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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2015  |  Volume : 26  |  Issue : 3  |  Page : 564-566
Multiple cephalic vein aneurysms with calcification in a patient undergoing hemodialysis: An unusual entity


1 Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication20-May-2015
 

   Abstract 

Peripheral venous aneurysms are a known complication following autogenous arteriovenous fistula (AVF) for hemodialysis. We present a case of aneurysms involving the cephalic vein associated with calcification, a condition that, to the best of our knowledge, has not been reported earlier in the literature.

How to cite this article:
Yadav MK, Bhatia A, Singh S, Khandelwal N. Multiple cephalic vein aneurysms with calcification in a patient undergoing hemodialysis: An unusual entity. Saudi J Kidney Dis Transpl 2015;26:564-6

How to cite this URL:
Yadav MK, Bhatia A, Singh S, Khandelwal N. Multiple cephalic vein aneurysms with calcification in a patient undergoing hemodialysis: An unusual entity. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Jun 14];26:564-6. Available from: https://www.sjkdt.org/text.asp?2015/26/3/564/157369

   Introduction Top


Aneurysmal dilatation of the arterialized veins is one of the complications [1] seen following autogenous arteriovenous fistula (AVF) created for hemodialysis in patients with chronic renal failure (CRF). The patients with CRF usually develop secondary hyperparathyroidism (HPT) leading to hypercalcemia. Vascular calcification is commonly seen in this setting. [2] We herein present a case report of aneurysms of cephalic vein with associated calcification, a finding not previously described in the literature.


   Case Report Top


A 33-year-old female patient of CRF with secondary hyperparathyroidism who was on long term hemodialysis for the last eight years through surgically created left brachio- cephalic fistula presented with swelling in the arm for three months. On examination, areas of bruit were felt along the course of cephalic vein. With clinical suspicion of the possible narrowing at the anastomotic site and to rule venous stenosis, the patient underwent computed tomography angiography (CTA) of the left upper limb from the level of the arch of aorta till the palmar arch. CTA showed arterialized cephalic vein running along the lateral aspect of the limb that was dilated and tortuous in its entire course, draining in the axillary vein high up in the region of the axilla. There was aneurysmal dilatation of the cephalic vein seen at two places, proximal as well as distal to the fistula site. The distal aneurysm also showed curvilinear calcification in its peripheral part [Figure 1]. In addition, there was evidence of central vein stenosis in the subclavian vein in its proximal course. No mural calcification was seen in the arch of the aorta, its branches as well as the upper limb arteries.
Figure 1: Coronal (A) and axial (B) maximum intensity projection images showing arterialized dilated and tortuous cephalic vein (thick white arrow in A). Two aneurysms are seen (thin white arrows in A) with dense peripheral curvilinear calcification in the distal aneurysm (black arrows).

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Investigations including serum electrolytes, renal and liver function tests as well as intact parathyroid hormone (iPTH) assays were carried out in this patient. The patient was kept on medical treatment alongside hemodialysis. [Table 1] summarizes the available laboratory values of calcium, phosphorus and iPTH in the index patient during her course of illness.
Table 1: Laboratory values of the metabolites in the index patient.

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The patient also had complaints of fever one month ago. Chest X-ray (CXR) at that time showed evidence of left pleural effusion. The pleural fluid analysis showed increased adenosine deaminase (ADA) values, which was 44.9 U/L. Based on this, a diagnosis of tuberculosis (TB) was kept and the patient was started on antitubercular treatment (ATT).


   Discussion Top


Patients with CRF requiring hemodialysis usually undergo autogenous surgically created AVF for vascular access. The various complications encountered in the long term include hematoma, infection, thrombosis, edema, steal syndrome, central venous stenosis, poor flow and aneurysm formation. [1] The aneurysm formation occurs in the arterialized veins due to high flow and/or outflow obstruction. The patients with aneurysm formation present with enlarging swelling with a potential risk of rupture or skin atrophy and ulceration. [3] CTA helps in delineating the vascular anatomy, including the arteries and veins. It also helps in delineating the morphology as well as the exact site of the origin of the aneurysms. In addition, it also helps in demonstrating the central venous obstruction, as seen in the index case where stenosis involving the subclavian vein was seen. Central venous angioplasty was offered but could not be performed due to lack of affordability of the patient.

In patients with CRF, complications including hypocalcemia, hyperphosphatemia, vascular calcification and secondary hyperparathyroidism are encountered during the course of the disease in the long term. [2] The index case also had secondary hyperparathyroidism and was the likely cause of calcification in the cephalic vein aneurysm, a finding that has not been described before in the literature.

The patient had concurrent tubercular infection for which she was taking ATT. TB is one of the common chronic inflammatory disorders that are associated with production of cytokines, which promote calcification. [4] Tubercular vasculitis is a known but rare entity; [5] however, tubercular involvement of the veins, to the best of our knowledge, and after extensive literature search has not been previously described in the literature. Also, the patient was only recently diagnosed with TB and calcification is usually a long-term sequelae of ongoing inflammation and healing process. [4]

To conclude, calcification involving the aneurysms of cephalic vein is a rare entity, with secondary hyperparathyroidism in the setting of CRF as a possible etiology.

Conflict of interest: None declared.

 
   References Top

1.
Yilmaz M, Senkaya I, Saba D, Bicer M. Longterm outcomes of basilic vein transposition fistula for hemodialysis. Vasa 2007;36:29-32.  Back to cited text no. 1
    
2.
Terai K, Nara H, Takakura K, et al. Vascular calcification and secondary hyperparathyroidism of severe chronic kidney disease and its relation to serum phosphate and calcium levels. Br J Pharmacol 2009;156:1267-78.  Back to cited text no. 2
    
3.
Bachleda P, Utikal P, Kalinova L, Vachalova M. Surgical remodelling of hemodialysis fistula aneurysms. Ann Acad Med Singapore 2011;40:136-9.  Back to cited text no. 3
    
4.
Abedin M, Tintut Y, Demer LL. Vascular Calcification: Mechanisms and Clinical Ramifications. Arterioscler Thromb Vasc Biol 2004;24: 1161-70.  Back to cited text no. 4
    
5.
Narang S, Khan AA, Gupta AK. c-ANCA (Antineutrophil Cytoplasmic Antibody) Vasculitis with Tubercular Osteomyelitis. JIACM 2007;8:182-4.  Back to cited text no. 5
    

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Correspondence Address:
Dr. Mukesh K Yadav
Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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DOI: 10.4103/1319-2442.157369

PMID: 26022029

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