Nephrol Dial Transplant (2001) 16: 639-640
© 2001 European Renal Association-European Dialysis and Transplant Association
Letters
Bilateral venous thoracic outlet syndrome in a haemodialysis patient with long-standing body building activities
1 Nephrology and Dialysis Unit Hospitals of Martina Franca and 2 Acquaviva delle Fonti Italy
Sir,
Haemodialysis-associated subclavian-vein stenosis has emerged as a very serious vascular access complication [1,2]. It should be suspected when persistent gross upper extremity oedema occurs after a graft or arteriovenous fistula has been placed in the ipsilateral arm. A history of prior cannulation of the subclavian vein is common [3]. Alternatively, venous thoracic outlet syndrome (TOS) may also produce venous congestion, simulating subclavian stenosis [4], as shown in the present end-stage renal disease patient.
Case.
A 35-year-old man, trained for a long time with body-building activities, was affected by chronic uraemia due to IgA nephropathy. He underwent vascular surgery for the placement of an arteriovenous fistula for haemodialysis in the left arm. A massive left upper extremity oedema developed in the hours immediately following the intervention. There was no history of previous subclavian vein dialysis catheter placement. Doppler flowmetry was highly suspicious for bilateral venous TOS [5]. Proximal venography with the left arm in the dependent position revealed subclavian-vein obstruction near where it passed between the clavicle and the first rib. With the left arm passively hyperabducted, complete cessation of flow occurred, with bypass collateral flow seen through adjacent veins. A venous TOS was diagnosed. A venous stenting was attempted unsuccessfully.
Subsequently, the patient underwent a proximal venography of the right arm, which showed the same picture as in the left arm (Figure 1
); venous stenting was also unsuccessful in this arm. A computerized tomography scan of the neck and of the thorax excluded tumours or masses. Neither a cervical rib nor any elongated transverse process of C7 was found in cervical spine films. Arteriography and venography of the lower limbs were normal; no haematological disturbances were found except for a slight decrease of serum antithrombin III levels.
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Thus, the arteriovenous fistula was ligated and the patient began dialysis through a femoral-vein catheter while a continuous ambulatory peritoneal dialysis programme was begun. He is at present awaiting a cadaver kidney transplant.
Discussion
TOS refers to symptoms that are produced by obstruction of the neurovascular bundle serving the arm as it passes from the thoracocervical region to the axilla. The subclavian vessels and the lower trunk of the brachial plexus pass through three triangular channels that make up the thoracic outlet: the space between the scalene muscles as they attach to the first rib, the costoclavicular space bordered by the clavicle, first rib, and superior margin of the scapula, and the pectoralis minor space under the pectoralis minor muscle and the coracoid process. These channels are frequent sites for congenital lesions (e.g. cervical ribs, fibrous bands, anomalies of the first rib) and acquired lesions (e.g. trauma to the shoulder girdle, postural disturbances) that can lead to nerve or blood vessel obstruction.
The propositus was certainly affected by an acquired TOS, due to his body-building activities. Pure vascular obstruction can be either venous or arterial; both are rare [6]. While symptoms typically first appear in adults, the mechanism of compression may not be readily apparent [7]. When TOS produces symptoms of venous congestion in a haemodialysis patient, subclavian vein stenosis is simulated. In haemodialysis patients the syndrome may be silent until a fistula or graft is created in the ipsilateral arm; likewise, many haemodialysis patients with central-vein stenosis remain asymptomatic until creation of a graft or fistula [2]. Thus, TOS should be considered in the differential diagnosis of upper extremity swelling in the haemodialysis patient with a downstream fistula or graft, especially when no previous subclavian catheter placement has occurred.
Venography is the essential diagnostic test for venous TOS: during venography, as in this case, the hyperabduction manoeuvre provokes venous compression by the pectoralis muscle, and cessation of venous flow ensues. However, colour Doppler flowmetry, magnetic resonance angiography, and intravascular ultrasonography are undergoing evaluation [6]. Treatment of TOS should be either conservative for milder cases [6] or surgical for more severe cases [8].
To the best of our knowledge, ours is only the second case report describing the occurrence of venous TOS in a haemodialysis patient [4], the first one describing a bilateral venous TOS in such patients.
References
- Uldall PR. Subclavian cannulation is no longer necessary or justified in patients with end-stage renal failure. Semin Dial1994; 7: 161–164[Web of Science]
- Okadomek K, Komori K, Fukamitsu T, Sugimachi K. The potential risk for subclavian vein occlusion in patients on hemodialysis. Eur J Vasc Surg1992; 6: 602–606[Web of Science][Medline]
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Surrat RS, Picus D, Hicks ME. The importance of preoperative evaluation of the subclavian vein in dialysis access planning. Am J Radiol1991; 156: 623–625
[Abstract/Free Full Text] - Williams ME. Venous thoracic outlet syndrome simulating subclavian stenosis in a hemodialysis patient. Am J Nephrol1998; 18: 562–564[Web of Science][Medline]
- Napoli V, Vignali C, Braccini G et al. Echography and eco– Doppler in the study of thoracic outlet syndrome. Correlation with angiographic data. Radiol Med1993; 85: 733–740[Medline]
- Sheon RP. Thoracic outlet syndrome. UpToDate2000; 8: Wellesley, MA, USA
- Salo JA, Varstela E, Ketonen P. Management of vascular complications in thoracic outlet syndromes. Acta Chir Scand1988; 154: 349–352[Web of Science][Medline]
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Dale WA. Thoracic outlet compression syndrome. Critique in 1982. Arch Surg1982; 117: 1437–1445
[Abstract/Free Full Text]
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