Vision-Threatening Arteriovenous Fistula in the …tndt.org/pdf/pdf_TNDT_1111.pdf132 Olgu Sunumu/Case Report Turk Neph Dial Transpl 2016; 25 (Ek / Suppl 1): 132-135 Vision-Threatening

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Olgu Sunumu/Case Report

Turk Neph Dial Transpl 2016; 25 (Ek / Suppl 1): 132-135

Vision-Threatening Arteriovenous Fistula in the Upper Extremity

Görmeyi Tehdit Eden Üst Ekstremite Arteriovenöz Fistülü

Güner Karaveli Gürsoy1

Ebru GöK oğuz1

Gülay ulusal oKyay1

Cengiz Bulut1

tuğba Kip teymur1

mutlu ACAR2

Sinan ÇalışKan2

mustafa KöşKer2

Başol CanBaKan1

mehmet Deniz aylı1

1 DışkapıYıldırımBeyazıtEducationandResearchHospital,

DepartmentofNephrology, Ankara,Turkey2 DışkapıYıldırımBeyazıtEducationand

ResearchHospital, DepartmentofOphthalmology, Ankara,Turkey

doi:10.5262/tndt.2016.30

CorrespondenceAddress:Güner Karaveli GürsoyDışkapıYıldırımBeyazıtEğitimveAraştırmaHastanesi,NefrolojiBölümü,Ankara,TurkeyPhone :+903123410300E-mail :[email protected]

aBstraCt

Arteriovenousfistulas(AVFs),whichhavelowcomplicationratesandcanstayopenforalongtime,arepreferentiallyusedforhemodialysisinpatientswithend-stagerenaldisease(ESRD).Arteriovenousfistulas for hemodialysis frequently cause complications such as bleeding, thrombosis, ischemia ofextremities, infection,edema,venoushypertensionandvenousaneurysm.Thesecomplicationshavenegativeeffectsonthequalityoflifeandsurvival.Inthisreport,adialysispatienthavingsevereedemainthelefteyeandarmforoneyearduetothrombosisintheAVFandexperiencingafastregressionofedemaafterclosureoftheAVFwillbepresented.Thepresentcaseemphasizesthatthrombosisinthefistula,afrequentcomplicationofAVFinpatientswithESRD,canpresentwithraresymptomslikeperiorbitaledemawhichpreventsunilateralvisioninadditiontoitswell-knownsymptoms.

Key worDs: Arteriovenousfistula,End-stagerenaldisease,Periorbitaledema,Thrombosis

öz

Sondönemböbrekyetmezliğihastalarındahemodiyalizişlemiiçin,düşükkomplikasyonoranınasahipve uzun süre açık kalabilen kalıcı arteriyovenöz (AVF) fistüller öncelikli olarak kullanılmaktadır.Arteriyovenözfistüllerdekanama,tromboz,ekstremiteiskemisi,enfeksiyon,ödem,venözhipertansiyonvevenözanevrizmagibikomplikasyonlarla sıkçakarşılaşılmaktadır.Bukomplikasyonlarhastalarınyaşam kalitesi ve süresini olumsuz etkilemektedir. BuradaAVF trombozuna bağlı 1 yıldır sol kolve gözde görmeyi engelleyen ileri derecede ödemolan veAVFkapatılması sonrası gözdeki ödemihızlagerileyenbirhemodiyalizhastasısunulmuştur.SondönemböbrekyetmezliğihastalarındaAVFkomplikasyonlarından sık olan tromboze fistülün bilinen bulgularının yanı sıra olgumuzdaki gibitek taraflı görmeyi engelleyenperiorbital ödemgibi az rastlanılanbulgularla prezenteolabileceğiniolgumuzlavurguladık.

anahtar sözCüKler: Arteriovenöz fistül, Periorbital ödem, Son dönem böbrek yetmezliği,Tromboz

Received :26.11.2015Accepted :28.01.2016

ıntroDuCtıon

Arteriovenous fistulas (AVFs), whichhave low complication rates and can stayopen for a long time, are preferentiallyusedforhemodialysisinpatientswithend-stage renal disease (ESRD) (1). Problemswith permanent intravenous routes are stillan importantcauseofmorbidity leading tohospitalization of patients on dialysis (2).Thrombosis in AVF, which is common inthesepatients,canoccurintheshort-termorthelong-termwithhemodialysis.Thrombosis

in the short-term mostly results from the surgical technique used while the one inthe long-term develops due to insufficientflow in the fistula, hypotensive processes,hypercoagulability and dehydration (3).Thrombosis in AVF usually presents withchanges in the quality of murmur at theanastomosis site, an increase in venouspressure, a decrease in arterial pressure,failure to keep bleeding under controlafter removal of the needle, difficulty inpreservation of intradialytic blood flow,difficulty in cannulation, an unexplained

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türk nefroloji Diyaliz ve transplantasyon DergisiTurkish Nephrology, Dialysis and Transplantation Journal Karaveli Gürsoy G et al: Vision-Threatening Arteriovenous Fistula


increaseinureaandcreatininelevelsanddisappearanceofthrillandmurmur(4).Inthisreport,adialysispatienthavingsevereedemain the lefteyeandarmforoneyeardue to thrombosisin theAVFandexperiencinga fast regressionofedemaafterclosureoftheAVFwillbepresented.

CASE

Afifty-fiveyearoldwomanonchronicdialysisforESRDduetosystemiclupuserythematosus(SLE)for21yearspresentedtoourclinicwithherclosedlefteyeduetoedemalastingforonemonthanddysfunctionoftheAVFinherleftarminthepastoneweekandswellingintheleftarm,breastandeyeprogressingforoneyear.Onhistory,therewasthrombosisintunnelledcathetersinsertedintherightandleftsubclavianveinsatshortintervalsand closureof the arteriovenousfistulaopening into the rightupperextremityduetoswellingandinfectionafterbeingusedfor15years.ThepatientalsohadahistoryofhypertensioninadditiontoSLE;however,shedidnothaveahistoryofdiabetes.Onphysicalexamination,therewasedemapreventingvisioninthelefteye,edemaintheleftbreastandarm,achangeinskincomplexioninthehandandthearmwheretheAVFwascreatedand collateral formations in the left hemithorax (Figure 1).TherewasnoedemaonherrightarmwheretheAVFwasclosed15years ago. In addition, thrombosiswasdetected in the leftexternaljugularveinonpalpation.Thepatientwasontreatmentwithamlodipine10mg/day,doxazosin8mg/day,calcitriol0,5mcg/day, cinacalcet 90 mg/day, sevelamer 2400 mg/day andlansoprazole30mg/day.

Resultsofthelaboratoryinvestigationsonadmissionwereasfollows:Hb:12.5g/dl,htc:43.8%,WBC:5000,PLT:179.000,

bloodfastingglucose:76mg/dl,bloodureanitrogen:124mg/dl,creatinine:8.3mg/dl,ALT:7U/L,Na:141mmol/L,K:5mmol/LLDH:154U/L,ferritin:29ng/mlPTH:824pg/ml,PT:13.4seconds,aPTT:36.4seconds,INR:1.17

The patientwas not found to have trauma in her left armandwas initiated lowmolecule density heparin for thrombusin the left jugular vein. Consultation was requested from theOphthalmology department for severe edema in the left eye

Figure 1: Before closure of the AVF.

Figure 2: A) Collateral circulations on the arm B) Collateral circulations on the chest.

A B

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There was sufficient thrombosis in the AVF to createcollaterals and the resultant flow allowed hemodialysis untiladmissiontoourclinic.

Thepresentcasehadararecomplicationofanarteriovenousfistulaforhemodialysis.Wethoughtthatinboththepresentcaseandthetwocasesreportedintheliterature,highpressureintheleftjugularveinduetoocclusionoftheleftbrachiocephalicveinincreased carotid venous pressure,which resulted in a rise inthesuperiorophthalmicveinpressureandintraocularpressure.Incompetence of the anti-reflux mechanism associated with

preventingvision.However,anophthalmologicalexaminationcouldnotbeperformedsincetheeyewasclosedduetoedema.Therefore, the patient was diagnosed as orbital cellulitis andinitiatedantibiotics.OnleftarmDopplerultrasonography,therewas a thrombus 5 mm in length in the AVF. ArteriovenousfistulogramshowedthattheAVFwastotallyblockedandthatcollateral circulationshelped tocontinue sanguination (Figure2A,B).Atunnelledcatheterwasinsertedtotheleftjugularveinandhemodialysiswasinitiated.ThepatientwasexaminedbyacardiovascularsurgeonandtheAVFontheleftarmwasclosed.Onday2afterclosureoftheAVF,edemainthelefteyeregressedalmost completely (Figure 3). Ophthalmological examinationby an ophthalmologist revealed slightly dilated episcleral andconjunctivalvessels,butdidnotshowcornealedema(Figure4).On fundoscopy, intraocularpressurewasnormal.Consideringthat the ocular edema was due to thrombosis in the AVF,the large spectrum antibiotic, which was initiated for ocularcellulitis,wasdiscontinued.Since thepatienthadahistoryofSLE, anticardiolipin antibodies and lupus anticoagulantswereinvestigatedbuttheresultswerenegative.Otherhematologicalteststhatdetectotherpossiblecausesofthrombosis(proteinC,proteinS,factor5leidenmutation)wereperformed.Sincethepatienthadwidespreadthrombosis,shewasgivencoumadinandwasdischargedandinvitedtothehospitalforregularfollow-up.Thepatienthadnovisionlossthreemonthsafterherdischargefrom the hospital. The patient,whose anticoagulant treatmentwasstoppedbasedontherecommendationfromthehematologydepartment, is receiving anticoagulant treatment only duringdialysis. Currently the patient is receiving dialysis from atunnelledcatheterandisonthecadavertransplantlist.

DısCussıon

Arteriovenous fistulas for hemodialysis frequently causecomplications such as bleeding, thrombosis, ischemia ofextremities,infection,edema,venoushypertensionandvenousaneurysm. These complications have negative effects on thequalityoflifeandsurvival(5).Inthisreport,acaseofunilateralsevere orbital edema secondary to venous thrombosis in theAVFispresented.

Asfarasweareaware,therehavebeentwocasesofend-stagerenaldisease(ESRD)presentingwithintermittentlossofeyesight,diplopiaandedema,whichwereattributedtoincreasedintraocularpressureduetocarotidcavernousfistula.However,the diagnosis was ruled out on cerebral angiography (6, 7).Subclavian angiography showed that the left brachiocephalicveinwascompletelyoccluded.Inbothcases,ocularsymptomsregressedanddisappearedwhenthefistulaewereclosed.Unlikethe two cases reported in the literature, in the case presentedhere, funduscopic examination could not be performed onadmissionsince theeyewascompletelycloseddue toedema.Upon detection of thrombosis on fistulogram the AVF wasclosedimmediately.Asintheabovementionedtwocases,ocularedemaquicklyregressedafterclosureofthefistula.

Figure 3: On day 2 after closure of the AVF.

Figure 4: Left eye; after closure of the AVF.

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elevated venous pressuremight have caused unilateral ocularedemasufficienttopreventvision(8).

ConClusıon

Thepresentcaseemphasizesthatthrombosisinthefistula,a frequent complication of AVF in patients with ESRD, canpresent with rare symptoms like periorbital edema whichprevents unilateral vision in addition to its well-knownsymptoms.EspeciallypatientswithSLE,whotendtodevelopthrombosisintheAVF,shouldbecloselymonitoredevenifthefistulaworkswellsincecollateralsthatallowittofunctionmaydevelop.

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TypeofvascularaccessandmortalityinUShemodialysispatients.KidneyInt2001;60:1443-1451

2. PisoniRL,ArringtonCJ,AlbertJM,EthierJ,KimataN,KrishnanM,RaynerHC,SaitoA,SandsJJ,SaranR,GillespieB,WolfeRA,Port FK:Facility hemodialysis vascular access use andmortalityin countries participating in DOPPS: An instrumental variableanalysis.AmJKidneyDis2009;53:475-491

3. Malovrh M: Vascular access for hemodialysis: Arteriovenousfistula.TherApherDial2005;9:214-217

4. Al-JaishiAA,OliverMJ,ThomasSM,LokCE,ZhangJC,GargAX,KosaSD,QuinnRR,MoistLM:Patencyratesofthearteriovenousfistula for hemodialysis:A systematic review and meta-analysis.AmJKidneyDis2014;63:464-478

5. Mennes PA,Gilula LA,Anderson CB, Etheredge EE,Weerts C,HarterHR:Complicationsassociatedwitharteriovenousfistulasinpatientsundergoingchronichemodialysis.ArchInternMed1978;138:1117-1121

6. WatsonRR,RussoC:Upperextremityarteriovenousdialysisfistularesulting in cavernous sinus arterializedbloodflow.AJNRAmJNeuroradiol2007;28:1155-1156

7. KiernanM,BhogalM,WongK,SivaprakasamR,AshmanN,AliN:Sight-threateningintraocularpressureduetoanupperarmdialysisfistula.Lancet2015;386:101-102

8. TankaH,FujitaN,HirabukiN,KashiwagiN, WatanabeY, FujinakaT, YoshimineT, NakamuraH:Originofhighsignalintensityinthecavernous sinus inMR angiographic source images:Correlation betweenMRandconventionalangiography.JComputAssistTomgr2004;28:728-734

Documents

Vision-Threatening Arteriovenous Fistula in the …tndt.org/pdf/pdf_TNDT_1111.pdf132 Olgu Sunumu/Case Report Turk Neph Dial Transpl 2016; 25 (Ek / Suppl 1): 132-135 Vision-Threatening