Subclavian vein thrombosis and/or stenosis has been reported as a frequent complication of vascular access in hemodialysis patients who have undergone venous catheterization for temporary blood access. It rarely occurs, however, in patients without predisposing catheter cannulation.
We observed cases of proximal subclavian vein stenosis and brachiocephalic vein stenosis on the same side as an existing arteriovenous (A-V) fistula in patients who had no venous catheterization.
The first case was a 19-year-old male who had a right A-V fistula between the brachial artery and the medial cephalic vein. Right upper arm and neck edema developed 7 years after establishment of the fistula. Venograms and magnetic resonance angiography (MRA) showed remarkable stenosis of the right subclavian vein at the site of the thoracic outlet. He was treated with percutaneous transluminal angioplasty (PTA), but the stenosis recurred 4 months later. After a second PTA therapy, combined with surgery to reduce the blood flow of the A-V fistula, his symptoms disappeared.
The second case was a 48-year-old male who had a left A-V fistula between the brachial artery and the medial cephalic vein. He experienced left upper arm and shoulder edema and pain during hemodialysis treatment. Venography and MRA revealed remarkable stenosis of the left brachiocephalic vein just distal to the inflowing axillary vein. He was treated with PTA, and surgery was performed to reduce the blood flow at the A-V fistula, but the A-V fistula occlusion relapsed 3 months later. His symptoms disappeared after reconstruction of the obstructive lesion was achieved. Histopathological findings of the resected vein revealed severe endothelial thickening and narrowing around the valve.
The following conclusions are documented and discussed. 1) There is the possibility that venous stenosis and/or thrombosis can occur in hemodialysis patients without predisposing catheter cannulation. 2) There are two major reasons for venous stenosis: the first is blood overflow from an A-V fistula, the second is anatomical narrowing at the thoracic outlet (1st case) and around the venous valve (2nd case). 3) PTA and/or reconstruction against a stenotic vein should be done in combination with an operation to reduce A-V blood flow.