|Year : 2021 | Volume
| Issue : 5 | Page : 77-79
Iliac vein stenosis and venous hypertension after polytetrafluoroethylene arteriovenous loop graft in the thigh for hemodialysis access
Natarajan Sekar1, Kamala Sekar Kanagasabai2
1 Department of Vascular and Endovascular Surgery, Kauvery Hospital, Chennai, Tamil Nadu, India
2 Department of Radiology, Kauvery Hospital, Chennai, Tamil Nadu, India
|Date of Submission||27-Sep-2020|
|Date of Acceptance||15-Oct-2020|
|Date of Web Publication||30-Aug-2021|
Department of Vascular and Endovascular Surgery, Kauvery Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Central venous stenosis occurs commonly as a complication of central venous catheterization. It is most often seen after arteriovenous (AV) graft or proximal AV fistula in the ipsilateral upper limb. Iliac vein stenosis after thigh AV graft has not been reported in the literature. Successful endovascular management of an iliac vein stenosis after AV loop graft in the thigh is presented here.
Keywords: Arteriovenous graft, central venous stenosis, hemodialysis, lower extremity
|How to cite this article:|
Sekar N, Kanagasabai KS. Iliac vein stenosis and venous hypertension after polytetrafluoroethylene arteriovenous loop graft in the thigh for hemodialysis access. Indian J Vasc Endovasc Surg 2021;8, Suppl S1:77-9
|How to cite this URL:|
Sekar N, Kanagasabai KS. Iliac vein stenosis and venous hypertension after polytetrafluoroethylene arteriovenous loop graft in the thigh for hemodialysis access. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jan 26];8, Suppl S1:77-9. Available from: https://www.indjvascsurg.org/text.asp?2021/8/5/77/324931
| Introduction|| |
Uncuffed short catheter insertion in central veins for hemodialysis is known to produce stenosis. It is more common when the catheter is retained for long. Femoral vein cannulations are more prone to thrombosis and iliac vein stenosis after dialysis catheter insertion has not been reported in the literature. We report here a case of iliac vein stenosis in a hemodialysis patient which developed 2 years after thigh arterio venous (AV) graft was created.
| Case Report|| |
A 78-year-old female on regular hemodialysis presented with sudden-onset painless swelling of the right lower limb. Two and a half years ago, she underwent right femoral vein uncuffed short catheter insertion for emergency dialysis. She had no infection or limb swelling and the catheter was removed after 2 weeks. Six months later, she underwent a polytetrafluoroethylene AV loop graft implantation in the right upper thigh from the proximal superficial femoral artery to the great saphenous vein. A duplex scan done prior to surgery had shown normal veins. She has been undergoing regular problem-free dialysis for the past 2 years and there was no increase in the venous pressure.
Duplex scan now revealed patent dilated common femoral vein and reversal of flow in the superficial femoral vein. Computed tomography venogram showed patent graft, mild stenosis at the venous end of the graft, and a tight stenosis in the external iliac vein with extensive venous collaterals [Figure 1] and [Figure 2].
|Figure 1: Computed tomography venogram showing patent arteriovenous graft in the thigh. There is tight stenosis of the external iliac vein with extensive venous collaterals|
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|Figure 2: Computed tomography venogram showing narrowing of the venous end of the graft (thin arrow) and tight stenosis of the external iliac vein (thick arrow)|
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She underwent endovascular intervention and a 14 mm × 40 mm self-expanding stent (eV3 Protégé GPS) was deployed and postdilated with a 14 mm high-pressure balloon [Figure 3] and [Figure 4]. Post procedure, she was given warfarin for 3 months. Her leg edema completely regressed immediately. A duplex scan done after 6 months showed a patent stent.
|Figure 4: Venogram after deployment of the stent showing good dilatation of the vein|
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| Discussion|| |
Commonly central venous stenosis (CVS) occurs as a complication of central venous catheterization. The incidence of central vein stenosis can be as high as 25%–40%. Several studies have shown that 95% of patients with central vein stenosis have a history of an indwelling catheter. Thrombus and endothelial damage usually starts at the tip of the catheter. When the catheter stays in for a longer duration, the entire length undergoes thrombosis. It has been shown in animal models that structural changes in the vein wall like endothelial denudation and platelet microthrombi occur within 24 hours of venous catheterization. Smooth muscle proliferation and intimal hyperplasia develop by 7 days.
Wang et al. found the incidence of infection and venous thrombosis in the femoral vein to be much higher than that in the internal jugular vein and subclavian vein. The incidence of CVS in the left-sided and right-sided internal jugular vein was not significantly different, but iliac or inferior vena cava stenosis was not seen with femoral vein catheterization in any of their patients.
CVS is also known to occur without any previous venous cannulation in 10% of patients with CVS. CVS in the absence of central venous catheter placement has been associated with proximal vascular access with very high flow rates in the ipsilateral upper limb. Venous wall hyperplasia and stenosis may occur secondary to changes in shear stress and turbulence resulting from the high blood flow., In this patient, it is likely that the dialysis catheter produced minimal intimal injury which got aggravated later by the high flow in the graft.
CVS has been managed with plain balloon angioplasty as well as stents. Despite the initial success, the long-term patency is poor with both the methods. Multiple dilatations may be needed to maintain patency. If the symptoms of CVS are mild, it is better to treat them conservatively since more aggressive neointimal hyperplasia and proliferative lesions were found in restenotic areas after angioplasty than in the original stenotic lesions. When further dilatation is not possible, the AV graft or fistula has to be ligated to reduce the edema.
All of these studies have been done on upper limb dialysis access and CVS in the subclavian and innominate veins. The literature search did not reveal any report of iliac vein stenosis after femoral AV graft. It is difficult to predict whether this iliac vein lesion also will behave in the same way. This patient has been now followed up for 6 months and Doppler study did not show recurrence.
The patient agreed to the publication of her clinical details and images.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]