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Abstract: PO1048

Facial Swelling: Angioedema or Superior Vena Cava (SVC) Syndrome

Session Information

Category: Dialysis

  • 703 Dialysis: Vascular Access

Authors

  • Qazi, Moarij A., Cleveland Clinic, Cleveland, Ohio, United States
  • Qazi, Huma, Army Medical College, Rawalpindi, Punjab, Pakistan
  • Huml, Anne M., Cleveland Clinic, Cleveland, Ohio, United States
  • Vachharajani, Tushar J., Cleveland Clinic, Cleveland, Ohio, United States
Introduction

Central venous stenosis is a common complication of recurrent central venous catheters (CVCs). Diagnosis can be challenging given its versatile presentation. Facial, unilateral breast or upper extremity swelling and signs of congestion mimicking pulmonary edema can be subtle clues. We describe a case of SVC syndrome that eluded clinicians as angioedema.

Case Description

55-year-old female with history of morbid obesity, CKD 4, recurrent bacteremia, endocarditis and anemia presented with 1-day history of facial and oropharyngeal swelling, requiring intubation for airway protection. She was unsuccessfully treated for presumed angioedema with steroids, H2 blocker and C1 esterase inhibitor. She deteriorated, requiring tracheostomy tube, dialysis and then transferred to our hospital. She had episodes of worsening facial swelling, drooling and dyspnea with dialysis. Her medical records revealed multiple infections of her more than 10 CVCs placed in the past 12 years for frequent IV draws, iron infusions and antibiotics. Six portacaths were on the right side including 3 in subclavian, 1 in internal jugular vein and 2 peripherally inserted central catheters.
A CO2 angiogram revealed stenosis of the right internal jugular, subclavian and brachiocephalic veins. The left internal jugular had the dialysis catheter with some narrowing around it. Endovascular interventions were unsuccessful at recanalization. Surgical bypass was not an option given her comorbidities. She was being evaluated for sharp or radiofrequency recanalization and/or inside-out device intervention. Unfortunately, devastated with failures, she opted for hospice.

Discussion

A high index of suspicion is crucial in patients with prior CV accesses and frequent access clotting, poor flows and facial or upper extremity swelling. The number, duration and infections of CVCs increase the risk of CV stenosis. Dialysis related dyspnea, drooling or treatment resistant angioedema should be evaluated with a venogram urgently. Prompt use of advanced treatments like endovascular recanalization can be lifesaving.

SVC syndrome