Case Study
Bilateral central vein stenosis in a dialysis patient with a pacemaker
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(8) 979–980 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313491583 aan.sagepub.com
Kuan Leong Yew1, Steven Anderson1, Razali Farah2 and Siong Hee Lim1
Abstract Central vein stenosis is not uncommon in hemodialysis-dependent patients as a result of mechanical damage to the vessel walls from prior cannulation. It can cause ipsilateral upper limb swelling and pain, resulting in suboptimal hemodialysis. It is unfortunate for bilateral central vein stenosis to develop concomitantly, and rare in the setting of an in-situ pacemaker. This case illustrates the successful ligation of a nondependent left arteriovenous fistula and stenting of the right subclavian vein with functioning ipsilateral arteriovenous fistula, to overcome the problem of symptomatic bilateral upper limb swelling.
Keywords Bilateral central vein stenosis, dual chamber pacemaker, bilateral upper limbs swelling, subclavian vein stenting, arteriovenous fistula ligation, renal dialysis, arteriovenous shunt, catheters, indwelling, pathologic
Introduction End-stage kidney disease patients may require vascular access for hemodialysis while awaiting maturation of an arteriovenous fistula. Temporary catheter insertion in the internal jugular vein or subclavian vein is a risk factor for the development of central vein stenosis (CVS). CVS can also develop in patients with a pacemaker, but they are mostly asymptomatic. When bilateral CVS happens in a hemodialysis-dependent patient with a vascular access problem and a pacemaker, this can be a management quagmire.
Case report A 67-year-old diabetic man first presented with a fainting episode to a peripheral hospital where he was discovered to have impaired renal function and hyperkaliemia associated with symptomatic junctional bradycardia. He was transferred to a tertiary center with a cardiac facility for consideration of cardiac pacing after stabilization of hyperkaliemia. A right internal jugular vein catheter (IJC) was inserted for hemodialysis. A dual chamber pacemaker (Adapta; Medtronic, Inc., Minneapolis, MN, USA) was implanted in the left side with CapSureFix Novus (Medtronic, Inc., Minneapolis, MN, USA) 1F leads inserted through the left cephalic vein. One month
after implantation, he had left radiocephalic arteriovenous fistula (RCAVF) construction, and noticed swelling of the left upper limb one week later. After 3 months, the left RCAVF had matured and was used for hemodialysis. However, the swelling increased with every dialysis session. A left venogram showed left axillary vein occlusion with collateral formation. Hence hemodialysis through the left RCAVF was stopped. The surgeon created a right RCAVF and inserted a right IJC for temporary dialysis access. The radial artery had moderate atherosclerotic changes. Subsequently, the right upper limb began to swell more severely. A repeat central venogram revealed occlusion of both subclavian veins. This was compounded by low blood flow through the right RCAVF during hemodialysis. Thus the surgeon ligated the left RCAVF and created a new right brachiocephalic fistula with temporary dialysis through the left IJC. The patient was referred back 1 Heart Center, Sarawak General Hospital, Kota Samarahan, Sarawak, Malaysia 2 Anesthesiology Department, Sarawak General Hospital, Kuching, Sarawak, Malaysia
Corresponding author: Kuan Leong Yew, Heart Center, Sarawak General Hospital, 94300 Kota Samarahan, Sarawak, Malaysia. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 6, 2015
980
Asian Cardiovascular & Thoracic Annals 22(8)
to the initial center for percutaneous intervention of the CVS. The occluded right subclavian vein was successfully stented with a Prote´ge´ 10 80-mm stent (EV3 Endovascular, Inc., Plymouth, MN, USA). The swelling in both arms gradually subsided.
Discussion From the Malaysian National Health Morbidity Survey 2006, the prevalence of diabetes mellitus has jumped from 6.3% to 11.6%, indirectly driving the rising prevalence of chronic kidney disease and the needs for hemodialysis treatment.1 Most patients do not have an existing arteriovenous fistula for their first hemodialysis session. During acute presentation, immediate catheter insertion for hemodialysis is often needed. IJC placement is preferred for its practicality and lower infection risk, predisposing them to CVS.2 Central vein cannulation can cause intimal injury, smooth muscle cell proliferation, and wall thickening. It is unsurprising that the incidence of venous lesions after pacemaker implantation can be as high as 45%, although mostly asymptomatic.3 In this patient, as the leads were introduced into the cephalic vein, the risk of CVS should be lower than in the subclavian approach. Perhaps by having two 6.1F or 2.0-mm silicone-coated leads in the subclavian vein contributed to the development of CVS. The indwelling pacemaker wires were in constant motion, causing mechanical irritation and injury along the venous vasculature. Unfortunately, the initial RCAVF was created ipsilateral to the pacemaker. The arteriovenous fistula increased the shunt volume on the left upper limb, leading to venous hypertension and unmasking the erstwhile silent left CVS. The patient actually started to have right upper limb swelling when the left RCAVF was used for regular hemodialysis, raising the possibility of concomitant right CVS. The creation of a right RCAVF also unmasked the right CVS. By this time, he had bilateral painful swollen upper limbs. The initial right IJC insertion and pacemaker implantation could probably have damaged both central veins and caused CVS. Retrospectively, the left RCAVF should not have been created on the same side as the pacemaker, because higher venous flow also increases the risk of CVS.4
Asymptomatic CVS warrants observation only. However, this patient had symptomatic bilateral upper limb swelling, and intervention either surgically or percutaneously was needed. In view of the potentially complex surgery, the 2006 K/DOQ1 guidelines recommend transluminal angioplasty.4 Stenting is required if there is acute elastic recoil after balloon plasty or recurrent stenosis in 3 month’s time. The right subclavian vein was stented because balloon plasty was unsatisfactory. It was prudent not to intervene on the left central vein as angioplasty may damage the pacemaker wires, and ligation of the left RCAVF was sufficient. Fortuitously, the left upper limb swelling subsided despite no intervention on the left CVS. We ought to reduce vascular interventions and hardware implantations to the minimum as this group of patients who are susceptible to CVS and pacemaker infection.5 Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared
References 1. Letchuman GR, Wan Nazaimoon WM, Wan Mohamad WB, et al. Prevalence of diabetes in the Malaysian National Health Morbidity Survey III 2006. Med J Malaysia 2012; 67: 31–38. 2. MacRae JM, Ahmed A, Johnson N, Levin A and Kiaii M. Central vein stenosis: a common problem in patients on hemodialysis. ASAIO J 2005; 5: 77–81. 3. Da Costa SS, Scalabrini Neto A, Costa R, Caldas JG and Martinelli Filho M. Incidence and risk factors of upper extremity deep vein lesions after permanent transvenous pacemaker implant: a 6-month follow-up prospective study. Pacing Clin Electrophysiol 2002; 25: 1301–1306. 4. Tourret J, Cluzel P, Tostivint I, Barrou B, Deray G and Bagnis CI. Central venous stenosis as a complication of ipsilateral haemodialysis fistula and pacemaker. Nephrol Dial Transplant 2005; 20: 997–1001. 5. Vascular Access Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006; 48(Suppl 1): S248–S273.
Downloaded from aan.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 6, 2015
Bilateral central vein stenosis in a dialysis patient with a pacemaker
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(8) 979–980 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313491583 aan.sagepub.com
Kuan Leong Yew1, Steven Anderson1, Razali Farah2 and Siong Hee Lim1
Abstract Central vein stenosis is not uncommon in hemodialysis-dependent patients as a result of mechanical damage to the vessel walls from prior cannulation. It can cause ipsilateral upper limb swelling and pain, resulting in suboptimal hemodialysis. It is unfortunate for bilateral central vein stenosis to develop concomitantly, and rare in the setting of an in-situ pacemaker. This case illustrates the successful ligation of a nondependent left arteriovenous fistula and stenting of the right subclavian vein with functioning ipsilateral arteriovenous fistula, to overcome the problem of symptomatic bilateral upper limb swelling.
Keywords Bilateral central vein stenosis, dual chamber pacemaker, bilateral upper limbs swelling, subclavian vein stenting, arteriovenous fistula ligation, renal dialysis, arteriovenous shunt, catheters, indwelling, pathologic
Introduction End-stage kidney disease patients may require vascular access for hemodialysis while awaiting maturation of an arteriovenous fistula. Temporary catheter insertion in the internal jugular vein or subclavian vein is a risk factor for the development of central vein stenosis (CVS). CVS can also develop in patients with a pacemaker, but they are mostly asymptomatic. When bilateral CVS happens in a hemodialysis-dependent patient with a vascular access problem and a pacemaker, this can be a management quagmire.
Case report A 67-year-old diabetic man first presented with a fainting episode to a peripheral hospital where he was discovered to have impaired renal function and hyperkaliemia associated with symptomatic junctional bradycardia. He was transferred to a tertiary center with a cardiac facility for consideration of cardiac pacing after stabilization of hyperkaliemia. A right internal jugular vein catheter (IJC) was inserted for hemodialysis. A dual chamber pacemaker (Adapta; Medtronic, Inc., Minneapolis, MN, USA) was implanted in the left side with CapSureFix Novus (Medtronic, Inc., Minneapolis, MN, USA) 1F leads inserted through the left cephalic vein. One month
after implantation, he had left radiocephalic arteriovenous fistula (RCAVF) construction, and noticed swelling of the left upper limb one week later. After 3 months, the left RCAVF had matured and was used for hemodialysis. However, the swelling increased with every dialysis session. A left venogram showed left axillary vein occlusion with collateral formation. Hence hemodialysis through the left RCAVF was stopped. The surgeon created a right RCAVF and inserted a right IJC for temporary dialysis access. The radial artery had moderate atherosclerotic changes. Subsequently, the right upper limb began to swell more severely. A repeat central venogram revealed occlusion of both subclavian veins. This was compounded by low blood flow through the right RCAVF during hemodialysis. Thus the surgeon ligated the left RCAVF and created a new right brachiocephalic fistula with temporary dialysis through the left IJC. The patient was referred back 1 Heart Center, Sarawak General Hospital, Kota Samarahan, Sarawak, Malaysia 2 Anesthesiology Department, Sarawak General Hospital, Kuching, Sarawak, Malaysia
Corresponding author: Kuan Leong Yew, Heart Center, Sarawak General Hospital, 94300 Kota Samarahan, Sarawak, Malaysia. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 6, 2015
980
Asian Cardiovascular & Thoracic Annals 22(8)
to the initial center for percutaneous intervention of the CVS. The occluded right subclavian vein was successfully stented with a Prote´ge´ 10 80-mm stent (EV3 Endovascular, Inc., Plymouth, MN, USA). The swelling in both arms gradually subsided.
Discussion From the Malaysian National Health Morbidity Survey 2006, the prevalence of diabetes mellitus has jumped from 6.3% to 11.6%, indirectly driving the rising prevalence of chronic kidney disease and the needs for hemodialysis treatment.1 Most patients do not have an existing arteriovenous fistula for their first hemodialysis session. During acute presentation, immediate catheter insertion for hemodialysis is often needed. IJC placement is preferred for its practicality and lower infection risk, predisposing them to CVS.2 Central vein cannulation can cause intimal injury, smooth muscle cell proliferation, and wall thickening. It is unsurprising that the incidence of venous lesions after pacemaker implantation can be as high as 45%, although mostly asymptomatic.3 In this patient, as the leads were introduced into the cephalic vein, the risk of CVS should be lower than in the subclavian approach. Perhaps by having two 6.1F or 2.0-mm silicone-coated leads in the subclavian vein contributed to the development of CVS. The indwelling pacemaker wires were in constant motion, causing mechanical irritation and injury along the venous vasculature. Unfortunately, the initial RCAVF was created ipsilateral to the pacemaker. The arteriovenous fistula increased the shunt volume on the left upper limb, leading to venous hypertension and unmasking the erstwhile silent left CVS. The patient actually started to have right upper limb swelling when the left RCAVF was used for regular hemodialysis, raising the possibility of concomitant right CVS. The creation of a right RCAVF also unmasked the right CVS. By this time, he had bilateral painful swollen upper limbs. The initial right IJC insertion and pacemaker implantation could probably have damaged both central veins and caused CVS. Retrospectively, the left RCAVF should not have been created on the same side as the pacemaker, because higher venous flow also increases the risk of CVS.4
Asymptomatic CVS warrants observation only. However, this patient had symptomatic bilateral upper limb swelling, and intervention either surgically or percutaneously was needed. In view of the potentially complex surgery, the 2006 K/DOQ1 guidelines recommend transluminal angioplasty.4 Stenting is required if there is acute elastic recoil after balloon plasty or recurrent stenosis in 3 month’s time. The right subclavian vein was stented because balloon plasty was unsatisfactory. It was prudent not to intervene on the left central vein as angioplasty may damage the pacemaker wires, and ligation of the left RCAVF was sufficient. Fortuitously, the left upper limb swelling subsided despite no intervention on the left CVS. We ought to reduce vascular interventions and hardware implantations to the minimum as this group of patients who are susceptible to CVS and pacemaker infection.5 Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared
References 1. Letchuman GR, Wan Nazaimoon WM, Wan Mohamad WB, et al. Prevalence of diabetes in the Malaysian National Health Morbidity Survey III 2006. Med J Malaysia 2012; 67: 31–38. 2. MacRae JM, Ahmed A, Johnson N, Levin A and Kiaii M. Central vein stenosis: a common problem in patients on hemodialysis. ASAIO J 2005; 5: 77–81. 3. Da Costa SS, Scalabrini Neto A, Costa R, Caldas JG and Martinelli Filho M. Incidence and risk factors of upper extremity deep vein lesions after permanent transvenous pacemaker implant: a 6-month follow-up prospective study. Pacing Clin Electrophysiol 2002; 25: 1301–1306. 4. Tourret J, Cluzel P, Tostivint I, Barrou B, Deray G and Bagnis CI. Central venous stenosis as a complication of ipsilateral haemodialysis fistula and pacemaker. Nephrol Dial Transplant 2005; 20: 997–1001. 5. Vascular Access Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006; 48(Suppl 1): S248–S273.
Downloaded from aan.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 6, 2015
