Images in Dialysis Series Editors: Ursula C. Brewster and Mark A. Perazella: Facial and Left Arm Swelling in a Hemodialysis Patient

Abstract

A 43-year-old woman with end-stage renal disease on hemodialysis for 4 years presented complaining of recurrent edema of her left arm, neck and face during the last 12 months. She dialyzes via a left brachial artery to cephalic vein arteriovenous fistula. Due to difficulties in vascular access, she had three temporary left subclavian catheters placed previously. On examination, the left neck veins were dilated with large collateral veins on the chest wall. A computed tomography (CT) angiogram ( Fig. 1a,b) followed by a fistulogram (Fig. 2) was performed.What does the CT angiogram show (Fig. 1a,b)? What does the fistulogram show ( Fig. 2)? How should the patient be managed? AnswersThe CT angiogram showed an extensive collateral vein network involving the chest wall and suprascapular veins (Fig. 1a,b). The fistula is evident in the left upper arm on digital reconstruction images (Fig. 1b). A fistulogram was performed and revealed severe stenosis (>95%) of the left branciocephalic vein and a large collateral network of veins (Fig. 2). She underwent balloon angioplasty with successful vein dilatation with 8 and 10 mm balloons. There was no immediate angiographic improvement of collateral veins, but the edema on the face, arm and neck moderately subsided.Swelling of the face and neck in hemodialysis patients should prompt clinicians to consider impaired venous return due to central venous stenosis. The literature suggests that cannulation of central veins with catheters is associated with up to 50% stenosis rates. The number of catheters inserted and the increased duration of catheter days is also associated with the development of central venous stenosis (1). Such a stenosis is more common with subclavian catheters; they should be avoided even temporarily.