Obstructive Lung Diseases: Fellow Case Report Poster - Obstructive Lung Disease |

Not Quite a Hero (Hemodialysis Reliable Outflow Graft): A Rare Cause of Dyspnea and Positional Syncope in End Stage Renal Disease (ESRD) FREE TO VIEW

Mariam Anis, MD; David Harris, MD; Jean Elwing, MD
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University of Cincinnati Medical Center, Cincinnati, OH

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):908A. doi:10.1016/j.chest.2016.08.1008
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SESSION TITLE: Fellow Case Report Poster - Obstructive Lung Disease

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: HeRO graft provides upper extremity access as a last resort. Catheter related thrombosis of a central vein or the right atrium leading to pulmonary embolism (PE) is a rare but potentially fatal complication. We describe a case of positional syncope and dyspnea as a complication of a malpositioned HeRO graft.

CASE PRESENTATION: 43 year old African American male with ESRD and recently diagnosed PE presented to our center in 2015 with dyspnea and positional syncope. He endorsed NYHA class IV symptoms with minimal improvement in shortness of breath from anticoagulation. He was admitted for further workup. Ventilation perfusion scan revealed multiple bilateral defects. Chest x-ray demonstrated the tip of a left HeRO graft in the right atrium. Echocardiography (ECHO) showed normal left ventricular size and function but severely dilated right ventricle (RV) with severe tricuspid regurgitation (TR). A HeRO graft was found coursing through the tricuspid valve with tip visualized in the RV. Further history revealed syncope related to changing positions of left arm. ECHO repeated with left arm maneuvers demonstrated intermittent prolapse of HeRO graft through the tricuspid valve. The thrombosed HeRO graft was removed. A subsequent right heart catheterization showed normal hemodynamics. Follow up pulmonary angiogram revealed resolving thromboembolic disease with decrease in filling defects. HeRO graft was determined to be the source of recurrent thromboembolism as well as intermittent severe TR from intermittent prolapse and probable resultant arrhythmia associated syncope. On reevaluation in 2016, the patient endorsed NYHA class I symptoms without recurrence of PE or syncope.

DISCUSSION: Subclavian steal syndrome and bacteremia are well reported complications of HeRO graft. Cardiac arrhythmias and thromboembolic disease are less common but real risks which mandate careful monitoring. Removal of the graft should be strongly considered in the absence of alternate thromboembolic source. There are no reports of valvular complications or syncope related to the HeRO graft.

CONCLUSIONS: This is the first case showing migration and prolapse of HeRO graft leading to life threatening complications including severe tricuspid regurgitation and syncope. It also reiterates the possibility of pulmonary embolism due to catheter related thrombosis in patients with indwelling lines.

Reference #1: Katzman HE, McLafferty RB et al. Initial experience and outcome of a new hemodialysis access device for catheter-dependent patients. J Vasc Surg. 2009.

DISCLOSURE: The following authors have nothing to disclose: Mariam Anis, David Harris, Jean Elwing

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