Venous dialysis pressures were measured consecutively in 168 chronic hemodialysis patients for 265 patient-years of monitored dialysis. Venous dialysis pressure greater than 150 mm Hg measured by the protocol were considered elevated. Seventy-three patients had elevated venous dialysis pressures and 58 agreed to undergo elective venography (fistulogram). Fifty of 58 patients studied (86%) had significant venous stenoses. A combination of percutaneous transluminal angioplasty (PTA) and surgical revision were used to electively treat these stenoses. Early detection and treatment of these stenoses decreased fistula thrombosis and fistula replacement threefold compared with our earlier experiences. Patients with elevated venous dialysis pressure who were venogramed and treated had an occurrence of fistula thrombosis similar to patients with normal dialysis pressure (0.15 and 0.13 episodes per patient year of dialysis respectively, P = NS). In contrast patients with elevated venous dialysis pressure who refused elective fistulogram and treatment averaged 1.4 episodes of thrombosis per patient year of dialysis (P less than 0.001) compared to both other groups). We conclude that elevated venous dialysis pressure is a reliable method of detecting fistula stenoses and that the elective treatment of these stenoses significantly decreases fistula thrombosis and fistula loss.

This study was undertaken to evaluate hemodialysis-associated subclavian vein stenosis (SVS) and to clarify treatment of this condition. Forty-seven patients underwent upper arm venography to evaluate fistula dysfunction. Subclavian vein stenosis was documented in 12. Eleven of 12 had elevated venous dialysis pressure (196 +/- 8.9 mm Hg), and six had arm edema. All 12 had previously undergone subclavian cannulation on the side of the fistula. Thirty-five patients showed no evidence of subclavian vein stenosis. Twelve of these 35 patients (mean venous dialysis pressure 113 +/- 2.3 mm Hg) had undergone previous subclavian cannulation on the side of the fistula. The mean age of the fistula at the time of venogram in patients with subclavian vein stenosis was 17.0 months versus 5.8 months in patients with ipsilateral subclavian cannulation without subclavian vein stenosis. Percutaneous transluminal angioplasty (PTA) was performed on 11 of 12 patients with SVS lowering venous dialysis pressure and restoring patency to the fistula in 100%. Lesions recurred in two of 11 patients and were successfully retreated with PTA. We conclude that SVS is a common dialysis problem that is amenable to treatment with PTA. Elevated venous dialysis pressures are a sensitive indicator of this condition.

Although uncommon, bleeding following pancreaticoduodenectomy is associated with high mortality. Management generally includes surgical reexploration or, alternatively, transarterial embolization. We report the case of a 62-year-old man who presented with massive upper gastrointestinal bleeding 3 weeks after pancreaticoduodenectomy. Selective coeliac angiography revealed a large pseudoaneurysm involving the proper hepatic artery. This was treated successfully with a stent graft. There was no recurrence of bleeding at the 6-month follow-up. To our knowledge, this is the first report of stent graft repair of bleeding hepatic artery pseudoaneurysm following pancreaticoduodenectomy.