Meric Mert, Oztas Didem Melis, Cakir Mehmet Semih, Ulukan Mustafa Ozer, Sayin Omer Ali, Kilickesmez Ozgur, Erdinc Ibrahim, Rodoplu Orhan, Oteyaka Emre, Ugurlucan Murat
Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey.
Cardiovascular Surgery Clinic, Istanbul Training and Research Hospital, Istanbul, Turkey.
Vascular. 2023 Oct;31(5):1017-1025. doi: 10.1177/17085381221092502. Epub 2022 May 13.
In this case report, we present two chronic hemodialysis patients with upper extremity swelling due to central venous occlusions together with their clinical presentation, surgical management and brief review of the literature.
The first patient who was a 63-year-old female patient with a history of multiple bilateral arteriovenous fistulas (AVFs) was referred to our clinic. Physical examination demonstrated a functioning right brachio-cephalic AVF, with severe edema of the right arm, dilated venous collaterals, facial edema, and unilateral breast enlargement. In her history, multiple ipsilateral subclavian venous catheterizations were present for sustaining temporary hemodialysis access. The second patient was a 47-year-old male with a history of failed renal transplant, CABG surgery, multiple AV fistula procedures from both extremities, leg amputation caused by peripheral arterial disease, and decreased myocardial functions. He was receiving 3/7 hemodialysis and admitted to our clinic with right arm edema, accompanied by pain, stiffness, and skin hyperpigmentation symptoms ipsilateral to a functioning brachio-basilic AVF. He was not able to flex his arms, elbow, or wrist due to severe edema.
Venography revealed right subclavian vein stenosis with patent contralateral central veins in the first patient. She underwent percutaneous transluminal angioplasty (PTA) twice with subsequent re-occlusions. After failed attempts of PTA, the patient was scheduled for axillo-axillary venous bypass in order to preserve the AV access function. In second patient, venography revealed right subclavian vein occlusion caused secondary to the subclavian venous catheters. Previous attempts for percutaneously crossing the chronic subclavian lesion failed multiple times by different centers. Hence, the patient was scheduled for axillo-axillary venous bypass surgery.
In case of chronic venous occlusions, endovascular procedures may be ineffective. Since preserving the vascular access function is crucial in this particular patient population, venous bypass procedures should be kept in mind as an alternative for central venous reconstruction, before deciding on ligation and relocation of the AVF.
在本病例报告中，我们介绍了两名因中心静脉闭塞导致上肢肿胀的慢性血液透析患者，包括他们的临床表现、手术治疗方法以及文献简要回顾。
首例患者为一名63岁女性，有多次双侧动静脉内瘘（AVF）病史，被转诊至我院。体格检查显示右侧头臂动静脉内瘘功能良好，但右臂严重水肿、静脉侧支扩张、面部水肿以及单侧乳房增大。其病史中存在多次同侧锁骨下静脉置管以维持临时血液透析通路。第二例患者是一名47岁男性，有肾移植失败、冠状动脉旁路移植术（CABG）手术史、双上肢多次动静脉内瘘手术史、因外周动脉疾病导致的腿部截肢以及心肌功能下降。他正在接受3/7血液透析，因右臂水肿伴疼痛、僵硬以及同侧一个功能良好的肱桡动静脉内瘘出现皮肤色素沉着症状而入住我院。由于严重水肿，他无法弯曲手臂、肘部或手腕。
血管造影显示首例患者右侧锁骨下静脉狭窄，对侧中心静脉通畅。她接受了两次经皮腔内血管成形术（PTA），随后再次闭塞。PTA尝试失败后，该患者被安排进行腋-腋静脉旁路手术以保留动静脉通路功能。在第二例患者中，血管造影显示右侧锁骨下静脉闭塞是由锁骨下静脉置管引起的。此前不同中心多次尝试经皮穿过慢性锁骨下病变均失败。因此，该患者被安排进行腋-腋静脉旁路手术。
对于慢性静脉闭塞，血管内介入治疗可能无效。由于在这一特定患者群体中保留血管通路功能至关重要，因此在决定结扎和重新安置动静脉内瘘之前，应考虑将静脉旁路手术作为中心静脉重建的替代方法。
