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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2003  |  Volume : 14  |  Issue : 2  |  Page : 194-196
Brachiocephalic Vein Stenosis in a Patient with End-Stage Renal Disease Without Prior Central Vein Cannulation

Medical Department, National University of Malaysia, Kuala Lumpur, Malaysia

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Central vein stenosis is usually associated with previous cannulation or trauma to the affected vein. This pathology may present as ipsilateral arm swelling in patients in whom a recent arteriovenous fistula has been prepared for chronic hemodialysis. The presence of central vein stenosis without prior trauma or cannulation is not hitherto reported to the best of our knowledge. We herewith report a patient with end-stage renal disease who was initiated on chronic dialysis using an arteriovenous fistula, who was noted to have central vein stenosis. This was despite her never having had any central vein cannulation or previous known trauma. Venogram confirmed the presence of brachiocephalic vein stenosis. The patient underwent venographic stenting of the involved vein with good success.

How to cite this article:
Fauzi A R, Jeyabalan V, Kong NC, Selvam T. Brachiocephalic Vein Stenosis in a Patient with End-Stage Renal Disease Without Prior Central Vein Cannulation. Saudi J Kidney Dis Transpl 2003;14:194-6

How to cite this URL:
Fauzi A R, Jeyabalan V, Kong NC, Selvam T. Brachiocephalic Vein Stenosis in a Patient with End-Stage Renal Disease Without Prior Central Vein Cannulation. Saudi J Kidney Dis Transpl [serial online] 2003 [cited 2021 Apr 16];14:194-6. Available from: https://www.sjkdt.org/text.asp?2003/14/2/194/33029

   Introduction Top

Central vein stenosis in patients with end­stage renal disease (ESRD) occurs mainly due to previous cannulation of the central veins for temporary hemodialysis access. It may then impede the placement of the arteriovenous fistula in the same arm as the venous flow is reduced. Venous stenosis is suspected when the ipsilateral arm is swo­llen or, in rare occasions, when it causes ipsilateral breast enlargement. Subclavian stenosis is reported in 11-50% of patients [1] and internal jugular vein stenosis in 10% of patients [1] who have undergone catheteriza­tion of the respective vessels.

Venous stenting and angioplasty have been used for treatment of central vein stenosis with favorable results. Although the commonest vein stented is the internal jugular vein, the subclavian and even the superior vena cava have been stented with equally good results.

   Case report Top

NM is a 54-year old Malay woman with long standing Type-2 diabetes mellitus and hypertension. She was first seen in December, 2000 for uncontrolled hypertension. She was severely nephrotic with a spot urine protein-creatine index of 1.11 gm/mmol and 24-hr urine protein excretion of 4.2g. Her blood urea was 21.7 mmol/L and the serum creatinine was 354 µmol/L. Total cholesterol and LDL-cholesterol were raised at 8.35 mmol/L was 5.68 mmol/L respectively. She was prepared for chronic hemodialysis therapy with a left radial arteriovenous fistula. Intermittent peritoneal dialysis was perfor­med whilst awaiting arteriovenous fistula maturation.

Ten days after the creation of the fistula she presented with gross swelling of the left hand although the fistula bruit was well heard. Axillary vein thrombosis was suspected clinically. However, a fistulogram revealed right brachiocephalic vein stenosis with no evidence of thrombosis. She was, thus, referred to the interventional cardiologist for venous dilatation. She underwent a percutaneous venogram through the femoral vein, which revealed severe stenosis just after the origin of the brachiocephalic vein extending right up to the entry site of the left jugular vein [Figure 1].

She underwent angioplasty of the lesion followed by stenting with a wallstent, 20 mm in diameter and 80 mm in length, with good results [Figure 2].

The swelling of the hand started to subside the day after angioplasty was performed and the fistula was needled successfully for hemodialysis on Day-5 post-stenting. She remains on regular hemodialysis with good fistula function.

   Discussion Top

Central vein stenosis secondary to vascular access catheterization is a well recognized complication. It is related to the site of catheterization (subclavian commoner than internal jugular), infection of catheter site and duration of catheter placement. [2]

Subclavian vein stenosis is rare but has been reported with central vein cannulation. However, the authors are not aware of any reports of native central vein stenosis especially of the brachiocephalic vein. The pathology of the brachiocephalic vein stenosis in this patient is uncertain, although previous forgotten blunt trauma is a possibility.

A good response to angiographic/ veno­graphic intervention is found even in venous stenosis of the native forearm arteriovenous fistula and they rarely require stenting.[3] In contrast, a high percentage of central vein stenosis requires stenting to maintain patency after the dilatation procedure. As shown in this patient, the patency has been maintained after four months of catheter placement.

   Conclusion Top

Central vein stenosis may occur in ESRD patients even without previous catheteriza­tion. The diagnosis needs to be entertained if an ipsilateral upper limb swelling occurs after fistula creation. However, routine venography prior to fistula placement is not indicated.

   References Top

1.Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterisation vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant 1991; 6(10):722-4.  Back to cited text no. 1    
2.Barrett N, Spencer S, McIvor J, Brown EA. Subclavian stenosis: a major complication of subclavian dialysis catheters. Nephrol Dial Transplant 1998;3(4):423-5.  Back to cited text no. 2    
3.Turmel-Rodrigues L, Mouton A, Birmele B, et al. Salvage of immature forearm fistulas for haemodialysis by interventional radiology. Nephrol Dial Transplant 2001;16:2365-71.  Back to cited text no. 3    

Correspondence Address:
A R Fauzi
Medical Department, National University of Malaysia, 56000 Cheras, Kuala Lumpur
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PMID: 18209446

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