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CASE REPORT
Year : 2022 | Volume
: 9
| Issue : 4 | Page : 309-312
Central vein stenosis in hemodialysis patients during COVID pandemic: A case series analysis
Manoj Prabhakaran, Himansu Sekhar Mahapatra, Navjot Kaur, Amandeep Singh, Sanket Patil, Abhisek Gautam, Anamika Kumari
Department of Nephrology, DR.RML Hospital, New Delhi, India
Correspondence Address:
Manoj Prabhakaran
Department of Nephrology, DR.RML Hospital, New Delhi
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijves.ijves_5_22
End-stage kidney disease (ESKD) patients who were on maintenance hemodialysis require a stable, permanent vascular access as a lifeline. Venous mapping during prearteriovenous fistula (AVF) construction does not include central vein assessment. The guidelines on angiographic assessment of central veins during pre-AVF construction are yet to be streamlined. Moreover, during COVID pandemic, assess difficulty in catheterization laboratory and interventional radiology created devastating situation. We report 15 ESKD cases of central venous stenosis presented during the COVID pandemic time from February 2020 to July 2021. Patients' basic details were collected and initial clinical examination findings were recorded; they were subjected to Doppler and fistulogram. After the combined decision of nephrologist, interventional cardiologist, and vascular surgeon, the management (fistula closure/repair) was planned. Of 15 patients, 13 were males. Basic disease is chronic glomerulonephritis in 9, diabetic nephropathy in 4, and chronic interstitial nephritis in 2. Average number of central vein cannulation prior to AVF creation was 2.6. The median time to the development of symptoms after fistula creation was 13 months. Major initial symptoms were swelling of the upper limb in 4, dilatation of outflow veins in 5, swelling and dilatation in 2, poor flow during dialysis in 3, and dilatation of neck and chest vein in 1. Arm elevation test was positive in most of the cases. On Doppler assessment, dilated veins (>12 mm) with high outflow (>2000 ml/min) in 5, 4 patients showed low flow (<400 ml/min), and six patients showed normal findings. In fistulogram, the common location of stenosis/thrombosis was brachiocephalic vein (BV) in 5 and subclavian vein (SC) in 3, BV vein + SC vein in 4, and superior vena cava in 3. Out of 15, 3 underwent balloon dilatation, 7 underwent fistula closure, 1 no intervention done, 3 lost to follow-up, and 1 expired. This is the first case series of central vein stenosis (CVS) brought in light during COVID pandemic. CVS is a serious issue, which might result in permanent vascular access failure. Further study is needed on impact of previous central vein catheterization leading to stenosis and role of pre-AVF creation angiographic assessment to avoid this type of devastating AVF complication.
Keywords: Arteriovenous fistula complication, central vein stenosis, hemodialysis vascular access
Chronic kidney disease patients who were on maintenance hemodialysis maintaining a stable permanent vascular access remains a lifeline. Even though the expert opinion of Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines suggests for case-based assessment of central veins,[1] in the usual clinical practice prearteriovenous fistula (AVF) construction vessel mapping does not include central vein assessment unless patient have clinical sign/symptoms of central vein obstruction, rather its difficult on Doppler to assess for central veins. Central venous stenosis is a well-described sequel to the placement of hemodialysis catheters. The presence of an ipsilateral arteriovenous fistula or graft often leads to severe venous dilatation, arm edema, and recurrent infections secondary to increased blood flow along with upstream central vein stenosis. Vascular access thrombosis, compromised blood flow, and inadequate dialysis delivery is dreaded complications that eventually render the access unusable for dialysis. We describe a case series analysis of 15 cases of central vein obstruction presented to our nephrology department during the COVID pandemic time, where the assess to the interventional laboratories was limited.
Case ReportThe case series analysis study was done in the Department of Nephrology, DR. RML hospital, New Delhi, after permission from the institutional review board. Written informed consent was obtained from the patients to publish images of the fistula. All cases of suspected central vein obstruction presented to the department between February 2020 and July 2021 were included for analysis. Basic summary of the 15 patients is mentioned in [Table 1] and their presenting clinical images are shown in [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h, [Figure 1]i, [Figure 1]j, [Figure 1]k, [Figure 1]l, [Figure 1]m, [Figure 1]n, [Figure 1]o Out of 15, 13 were male and 2 were female patients; average age of the patients in the case series was 42.2 (±10.35). Basic disease is chronic glomerulonephritis in 9, diabetic nephropathy in 4, and chronic interstitial nephritis in 2. Average number of central venous dialysis catheter cannulation prior to AVF creation was 2.6, and median time to the development of symptoms after fistula creation was 13 months (±4.4 months). Major initial symptoms were swelling of the upper limb in 4, dilatation of outflow veins in 5, swelling and dilatation in 2, poor flow during dialysis in 3, and dilatation of neck and chest vein in 1, and one patient (h) present during the posttransplant period. The patients underwent structured physical examination of AVF as per the look, listen, and feel approach, the important physical examination finding among them were arm elevation test positive (12) and harsh thrill and bruit (4). Doppler assessment done showed dilated veins (>12 mm) high outflow (>2000 ml/min) in three patients, six patients doppler could not be done, three patients showed low flow (<400 ml/min), and two patients showed normal findings. Subsequently, patients underwent fistulogram/computed tomography angiography. The common location of stenosis/thrombosis was brachiocephalic vein in 5 and subclavian vein (SC) in 3, BV vein + SC vein in 4, and superior vena cava in 3. Further management options were planned in discussion with cardiothoracic vascular surgery and interventional cardiologist's opinion. Out of 15, 2 underwent balloon dilatation, even though the initial improvement was there but subsequently over the next 6 months, the patient again developed central venous obstruction (CVO), their fistula closure was planned because of recurrent central vein obstruction and congestive symtoms. Two patients who were planned for balloon dilatation because of the prevailed COVID pandemic situation, the procedure was unduly delayed and eventually they were taken for fistula closure, six patients underwent fistula closure with gradual improvement in the symptoms, 4 no intervention done because of the anatomic complexity and absence of any progressive symptoms, 3 lost to follow up, 1 expired. Even though four patients out of 15, recovered from COVID at the time of assessment, the exact etiology whether COVID infection prior to this symptoms' development has any causal role is not clear.
Figure 1: (a-o) Clinical images of patient with central venous obstruction Discussion Central venous system consists of those veins located inferior to the thoracic outlet (C7 to T1-intervertebral disc level), proximal to the lateral margin of the first rib margin, and superior to the diaphragmatic hiatus. Central vein stenosis (CVS) in a dialysis patient is mostly secondary to trauma caused by temporary or permanent hemodialysis catheter placement. CVO more common with subclavian vein catheterisation than internal jugular vein catheterisation. This might result in swelling of the arm, which may preclude cannulation of the arm veins during hemodialysis and may cause increased rates of recirculation during dialysis. It may also cause difficulties for future placement of temporary or permanent central venous catheters.[2] As of now, the mechanism that induces stenosis/occlusion of the central veins without a catheter placement remains unclear in hemodialysis patients. Proposed mechanisms are high and prolonged arterial flow through the central veins causing fibrosis and thickening of the venous valves.[3],[4] High flow volume through the vascular access is the main determinant in the development of central venous stenosis in patients without a previous history of central catheter placement. Long duration of the AVF might also a factor in the development of CVO in these patients but its role is not clear yet.[2] Moreover, rarely CVO might present as megafistula in hemodialysis patients, and it can be defined as generalized aneurysmal dilatation of arteriovenous fistula.[5] Other suggested criteria for the definition of megafistula are blood flow in AVF >2.2 L/min, hypertrophied feeding artery, high output heart failure with cardiac output >4–8 L/min, and cardiac index >3 (ratio of cardiac output to body surface area).[6] In our case series, three patients had features of megafistula with high flow rate fistula flow criteria [Figure 1]a, [Figure 1]d and [Figure 1]g. COVID– Patients with kidney failure on dialysis may have a higher risk of worse outcomes because of COVID. There was a multicenter case‒control study in 2019 with 82 patients shown that COVID-19 indeed predisposes to catheter-related thrombosis in critically ill patients. A possible explanation for the hypercoagulable state is an overproduction of early response proinflammatory cytokines, causing activation of coagulation pathways.[7] Currently, there is a paucity of data and guidelines to address the problem of dialysis catheters clotting in COVID-19 patients.
ConclusionCentral vein obstruction in a dialysis patient is a serious issue, and it has a greater impact compared with obstruction of a peripheral vein. To our knowledge, this is the first case series published on this topic and to bring light on this CVC and CVS. This case series from India will again emphasize the importance of KDOQI expert opinion of angiographic assessment of central veins. Thus before AVF creation in these kinds of clinical situations with multiple prior central vein cannulations in patients even without signs/symptoms of CVO also require angiographic assessment of central veins, which is currently not in major practice.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
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Conflicts of interest
There are no conflicts of interest.
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