DIGITAL SUBTRACTION VENOGRAPHY

FOR DIGNOSTIC VENOUS

HYPERTENSION AFTER A-V SHUNT

(Case Serial)

Author :

Kurniadi Wirandhani

Consultant:

dr. Darmawan Ismail Sp. BTKV

Surgery Department

Sebelas Maret University / RSUD Dr. Moewardi Surakarta

2018
DIGITAL SUBTRACTION VENOGRAPHY FOR DIGNOSTIC VENOUS
HYPERTENSION AFTER A-V SHUNT
Case Serial

Kurniadi W 1, Darmawan I 2
1
Medical Faculty of Sebelas Maret University, Surakarta, Indonesia
2
Division of Thoracic Surgery, Department of Surgery, Moewardi General Hospital, Surakarta,
Indonesia

Abstract :
Introduction :
Patients with end-stage renal disease are usually dependent on haemodialysis. A native
arteriovenous fistula, synthetic arteriovenous graft fistula, or silastic cuffed central venous catheter
may be used for vascular access in these patients. Upper limb venous hypertension due to these
interventions may occur. This is often the result of subclavian stenosis or occlusion which may
occur in haemodialysis patients with a history of previous subclavian canulation for vascular
access and an ipsilateral arteriovenous fistula.In this study, we present the patient who developed
symptoms of left subclavian vein stenosis (including venous hypertension, arm swelling, pain and
oedema) caused by a permanent catheter and creation of the arteriovenous fistula.
Report : we have three patients were admitted to hospital with swelling from the hand up to the
shoulder, and pain in the upper limb. they had chronic renal failure and haemodialysis had been
commenced. A permanent dialysis catheter was inserted in the subclavian vein previously, and an
arteriovenous fistula were constructed between cephalic vein and brachial artery. Venous pressure
during dialysis treatment was increased.
Conclusion: Have reported three patients with complaints of swelling from the hand up to the
shoulder, and pain in the upper limb with diagnosis venous hypertension. It had been confirmed
by Digital Subtraction venography.
Keyword : venous hypertension, arteriovenous fistula, digital substraction venography
 Introduction
Patients with end-stage renal disease are
usually dependent on haemodialysis. A
native arteriovenous fistula, synthetic
arteriovenous graft fistula, or silastic cuffed
central venous catheter may be used for
vascular access in these patients.1,2 Upper
limb venous hypertension due to these
interventions may occur. This is often the
result of subclavian stenosis or occlusion
which may occur in haemodialysis patients
with a history of previous subclavian
canulation for vascular access and an
ipsilateral arteriovenous fistula.1 In this
study, we present the patient who developed
symptoms of subclavian vein stenosis
(including venous hypertension, arm
swelling, pain and oedema) caused by a
permanent catheter and creation of the
arteriovenous fistula.
Peripheral venous hypertension is now less
frequent than in the 1970s and 1980s, when it
occurred as a complication connected with the
radiocephalic sideto-side fi stula and was caused
by a technical mistake in the construction of
anastomosis, resulting in stenosis or thrombosis
of the central discharge branch of the fi stula and
infl ow of blood into the peripheral venous
branch of the fi stula. This complication was
more frequent as a delayed complication,
characterised by the development of a typical
stenosis of the central vein app. 2–3 cm after the
anastomosis due to haemodynamic factors. This
results in a reversed blood fl ow, alteration of
venous valves and fi lling of the veins of the
periphery of the upper extremity
Case 1
A 44-year-old male patient was admitted to
hospital with swelling from the hand up to the
shoulder, and pain in the left upper limb. He had
had chronic renal failure for 9 months and
haemodialysis had been commenced. A
permanent dialysis catheter was inserted in the
right subclavian vein 1 month previously, and an
arteriovenous fistula was constructed between
left cephalic vein and brachial artery. The patient
suffered swelling and pain in the left upper limb
in early postoperative period. There was
increased venous collateral circulation, brown
pigmentation and fibrous thickening in the skin
of right upper extremity. Increased skin
temperature, a palpable thrill, pigmentation and
oedema in arm were detected on clinical
examination (FOTO).
Case 2
A 44-year-old male patient was admitted to our
clinic with swelling from the hand up to the
shoulder, and pain in the right upper limb. He
had had chronic renal failure for 9 months and
haemodialysis had been commenced. A
permanent dialysis catheter was inserted in the
right subclavian vein 1 month previously, and an
arteriovenous fistula was constructed between
right cephalic vein and brachial artery. The
patient suffered swelling and pain in the right
upper limb in early postoperative period. There
was increased venous collateral circulation,
brown pigmentation and fibrous thickening in
the skin of right upper extremity (Fig. 1).
Increased skin temperature, a palpable thrill,
pigmentation and oedema in arm were detected
on clinical examination. ( FOTO )
Case 3
A 44-year-old male patient was admitted to our
clinic with swelling from the hand up to the
shoulder, and pain in the right upper limb. He
had had chronic renal failure for 9 months and
haemodialysis had been commenced. A
permanent dialysis catheter was inserted in the
right subclavian vein 1 month previously, and an
arteriovenous fistula was constructed between
right cephalic vein and brachial artery. The
patient suffered swelling and pain in the right
upper limb in early postoperative period. There
was increased venous collateral circulation, Conclusion
brown pigmentation and fibrous thickening in
Have reported three patients with complaints
the skin of right upper extremity (Fig. 1).
Increased skin temperature, a palpable thrill, of swelling from the hand up to the shoulder,
pigmentation and oedema in arm were detected and pain in the upper limb with diagnosis
on clinical examination. ( FOTO ) venous hypertension. It had been confirmed
by Digital Subtraction venography.
Discussion
In conclusion, cuffed and tunnelled
Central venous catheters are useful alternatives haemodialysis catheters may cause stenosis
for permanent vascular access when a native or occlusion of the subclavian vein.
arteriovenous fistula or synthetic arteriovenous Symptoms may arise after creation of an
graft fistula are not possible.2 Significant ipsilateral arteriovenous fistula. If subclavian
stenosis or occlusion of the subclavian vein is vein stenosis or occlusion is demonstrated it
known to occur in 20– 50% of patients who have is not advisable to form an ipsilateral upper
central venous catheters inserted into the extremity arteriovenous fistula.
subclavian vein or the internal jugular vein.1,2
Digital subtraction venography is the most
valuable non-invasive diagnostic test to identify
an arteriovenous fistula. Development of
subclavian vein stenosis and occlusion is
probably best demonstrated by venography in
symptomatic patients. Digital subtraction
venography were sufficient for diagnosis in our
case. In our patient permanent dialysis catheter
was preferred because no fistula was available.
A previous subclavian venous catheter had
proved inadequate due to stenosis or
thrombosis of this central vein. Subclavian vein
thrombosis and stenosis is frequently
asymptomatic in these patients until an
arteriovenous fistula is constructed.
Subsequently symptoms of venous hypertension
(including arm swelling, pain and neurological
symptoms) may occur.3 Surgical solutions to this
problem include ligation of fistula, surgical
bypass of an occluded or stenotic subclavian vein
segment or percutaneous transluminal balloon
angioplasty and stent placement.4-6 However,
non-operative management is recommended in
patients who develop oedema immediately after
creation of the fistula, because spontaneous
regression is likely.2-7 In our patient, symptoms
regressed after ligation of fistula.
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Mattingly SS. Massive upper extremity edema
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