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Abstract: TH-PO284

Arteriovenous Fistula (AVF) Placement Unmasking Chronic Aortic Dissection

Session Information

Category: Dialysis

  • 703 Dialysis: Vascular Access


  • Patel, Sagar, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Bhave, Gautam B., Vanderbilt University Medical Center, Nashville, Tennessee, United States

Swelling in the arm of an AVF can be a symptom of a stenotic or occlusive vascular process. It is often seen with a deep vein thrombosis (DVT) or central stenosis related to prior central lines or pacemakers. Here, we describe a rare presentation of a chronic aortic dissection being discovered as a result of AVF placement and subsequent swelling from mass effect of aorta.

Case Description

A 68 year old male with history of coronary artery disease, pacemaker placed 10 years ago, hypertension, and stage 5 chronic kidney disease with a left upper extremity brachio-basilic AVF placed 3 weeks prior presented with 2 weeks of worsening swelling in his left arm. He had some numbness and tingling in his arm but denied any pain.
He was afebrile with BP 132/80 and HR 62. Exam showed significant swelling throughout his left arm even above the fistula and into the shoulder. Fistula had weak thrill and bruit. Collateral veins were noted in left chest/neck area that patient reported had been present for a few years.
Duplex ultrasound showed DVT in the paired brachial veins. However, the degree and location of swelling was not consistent with the location of DVT. It was suspected that he had central stenosis related to his pacemaker. The initial plan was to perform a fistulagram to diagnose and treat such a stenosis. However, decision was made to pursue CT scan with contrast for further evaluation with understanding of risks of worsening kidney function. CT scan showed aneurysmal ascending aorta of 5.5cm and aortic dissection involving ascending thoracic aorta and aortic arch with mass effect on left brachiocephalic vein.
Patient was transferred to ICU for esmolol drip. CT surgery reported there was no need for surgical intervention as the dissection appeared chronic in nature. Patient’s kidney function worsened after contrast and a right IJ tunneled dialysis catheter was placed, and he was initiated on hemodialysis which was tolerated well without hemodynamic instability.


Swelling associated with an AVF is often presumed to be from an intravascular process such as a thrombus or central stenosis which can be diagnosed and treated by fistulagram. However, external compression by mass effect should also be taken into consideration. Cases such as ours as well as other reported cases of tumors causing similar presentation highlight the importance of CT imaging in the evaluation of AVF related swelling.