Abstract: TH-PO287
Case of Elevated Dialysis Access Venous Pressures From Cephalic Arch Pseudo-Stenosis
Session Information
- Vascular Access: From Biology to Managing Complications
November 03, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
Abstract Time: 10:00 AM - 12:00 PM
Category: Dialysis
- 703 Dialysis: Vascular Access
Authors
- Rasheed, Abdul Hannan A., Edward Hines Junior VA Hospital, Hines, Illinois, United States
- Barnes, Sylvester, Edward Hines Junior VA Hospital, Hines, Illinois, United States
Introduction
The patient is a 75-year-old male with ESRD getting hemodialysis via left brachiocephalic AVF created in March 2017. In May 2021, he was found to have elevated venous pressures (VP) of up to 260mmHg during dialysis causing frequent alarms.
Case Description
Duplex US of the access showed a patent brachiocephalic AVF with evidence of a significant stenosis at the cephalic / subclavian vein junction with a velocity ratio of 7.8 (659cm/s ÷ 83.8cm/s)(Fig 1). Based on the elevated VP and significant V2/V1 > 3.5 fistulogram was indicated. A fistulogram was performed which showed no significant stenosis within the fistula, as well as no significant stenosis in the central circulation. However, it showed significant angular entry of the cephalic vein at the subclavian junction (Fig 2)
Discussion
This case representing pseudo-stenosis, shows the difference of findings detected by the two modalities most commonly used for assessment of dialysis access. The duplex findings can be explained by the both the sharp angle of entry of the cephalic vein to the subclavian vein, along with the significant diameter difference. Since flow must remain constant then velocity has to increase accounting for the smaller diameter and increased vessel tortuosity. If the result was still in question, IVUS could be deployed to document the luminal diameter. The decision was made to follow the patient clinically and if the patient developed problems with prolonged bleeding or excessively high VPs then the patient would have a covered stent placed in the cephalic arch to straighten out the venous tortuosity. So far to date the patient has not had any increase in VPs from the current state nor any episodes of prolonged bleeding.
Figure 1: Duplex US
Figure 2: Fistulogram of AVF