Endovascular Treatment for Vascular Access Venous Hypertension with Complicated Venous Drainage Routes in a Hemodialysis Patient: A Case Report

Patient: Female, 68-year-old Final Diagnosis: Vascular access venous hypertension Symptoms: Difficulties during hemodialysis Medication: — Clinical Procedure: — Specialty: Cardiology • Nephrology • Radiology OBJECTIVE: Unusual clinical course BACKGROUND: Vascular access (VA) venous hypertension is a major complication for patients with long-term arteriovenous access in the upper extremities. Endovascular treatment (EVT) is the first option for treating it. A possible cause of VA venous hypertension is stenosis at a site downstream of the arteriovenous fistula. We report a case of VA venous hypertension with complex venous drainage routes. CASE REPORT: A 68-year-old woman had worsening VA venous hypertension that led to difficulties in the venous blood return during hemodialysis. The cephalic vein distal to the arteriovenous fistula branched into 3 routes. The most proximal branch was occluded just before the junction to the subclavian vein at the level of the first rib. The pressure gradient between the brachial artery and the VA vein was 30 mmHg. Therefore, we performed an EVT for the occlusion and deployed a 3.0-mm balloon-expandable bare-metal stent, achieving good vascular patency with favorable blood flow. When the outside of the implanted stent was stained with contrast media, the appearance suggested the formation of varices that could have lowered the pressure at that lesion. The pressure gradient between the brachial artery and the VA vein had increased to 80 mmHg, which indicated an improvement of the VA venous hypertension. CONCLUSIONS: EVT was effective for an occluded cephalic arch in a hemodialysis patient showing VA venous hypertension, despite the presence of collateral venous routes. VA venous hypertension can be life-threatening for hemodialysis patients. Therefore, it is essential that physicians who use vascular access interventional therapy should determine the cause of the VA venous hypertension and resolve it.