Abstract: FR-PO758

Upper Extremity Swelling in ESRD: DVT or Central Venous Disease

Session Information

Category: Dialysis

  • 603 Hemodialysis: Vascular Access

Authors

  • Safdi, Adam, Northwestern University, Chicago, Illinois, United States
  • Wasse, Monnie, Rush University Medical Center, Chicago, Illinois, United States
Background

Among end-stage renal disease (ESRD) patients, upper extremity deep vein thrombosis (DVT) and central venous disease (CVD) defined as stenosis or occlusion, may have similar clinical presentations, commonly a swollen arm ipsilateral to a functional dialysis access. However, management is different. Anticoagulation is prescribed for acute DVT, whereas angioplasty might be necessary for CVD. The objective of this study was to examine ESRD patients presenting with arm swelling who received a diagnosis of upper extremity DVT, the proportion undergoing central venous angiogram, and an alternate CVD diagnosis.

Methods

We retrospectively reviewed the medical records of all ESRD patients receiving hemodialysis admitted to a tertiary academic medical center between January 1, 2013 and June 30, 2015, and received a diagnosis of upper extremity DVT by ICD-9 code. Charts were reviewed to determine: 1) if duplex ultrasound was performed, 2) if referral was made for dialysis access angiogram and if CVD was determined, and 3) whether the patient was discharged on anticoagulation.

Results

An upper extremity ultrasound was ordered in 102 ESRD patients over 124 admissions, and one or more acute or chronic DVT was diagnosed in 118 of the 124 admissions. The most common vein location for DVT was the internal jugular (75%), followed by axillary (44%), subclavian (34%), brachial (23%), and brachiocephalic (14%). 25 of the 118 DVT cases (21.2%) were referred for angiography. Of these, only 4 of the 25 cases (16%) were diagnosed with DVT. In contrast, 18 of the 25 cases (72%) referred for angiogram had CVD. Of note, angiography was not always performed on the vessel noted to have a DVT by duplex ultrasound. Of 19 cases diagnosed with a DVT and subsequently studied with angiography, CVD was present in 18 cases (94.7%) and DVT was only observed in 4 cases (21.1%), all of whom had concurrent CVD. 39 of the 118 cases (33%) diagnosed with a DVT were discharged with a new prescription for anticoagulation.

Conclusion

Our retrospective study shows that when hemodialysis patients with ESRD receive a diagnosis of upper extremity DVT by ultrasound, and also have upper extremity venogram, they more often have CVD than DVT. This suggests that duplex ultrasound leads to an incorrect clinical diagnosis when hemodialysis patients present with a swollen arm, and suggests patients may be receiving inappropriate anticoagulation.

Funding

  • Other NIH Support