SESSION TYPE: Miscellaneous Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: SVCS results from obstruction of blood flow through the superior vena cava (SVC) caused by venous stenosis, thrombus, or external compression of the SVC. Malignancy is the most common cause, but recently the thrombosis related SVCS has increased due to use of intravascular devices.
CASE PRESENTATION: A 46-year-old male with a history of hypertension, chronic smoking and end stage renal disease on hemodialysis for 10 years presented with swelling of face and right upper extremity for three weeks but denied any other symptoms. Ten years ago central venous catheter in the right internal jugular (IJ) vein was used for first three months as dialysis access until the right forearm arterio-venous fistula matured. He had a fracture of the right elbow four years ago, and a tunneled dialysis catheter was placed in right IJ vein for 2 months. Vitals were stable except blood pressure 187/97 mm Hg. On examination, he had right sided swelling of the face, neck and right arm, right jugular venous distension. Chest CT with contrast (Fig-1), Doppler Ultrasound, Venogram (Fig-2), all revealed narrowing of SVC at the junction with brachiocephalic vein associated with calcification but no thrombus. Angioplasty and stenting were not an option due to the extent of calcification and fear of rupture of the vein, and the concern of obstruction of the SVC if the stent got displaced or thrombosed . Patient was started on aspirin with plan to close the fistula and use of an alternate site for hemodialysis. With continued dialysis and gradual reduction in the target weight, his edema mostly resolved and he has remained asymptomatic with better blood pressure control.
DISCUSSION: SVCS has been reported with central venous catheters used for hemodialysis. In our case there is extensive calcification of brachiocephalic vein with incomplete stenosis. The dilated innominate veins with collaterals suggest chronic nature. This has been reported in children with central venous catheters (1), and one adult patient reported with acutely calcified thrombus related to the dialysis catheter (2). Our case is unique because the patient presented with SVCS long after catheter removal, the venous calcification is unusual and because of these significant calcifications we could not place a stent. However it might have been contributed by previous catheter placements with possible partial thrombus.
CONCLUSIONS: We suggest that venous calcification with SVCS to be added to the complications of central venous catheters used for dialysis. Our case also illustrates importance of fluid management which controlled symptoms of SVCS and hypertension.
1)Hughes DB, et al , J Peditric Surg. 2006-Nov;41(11)1927-9.
2) Hanf W, et al, Nephrol Ther. 2011-Jun;7(3):188-90.
DISCLOSURE: The following authors have nothing to disclose: Ayham Aboeed, Priyank Shah, Chandra B Chandran
No Product/Research Disclosure InformationSt Joseph's Regional Medical Center, Paterson, NJ