Central Vein Obstruction in Vascular Access

Massive left arm edema in a 79 year old woman on HD for diabetic nephropathy due to filiform subclavian vein stenosis six months after creation of a brachiocephalic fistula. Note the subcutaneous venous collaterals around the left shoulder.

a. Approximately 50% narrowing of left innominate vein following subclavian vein catheterization for HD access in a 68 year old woman undergoing HD for diabetic nephropathy. Note the pacemaker wire inserted through right internal jugular vein two years earlier, which is not causing innominate or vena caval obstruction. b. Three months after creation of a radio-cephalic AV fistula on her left arm, massive arm edema developed. There is now subtotal occlusion of the left innominate vein. c. Successful PTA and stent placement (Wallstent™, 10x60mm) resulted in immediate relief of symptoms.

a. Massive left arm and breast swelling two years after creation of a left brachio-cephalic AV fistula for HD in a 59 year old woman with chronic glomerulonephritis. Note the extensive thoracic wall collaterals indicating bilateral CVO. b and c. Bilateral arm phlebography demonstrating complete occlusion of both innominate veins. The central superior vena cava is patent. The patient had had multiple central vein catheters for HD access and during intensive care treatment five years ago for peritonitis following perforated diverticulitis. d. Graft interposition between central cephalic and superior cava (ePTFE 12mm with external ring support) through a median sternotomy.