ASN's Mission

ASN leads the fight to prevent, treat, and cure kidney diseases throughout the world by educating health professionals and scientists, advancing research and innovation, communicating new knowledge, and advocating for the highest quality care for patients.

learn more

Contact ASN

1401 H St, NW, Ste 900, Washington, DC 20005

email@asn-online.org

202-640-4660

The Latest on Twitter

Kidney Week

Abstract: PO1361

Percutaneous Thrombectomy of an Ipsilateral Arteriovenous Dialysis Graft in a Patient with Dextrocardia

Session Information

  • Vascular Access
    October 22, 2020 | Location: On-Demand
    Abstract Time: 10:00 AM - 12:00 PM

Category: Trainee Case Report

  • 704 Dialysis: Vascular Access

Authors

  • Hlepas, Alexander, Rush University Medical Center, Chicago, Illinois, United States
  • Zemke, Anna M., Rush University Medical Center, Chicago, Illinois, United States
  • Wasse, Monnie, Rush University Medical Center, Chicago, Illinois, United States

Group or Team Name

  • Interventional Nephrology
Introduction

Dextrocardia with situs solitus (DSS) and associated duplicated left superior vena cava (DLSVC) is a rare condition. In affected patients with end-stage kidney disease (ESKD) the preferred dialysis access type and site are unclear, however anatomical variations may impact feasibility and success of dialysis access related procedures. In the setting of the altered anatomy, drainage of an access to the right atrium takes an altered pathway with differing technical concerns for stent deployment and avoidance of thrombus propagation in a clotted AVG.

Case Description

We report a rare case of covered stent placement during thrombectomy of a clotted ipsilateral right forearm loop AVG in the setting of DSS in an ESRD female. Given a severe venous anastomotic lesion and severe draining brachial vein stenosis, a covered stent was placed across the length of the stenosis. However, a guidewire could not be parked in the IVC to safeguard against potential stent migration to the heart, given the presence of dextrocardia, and the procedure was associated with a high risk of thrombus migration. An associated DLSVC draining into the CS (Coronary Sinus) was present, thus creating a direct path from the AVG through the central veins and the CS down to the heart. A right brachiocephalic vein was not present, and the right subclavian vein drained directly into the persistent right SVC (right part of duplicated left). After repeating the angiogram, measuring the length and marking it on the imager, a 6.10 cm Viabahn stent graft was passed to the level of the stenosis bridging the lesion with 2 cm maintained in the Acuseal 6 mm AVG and deployed. Thrombus was cleared with a 4 French Fogarthy catheter and after installation of TPA and excellent flow return achieved.

Discussion

DSS is a rare malformation which may impact the preference of dialysis access site and type in ERSD patients. Possible complications due to the altered anatomy need to be further evaluated. Appropriate precautions to prevent thrombus migration from a clotted ipsilateral graft in the setting of dextrocardia need to be further discussed. This case shows the feasibility of stent placement in a clotted AVG despite the inability of placing a guidewire down the IVC due to dextrocardia.