrome is decrease in the compartment size or increase in the content in a closed unyielding osteo-fascial compartment, which is sufficient to cause occlusion of small vessels. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] The occlusion quickly leads to muscle and nerve ischemia. If the compartment pressure is not relieved in time, it results in muscle damage with contracture and nerve damage. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12]

The tolerance of muscles and nerves to ischemia varies in terms of time and compartment pressure. [1],[3],[5],[6],[7],[8],[9],[11],[12] Nerve ischemia produces altered sensations within 30 min, but irreversible ischemic damage begins after 12 h. [3],[5],[6],[7],[8],[9],[11],[12] Muscle ischemia produces functional changes in the first 4 h and irreversible damage sets in 6-12 h later, and skin changes are seen after 12 h. [3],[5],[6],[7],[8],[9],[11],[12] The normal pressure in the tissue compartment is 0-8 mmHg. [3],[5],[6],[7],[8],[9],[11],[12] It rises with muscle contraction and drops to zero with relaxation. [13] A resting compartment pressure of over 30 mmHg above the diastolic pressure of the individual obliterates capillary circulation and leads to ischemia. [3],[5],[6],[7],[8],[9],[11],[12],[13] It has been shown that when surgical decompression was performed <8 h after the onset of a compartment syndrome, normal function was restored in 68% of the cases, whereas only 8% of those who had a fasciotomy after 8 h had restoration of normal function. [13] Often, and in this case, limb swelling is so massive that delayed closure is necessary.

Decrease in compartment size could occur due to many causes including, for example, constrictive casts and dressings, sustained localized external pressure, thermal injuries, burn eschar or closure of fascial defects. [3],[5],[6],[7],[8],[9],[10],[11],[12] On the other hand, an increase in compartment content could be due to hemorrhage, vascular injury, bleeding diathesis or anticoagulation. [3],[5],[6],[7],[8],[9],[10],[11],[12] Similarly, an increased volume of the compartment could occur due to soft tissue or skeletal trauma, post-ischemic swelling, infection, intra-arterial or intravenous injection, infiltrated infusion, exercise, thermal injuries, frostbite, animal bites, surgical intervention or compression, constrictive dressings and casts and prolonged immobilization with limb compression. [3],[5],[6],[7],[8],[9],[10],[11],[12] This is the first report describing delayed forearm compartment syndrome after vascular access surgery. Vascular access-associated compartment syndrome is reported rarely in hemodialysis patients, and there are only single case reports in the literature. [14],[15],[16]

Frequent objective neurovascular examinations should be performed and documented, including motor and sensory testing, assessment of distal pulses, capillary refill and palpation of adjacent compartments. The syndrome constellation for the diagnosis of forearm compartment syndromes includes any or all of the following signs and symptoms: pain out of proportion to the signs and symptoms, elevated compartment pressure, pain with passive stretch of the involved compartment, paresis, paresthesias and absent pulses (rarely does the intracompartment pressure get high enough to occlude a major artery). Pain out of proportion to the clinical situation is the most significant finding in a conscious patient; however, it can be misguided or masked by analgesics. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] Therefore, relying on pain to achieve a diagnosis can cause problems in obtunded patients. [4] Hence, there is a good argument for measuring the compartment pressures. [4] This can be measured and monitored using a catheter inserted into the muscle compartment in question. [4] No absolute threshold pressure exists over which a fasciotomy is indicated; however, the need for immediate fasciotomy is clear if the above clinical signs are present and fasciotomy is urgently needed when pressures are constantly >30 mmHg. [3],[5],[6],[7],[8],[9],[10],[11],[12]

Doppler ultrasonography aids in evaluating arterial flow as well as in visualizing any venous thrombosis. Doppler ultrasonography is not helpful in the diagnosis of compartment syndrome; however, it aids in the elimination of differential diagnoses. Computerized tomography or magnetic resonance imaging, and if doubt still exists, a diagnostic minifasciotomy will confirm the diagnosis. [3],[5],[6],[7],[8],[9],[10],[11],[12] However, the role and timing of diagnostic and/or imaging techniques are debatable because although they aid in diagnosis, they also delay treatment. [4]

The accepted treatment includes removal of constricting casts and dressings and fasciotomy of the involved compartments to relieve the elevated pressure. [2],[12],[13] In this patient, a single volar incision was used to decompress the superficial and deep flexor compartments.

Forearm compartment syndrome is a rare but potential complication after creation of AVF. The critical errors regarding compartment syndrome are failure to recognize or failure to act. This case report illustrates that swift diagnosis and immediate surgical intervention results in an excellent outcome and avoids the morbidity associated with this potentially devastating and debilitating process. Serial monitoring of the involved extremity is of utmost importance. No one can be faulted for proceeding with a fasciotomy on clinical grounds alone, but great fault can be assigned, however, to the clinician who chooses to ignore an evolving compartment syndrome, which unnecessarily places the patient at risk of permanent disability.

 
   References Top

1.Newton EJ, Love J. Acute complications of extremity trauma. Emerg Med Clin North Am 2007;25:751-61.  Back to cited text no. 1
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2.Friedrich JB, Shin AY. Management of forearm compartment syndrome. Hand Clin 2007; 23:245-54.  Back to cited text no. 2
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4.Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br 2003;85:625-32.  Back to cited text no. 4
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5.Velmahos GC, Toutouzas KG. Vascular trauma and compartment syndromes. Surg Clin North Am 2002;82:125-41.  Back to cited text no. 5
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7.Johansen K, Watson J. Compartment syndrome: New insights. Semin Vasc Surg 1998;11:294-301.  Back to cited text no. 7
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8.Ortiz JA Jr, Berger RA. Compartment syndrome of the hand and wrist. Hand Clin 1998; 14:405-18.  Back to cited text no. 8
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9.Botte MJ, Gelberman RH. Acute compartment syndrome of the forearm. Hand Clin 1998;14: 391-403.  Back to cited text no. 9
    
10.Yamaguchi S, Viegas SF. Causes of upper extremity compartment syndrome. Hand Clin 1998;14:365-70.  Back to cited text no. 10
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11.Dellaero DT, Levin LS. Compartment syndrome of the hand. Etiology, diagnosis, and treatment. Am J Orthop 1996;25:404-8.  Back to cited text no. 11
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12.Whitesides TE, Heckman MM. Acute compartment syndrome: update on diagnosis and treatment. J Emerg Acad Orthop Surg 1996; 4:209-218.   Back to cited text no. 12
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13.Sheridan GW, Matsen FA 3rd. Fasciotomy in the treatment of the acute compartment syndrome. J Bone Joint Surg Am 1976;58:112-5.  Back to cited text no. 13
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14.Wang KL, Li SY, Chuang CL, Chen TW, Chen JY. Subfascial hematoma progressed to arm compartment syndrome due to a non-transposed brachiobasilic fistula. Am J Kidney Dis 2006;48:990-2.  Back to cited text no. 14
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15.Pereira de Godoy JM, Meziara JC, Braile DM. Compartment syndrome in subcutaneous and skin tissue of a dialysis patient operated for creation of an AV fistula. Int Urol Nephrol 2005;37:437-8.  Back to cited text no. 15
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16.Reddy SP, Matta S, Handa A. Forearm compartment syndrome following puncture of haemodialysis access fistula. Eur J Vasc Endovasc Surg 2002;23:458-9.  Back to cited text no. 16
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Correspondence Address:
Sammy Al-Benna
Department of Plastic and Reconstructive Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, North Rhine-Westphalia
Germany
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DOI: 10.4103/1319-2442.109595

PMID: 23538359

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