The patient presents to the ER with right arm and facial swelling. He has a right radiocephalic AVF. A good thrill was palpated in the AVF body, which measured approximately 12 cm. This was the area where he was cannulated for hemodyalisis.
A fistulogram was performed. The findings are illustrated above.
Fistulogram shows a complete occlusion of the cephalic vein with collateral veins that drain into the basilic vein and an 80-90% stenosis in the right innominate vein, which is the culprit lesion.
I was not able to pass the wire to the basilic vein. Because of this I did a second ultrasound-guided cannulation in the upper arm and gained access to it.
After this, I did an angioplasty using a 10 x 4 mm balloon then a 12 x 4 mm. Angiography post-dilation showed more than 30% restenosis. A 14 x 4 mm balloon was then used to dilate the vein further. Post dilation angiography showed less than 30% restenosis.
The interesting point in this case is that despite a complete occlusion of the AVF at the body there was adequate function (good kt/v,) and drainage into the basilic vein through collateral veins. The second canulation and dilation of the right inomminate vein was performed in order to decrease the swelling in the arm and face, to avoid further complications, and to continue use of this AVF. The patient has been using the AVF for 1 month following the angioplasty with no subsequent problem with the AVF and no swelling in the arm or face.
Points of interest:
1) After the central lesion was dilated, the patient has no more swelling in the arm and face and the AVF has been working properly with no complications.
2) There are physicians that could think that this AVF will not continue working adequately, but the physical exam and history of the patient suggested that the problem was not AVF, it was the central lesion, reason why I decided to do this.
3) Physical exam and medical history will help us decide what is in the best interests of the patient.