Percutaneous closure of arteriovenous fistula for haemodialysis due to venous hypertension secondary to subclavian vein occlusion
Cierre percutáneo de fístula arteriovenosa para hemodiálisis por hipertensión venosa secundaria a oclusión de vena subclavia
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"titulo" => "Percutaneous closure of arteriovenous fistula for haemodialysis due to venous hypertension secondary to subclavian vein occlusion" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "857" "paginaFinal" => "859" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Ignacio Artigues, Rosa M. Borrás, M. José Barbas, Rita Granchel" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Ignacio" "apellidos" => "Artigues" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:4 [ "nombre" => "Rosa M." "apellidos" => "Borrás" "email" => array:1 [ 0 => "rosetamari@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "M. José" "apellidos" => "Barbas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "nombre" => "Rita" "apellidos" => "Granchel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía Vascular, Hospital General Universitario de Valencia, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital General Universitario de Valencia, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cierre percutáneo de fístula arteriovenosa para hemodiálisis por hipertensión venosa secundaria a oclusión de vena subclavia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11613_108_39887_en_f115.jpg" "Alto" => 481 "Ancho" => 654 "Tamanyo" => 86724 ] ] "descripcion" => array:1 [ "en" => "Humerocephalic anastomosis following the injection of thrombin" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor:</span></p><p class="elsevierStylePara">Central venous disease is a common issue in patients on haemodialysis following the creation of an arteriovenous fistula (AVF). The primary treatment of stenosis/occlusion of the central vein consists of recannalising the vein using endovascular techniques: percutaneous trans-luminal angioplasty (PTA) with or without stent placement. However, the venous patency produced by these procedures is limited, and on occasions, the fistula must be surgically closed due to symptoms of venous hypertension. We propose a simpler and less aggressive approach for closure, through ultrasound-guided thrombin injection.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT 1</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Our first patient was a 78-year old female on haemodialysis since 2009 with a left humerocephalic AVF. The patient developed oedema in the arm with the AVF, which produced progressively worsening pain and functional impairment. The patient was diagnosed with occlusion of the subclavian vein, and several attempts at PTA resulted in early recurrence. We decided to place a right central venous catheter and to close the AVF due to poor functioning. The AVF was annulled through ultrasound-guided injection of thrombin (Figure 1) into the cephalic vein, producing thrombosis. Ten days later, the oedema had disappeared and the artery was again patent with no symptoms.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT 2</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Our second patient was a 74-year old female on haemodialysis since 2010 with a right humerocephalic fistula, which developed pain and increased volume of the right arm, producing functional impairment and poor functioning of the AVF (Figure 2). We performed a phlebography of the right arm, observing obstruction of the subclavian vein. We attempted to re-establish patency using endovascular techniques with no success. Given the progressively worsening symptoms, we decided to place a central jugular venous catheter and to close the AVF. We injected thrombin into the cephalic vein under ultrasound guidance approximately 4-5cm from the AVF and confirmed thrombosis. In a follow-up consultation 7 days later, the patient reported improvements in sensations of pain, although oedema remained. A Doppler ultrasound analysis revealed patency along the first few centimetres of the cephalic vein, but the rest of the vein was thrombosed up to the junction with the axillary vein. We performed another proximal injection, obtaining thrombosis of the entire cephalic vein. Seven days later, the oedema had disappeared (Figure 3). A follow-up Doppler ultrasound analysis confirmed occlusion of the cephalic vein and patency of the humeral artery.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Between 17% and 40% of patients on haemodialysis will develop central vein stenosis due to multiple cannalisations.<span class="elsevierStyleSup">1,2</span> This can produce incapacitating oedema due to venous hypertension in up to 40%-50% of cases.<span class="elsevierStyleSup">2,3</span> Initial treatment generally involves angioplasty with or without stent placement. However, the duration of this solution is limited, producing primary patency and assisted patency rates of 20%-30% and 60%-70%, respectively, after 12 months.<span class="elsevierStyleSup">3,4</span> In addition, more than 50% of patients will require subsequent interventions.<span class="elsevierStyleSup">5</span> Revascularisation through open surgery involves higher rates of morbidity, and surgical interventions produce a final patency that is similar to that produced by repeated endovascular procedures.<span class="elsevierStyleSup">6 </span>Approximately 50% of patients on haemodialysis with central venous stenosis finally require ligation of the AVF, and this is particularly common in patients that produce no or only minimal initial responses to endovascular treatment.<span class="elsevierStyleSup">6</span> Closure of the fistula is commonly performed using surgical techniques, through dissection of the area of the anastomosis and ligation of the fistula under local anaesthetic. This intervention is not without risks, since it involves operating on an arm with oedema in an area that has already undergone multiple interventions due to complications of the AVF. In our case, we closed the AVF by injecting thrombin directly into the arterialised vein under ultrasound control. This provides the advantages of being more comfortable for the patient (avoids the need for subsequent interventions), is less expensive, and produces fewer complications.</p><p class="elsevierStylePara">For this procedure, we applied compression to the upper arm until flow to the fistula was completely occluded, thus preventing the possibility of migration of the thrombus, although even if this were to occur, it would not produce any clinical repercussions since the subclavian vein was also occluded. We used Doppler ultrasound guidance to locate the fistula and then continued 4-5cm distally along the vein in order to avoid accidental injection of thrombin into the artery. We then placed the needle into the arterialised vein in the direction of blood flow, in order to avoid migration of the thrombin towards the artery, and injected the thrombin until thrombosis was achieved. Finally, after removing compression, we placed a compressive bandage on the arm for 48 hours.</p><p class="elsevierStylePara">We performed this technique on two obese patients, after several failed attempts at re-establishing patency and with symptoms that incapacitated the patients. In both cases, the AVF was closed with no complications. This is a simple, fast, inexpensive, and comfortable technique for the patient and physician, and should be taken into account as a treatment alternative when planning to close an AVF.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors state that they have no potential conflicts of interest related to the content of this article.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><a href="grande/11613_108_39887_en_f115.jpg" class="elsevierStyleCrossRefs"><img src="11613_108_39887_en_f115.jpg" alt="Humerocephalic anastomosis following the injection of thrombin"></img></a></p><p class="elsevierStylePara">Figure 1. Humerocephalic anastomosis following the injection of thrombin</p><p class="elsevierStylePara"><a href="grande/11613_108_39889_en_f215.jpg" class="elsevierStyleCrossRefs"><img src="11613_108_39889_en_f215.jpg" alt="Internal right humerocephalic arteriovenous fistula with severe oedema and erythematous areas"></img></a></p><p class="elsevierStylePara">Figure 2. Internal right humerocephalic arteriovenous fistula with severe oedema and erythematous areas</p><p class="elsevierStylePara"><a href="grande/11613_108_39890_en_f315.jpg" class="elsevierStyleCrossRefs"><img src="11613_108_39890_en_f315.jpg" alt="Clear improvement following closure of the arteriovenous fistula"></img></a></p><p class="elsevierStylePara">Figure 3. Clear improvement following closure of the arteriovenous fistula</p>" "pdfFichero" => "P1-E544-S3783-A11613-EN.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11613_108_39887_en_f115.jpg" "Alto" => 481 "Ancho" => 654 "Tamanyo" => 86724 ] ] "descripcion" => array:1 [ "en" => "Humerocephalic anastomosis following the injection of thrombin" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11613_108_39889_en_f215.jpg" "Alto" => 486 "Ancho" => 662 "Tamanyo" => 100347 ] ] "descripcion" => array:1 [ "en" => "Internal right humerocephalic arteriovenous fistula with severe oedema and erythematous areas" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11613_108_39890_en_f315.jpg" "Alto" => 862 "Ancho" => 657 "Tamanyo" => 98268 ] ] "descripcion" => array:1 [ "en" => "Clear improvement following closure of the arteriovenous fistula" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "1.\u{A0}Hernández D, Díaz F, Rufino M, Lorenzo V, Pérez T, Rodríguez A, et al. 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| 2024 September | 100 | 29 | 129 |
| 2024 August | 96 | 56 | 152 |
| 2024 July | 86 | 31 | 117 |
| 2024 June | 122 | 44 | 166 |
| 2024 May | 148 | 36 | 184 |
| 2024 April | 123 | 48 | 171 |
| 2024 March | 127 | 24 | 151 |
| 2024 February | 122 | 38 | 160 |
| 2024 January | 137 | 25 | 162 |
| 2023 December | 169 | 30 | 199 |
| 2023 November | 319 | 28 | 347 |
| 2023 October | 322 | 24 | 346 |
| 2023 September | 273 | 38 | 311 |
| 2023 August | 232 | 14 | 246 |
| 2023 July | 264 | 30 | 294 |
| 2023 June | 255 | 18 | 273 |
| 2023 May | 302 | 37 | 339 |
| 2023 April | 234 | 37 | 271 |
| 2023 March | 237 | 21 | 258 |
| 2023 February | 257 | 30 | 287 |
| 2023 January | 182 | 31 | 213 |
| 2022 December | 188 | 29 | 217 |
| 2022 November | 158 | 27 | 185 |
| 2022 October | 174 | 40 | 214 |
| 2022 September | 159 | 33 | 192 |
| 2022 August | 165 | 50 | 215 |
| 2022 July | 180 | 45 | 225 |
| 2022 June | 242 | 34 | 276 |
| 2022 May | 275 | 43 | 318 |
| 2022 April | 289 | 61 | 350 |
| 2022 March | 349 | 56 | 405 |
| 2022 February | 288 | 50 | 338 |
| 2022 January | 383 | 42 | 425 |
| 2021 December | 315 | 44 | 359 |
| 2021 November | 220 | 38 | 258 |
| 2021 October | 236 | 53 | 289 |
| 2021 September | 156 | 42 | 198 |
| 2021 August | 185 | 34 | 219 |
| 2021 July | 220 | 42 | 262 |
| 2021 June | 164 | 22 | 186 |
| 2021 May | 227 | 28 | 255 |
| 2021 April | 443 | 21 | 464 |
| 2021 March | 219 | 44 | 263 |
| 2021 February | 231 | 24 | 255 |
| 2021 January | 141 | 17 | 158 |
| 2020 December | 111 | 16 | 127 |
| 2020 November | 106 | 12 | 118 |
| 2020 October | 116 | 21 | 137 |
| 2020 September | 156 | 14 | 170 |
| 2020 August | 110 | 13 | 123 |
| 2020 July | 136 | 14 | 150 |
| 2020 June | 108 | 28 | 136 |
| 2020 May | 132 | 8 | 140 |
| 2020 April | 125 | 15 | 140 |
| 2020 March | 157 | 12 | 169 |
| 2020 February | 141 | 19 | 160 |
| 2020 January | 225 | 23 | 248 |
| 2019 December | 197 | 22 | 219 |
| 2019 November | 180 | 16 | 196 |
| 2019 October | 80 | 6 | 86 |
| 2019 September | 162 | 22 | 184 |
| 2019 August | 133 | 9 | 142 |
| 2019 July | 182 | 23 | 205 |
| 2019 June | 191 | 14 | 205 |
| 2019 May | 130 | 20 | 150 |
| 2019 April | 221 | 34 | 255 |
| 2019 March | 113 | 30 | 143 |
| 2019 February | 71 | 22 | 93 |
| 2019 January | 102 | 19 | 121 |
| 2018 December | 199 | 38 | 237 |
| 2018 November | 266 | 13 | 279 |
| 2018 October | 269 | 16 | 285 |
| 2018 September | 367 | 11 | 378 |
| 2018 August | 147 | 18 | 165 |
| 2018 July | 159 | 12 | 171 |
| 2018 June | 125 | 13 | 138 |
| 2018 May | 144 | 18 | 162 |
| 2018 April | 120 | 7 | 127 |
| 2018 March | 115 | 11 | 126 |
| 2018 February | 100 | 10 | 110 |
| 2018 January | 82 | 6 | 88 |
| 2017 December | 109 | 18 | 127 |
| 2017 November | 76 | 8 | 84 |
| 2017 October | 75 | 6 | 81 |
| 2017 September | 88 | 11 | 99 |
| 2017 August | 95 | 8 | 103 |
| 2017 July | 101 | 25 | 126 |
| 2017 June | 99 | 10 | 109 |
| 2017 May | 141 | 11 | 152 |
| 2017 April | 108 | 10 | 118 |
| 2017 March | 119 | 12 | 131 |
| 2017 February | 189 | 17 | 206 |
| 2017 January | 101 | 14 | 115 |
| 2016 December | 95 | 2 | 97 |
| 2016 November | 159 | 6 | 165 |
| 2016 October | 231 | 7 | 238 |
| 2016 September | 335 | 5 | 340 |
| 2016 August | 462 | 4 | 466 |
| 2016 July | 275 | 11 | 286 |
| 2016 June | 202 | 0 | 202 |
| 2016 May | 193 | 0 | 193 |
| 2016 April | 184 | 0 | 184 |
| 2016 March | 108 | 0 | 108 |
| 2016 February | 143 | 0 | 143 |
| 2016 January | 142 | 0 | 142 |
| 2015 December | 168 | 0 | 168 |
| 2015 November | 136 | 0 | 136 |
| 2015 October | 140 | 0 | 140 |
| 2015 September | 84 | 0 | 84 |
| 2015 August | 76 | 0 | 76 |
| 2015 July | 107 | 0 | 107 |
| 2015 June | 50 | 0 | 50 |
| 2015 May | 54 | 0 | 54 |
| 2015 April | 5 | 0 | 5 |
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