Kaneko Yoko, Yanagawa Takamoto, Taru Yoshinori, Hayashi Sonoko, Zhang Hong, Tsukahara Tomoki, Matsunaga Tsuneaki, Ishizu Takashi
Department of Nephrology, Tsukuba Central Hospital, Ushiku, Japan.
J Vasc Access. 2018 Jul;19(4):404-408. doi: 10.1177/1129729818761279. Epub 2018 Mar 12.
We describe a hemodialysis patient who developed subclavian steal syndrome via an arteriovenous fistula after percutaneous transluminal angioplasty.
A 55-year-old female with end-stage renal failure due to polycystic kidney disease had been treated with hemodialysis for 10 years. Because of an autologous arteriovenous fistula stenosis, percutaneous transluminal angioplasty was performed. After successful treatment with percutaneous transluminal angioplasty, the patient developed dizziness. Magnetic resonance imaging with angiography of the brain and neck revealed normal bilateral subclavian and carotid arteries. However, flow in the left vertebral artery was not detected in time-of-flight magnetic resonance angiography. The left vertebral artery showed completely reversed blood flow as detected by color duplex ultrasound. We also confirmed anterograde flow in the left vertebral artery by color duplex ultrasound with arteriovenous fistula compression. Arteriovenous flows before the arteriovenous fistula stenosis and post-percutaneous transluminal angioplasty were 1146 and 2239 mL/min, respectively. These findings suggested high-flow arteriovenous fistula led to the subclavian steal syndrome. The patient was subsequently treated by a flow reduction in the high-flow arteriovenous access using a modified graft inclusion technique. We decreased the arteriovenous fistula flow to 851 mL/min, which remained under 850 mL/min, 1 year later. The brain natriuretic peptide level and right-ventricular pressure also decreased after treatment. A modified graft inclusion technique was successful in decreasing the high flow of the arteriovenous fistula, and improved subclavian steal syndrome symptom and cardiac overload.
This case shows that percutaneous transluminal angioplasty for an arteriovenous fistula may induce subclavian steal syndrome, and a modified graft inclusion technique was useful in improving the high flow of an arteriovenous fistula.
我们描述了一名血液透析患者，其在经皮腔内血管成形术后通过动静脉瘘发生了锁骨下窃血综合征。
一名55岁女性因多囊肾病导致终末期肾衰竭，已接受血液透析治疗10年。由于自体动静脉瘘狭窄，进行了经皮腔内血管成形术。经皮腔内血管成形术成功治疗后，患者出现头晕。脑部和颈部的磁共振血管造影显示双侧锁骨下动脉和颈动脉正常。然而，在时间飞跃磁共振血管造影中未检测到左椎动脉血流。彩色双功超声检测显示左椎动脉血流完全逆转。通过压迫动静脉瘘的彩色双功超声，我们还确认了左椎动脉的顺行血流。动静脉瘘狭窄前和经皮腔内血管成形术后的动静脉血流量分别为1146和2239毫升/分钟。这些发现提示高流量动静脉瘘导致了锁骨下窃血综合征。该患者随后采用改良移植物包裹技术对高流量动静脉通路进行了流量减少治疗。我们将动静脉瘘血流量降至851毫升/分钟，一年后仍保持在850毫升/分钟以下。治疗后脑钠肽水平和右心室压力也有所下降。改良移植物包裹技术成功降低了动静脉瘘的高流量，并改善了锁骨下窃血综合征症状和心脏负荷。
本病例表明，动静脉瘘的经皮腔内血管成形术可能诱发锁骨下窃血综合征，改良移植物包裹技术有助于改善动静脉瘘的高流量。
