Abstract
From January 1991 to December 1992, we studied 23 hemodialysis patients who suffered venous hypertension with marked edema of the upper limbs after the creation of arteriovenous fistulas (AVFs). Six patients had previous temporary catheterizations through the ipsilateral subclavian and/or internal jugular veins for 24.5±9.0 (mean±SD) days. One patient had a transvenous permanent pacemaker lead through the affected subclavian vein: One had been treated with radical mastectomy and radiation therapy for breast cancer 20 years previously. However, the remaining 15 patients (65.2%) had no previous trauma to their central veins including subclavian and axillary veins. Angiographic studies in 14 patients, 3 with previous trauma and 11 with no previous trauma, revealed 8 obstructions and 5 stenoses of central veins. One patient had no angiographic abnormalities. Surgical repair was performed in 22 patients. One patient received revision of the AVF, one received percutaneous transluminal angioplasty of a stenotic subclavian vein lesion in addition to revision of the AVF, and 4 patients had fistula revision and banding using a polytetrafluoroethylene sheet at the anastomosis site. However, the other 16 patients required closure of AVFs for improvement of their edema.
Many cases with venous hypertension showed occlusion or stenosis of central veins without a history of central vein trauma. This study suggests that repetitive intimal trauma caused by the powerful post-fistula jet may contribute to the formation of chronic fibrosis and intimal hyperplasia of the central veins. Furthermore, the naturally occuring stenosis at the merging of the central veins may accentuate this process.
