Central venous stenosis as a complication of ipsilateral haemodialysis fistula and pacemaker
Jérôme Tourret1,
Philippe Cluzel2,
Isabelle Tostivint1,
Benoit Barrou3,
Gilbert Deray1 and
Corinne Isnard Bagnis1
1 Department of Nephrology, 2 Department of Radiology and 3 Department of Urology, Pitie Salpétrière Hospital, Paris, France
Correspondence and offprint requests to: Dr Corinne Isnard Bagnis, Service de Néphrologie, Hôpital Pitié Salpêtrière, 83, Boulevard de L'hôpital, 75013, Paris, France. Email: corinne.bagnis{at}psl.ap-hop-paris.fr
Keywords: arteriovenous fistula; central venous stenosis; haemodialysis; pacemaker; phlebography; upper limb oedema
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Introduction
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Vascular access creation for haemodialysis in end-stage renal failure patients with a permanent pacemaker is not an infrequent event. Risk of central venous stenosis secondary to pacemaker wires is underreported. We report on a patient with end-stage renal failure of unknown origin, with a history of right pacemaker implantation and right temporary jugular catheter whose arteriovenous fistula (AVF) was complicated by severe right subclavian vein stenosis next to the pacemaker wires.
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Case report
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An autologous AVF was created in a 78-year-old patient with end-stage renal failure of unknown origin (because of late discovery). Ten days after angioaccess placement, he was admitted with serious right arm swelling. His main clinical history consisted of hypertension with secondary cardiomyopathy and rhythmic auricular disease, for which he had been implanted with a right dual chamber permanent pacemaker 22 months before vascular access was created. He also had been admitted in an intensive care unit 8 months before with Legionella pneumoniæ pneumopathy. Because of associated acute renal failure requiring temporary haemodialysis (only one session), right internal jugular vein cannulation had been necessary. Because of the history of internal jugular vein cannulation and pacemaker implantation, CO2 venography had been performed 1 month before the fistula was created to check for upper limbs proximal venous patency. Figure 1 shows the proximal part of the right upper limb phlebograph. No obvious stenosis (or collateral circulation) was evidenced and a basilica vein humeral artery fistula was created at the right elbow level. The left arm exhibited poor vascular web and the right arm was considered the best for AVF creation. When admitted for persisting right arm swelling, a contrast phlebograph was performed. Figure 2 shows a severe right subclavian vein stenosis around the permanent wires of the pacemaker. A successful percutaneous transluminal dilation of the subclavian vein was performed with a good immediate result, as shown in Figure 3. Despite technically optimal endovascular repair, and because of persistence of the right arm oedema, the arteriovenous fistula had to be ligated 2 months later.

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Fig. 1. CO2 venography before haemodialysis fistula creation. No obvious stenosis but poor collateral circulation is evidenced.
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Fig. 2. Contrast phlebography performed for persisting right arm swelling showing a severe right subclavian vein stenosis around the permanent wires of the pacemaker.
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Fig. 3. Contrast phlebography after successful percutaneous transluminal dilation of the subclavian vein.
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Discussion
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Subclavian vein, and to a lesser extent internal jugular vein cannulation, is an important risk factor for central venous stenosis (CVS). Dialysis fistula, increasing the venous flow, further increases the risk for CVS. That is the major reason why subclavian cannulation is now usually avoided in chronic renal failure (CRF) patients. Pacemaker wires can be considered as a permanent cannulation. CVS after pacemaker implantation occurs in 3060% of the cases, most of the times asymptomatically [14]. Hypoproteinaemia, CRF, impaired thyroid function, infections and low left ventricular ejection fraction are other known risk factors for CVS [5,6]. CVS, secondary to dialysis fistula creation, when an ipsilateral pacemaker is present, was first described by Stone in 1982. Table 1 describes all the published case reports so far [712]. Another two cases have been reported in the literature, but their report is not detailed enough to be integrated in Table 1 [5]. Several important notes can be made.
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Table 1. Published cases of CVS occurring in patients with an arteriovenous fistula together with an ipsilateral permanent pacemaker
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According to the literature, CVS in pacemaker-holder patients is a complication of native AVF (72%), as well as graft fistulae (36%). Subclavian vein insertion of the pacemaker wires increases the risk of CVS compared to the cephalic route (80% vs 20%). Stenosis occurs on the subclavian vein in 73% of the cases and on the innominate vein in 17% of the cases. In four cases including ours, percutaneous angioplasty (PCA) without stenting has been tried leading to a 100% rate of failure. Only one case has been published in which PCA has been performed with stenting of the stenosis. This technique has been able to restore a good fistula flow, and the preservation of the fistula as an available dialysis access. This observation suggests that PCA in this specific indication should not be used without stenting. This result seems to be confirmed by analysis of a retrospective series, including 20 cases of wall stent implantation, that shows a cumulative primary 1 year stent patency of 70% [13].
If we exclude case number 4 (death of the patient), ligation of the fistula or removal of the graft has been necessary in 80% of the cases. If we exclude cases number 4 and 11 (no dialysis), the creation of a dialysis access on the contralateral arm has been performed in 78% of the cases. These figures and the importance of lifetime access in haemodialysed patients stress the importance of figuring out a strategy to perform angioaccess in pacemaker-holder patients.
CVS may occur even when a long delay is expected between creation of the dialysis access and pacemaker insertion (maximum delay 10 years, case number 3). Conversely, it may appear when fistula creation and pacemaker insertion are performed almost simultaneously (1 month, cases number 5 and 6) or even when the pacemaker is inserted after the fistula creation (case number 10). CVS seems to appear with a short delay (or even immediately) after creation of the fistula (64% of the published cases indicate that CVS was discovered in the first 3 months, and 55% in the first month). In only one case, symptoms appeared 2 years after the fistula was created. Some authors suggest that a minimum delay is necessary for a collateral circulation to develop [8,12]. When CVS occurs progressively, collateral circulation develops, and stenosis is bypassed, which is the reason why the CVS usually shows no symptom and can be detected only by a systematic exploration. Conversely, when CVS occurs in a very short period, no new vascular web has time to develop and upper limb oedema appears.
In most of the papers reporting on CVS after fistula creation on the ipsilateral arm of a pacemaker, the authors suggest that phlebography should systematically be performed before the fistula is created, in order to track down a pre-existing CVS [7,9,11,12,14]. Contrast media phlebography means an iodine injection in an advanced renal failure patient associated with a risk of further alteration of renal function and loss of residual diuresis. It must be considered as an invasive procedure in a fragile patient. Magnetic resonance imaging with contrast of the central veins can show exquisite detail but is contraindicated in pacemaker patients. Alternatively, an upper extremity venous ultrasound (in experienced hands) may show abnormal phasicity and transmitted cardiac pulsatility in the subclavian and internal jugular veins. There is no straightforward way to screen for CVS in pacemaker renal failure patients.
Because it is almost impossible to predict the outcome of a fistula once an asymptomatic stenosis is diagnosed on the venography, some authors argue that fistula should preferentially be placed on the opposite limb whenever possible in pacemaker patients. No rules can be stipulated and each specific case has to be discussed. If the cephalic vein is amenable to fistula construction, provided that a good quality venograph rules out any stenosis on the central veins, it may be far preferable to create an autologous fistula on the side of a pacemaker instead of placing a prosthetic graft on the contralateral side. Indeed no data are available on the optimal side of pacemaker insertion, probably because the choice greatly depends on the performer. Notably, many of them prefer the non-dominant hand side (as for AVF) to avoid discomfort of dominant arm use because of the pacemaker generator. Nevertheless, it appears probably more important to be able to use one 's dominant hand three times a week during dialysis than to avoid minor discomfort due to the pacemaker generator. In chronic renal failure patients, a pacemaker should be inserted on the dominant-hand side, so that the non-dominant hand is preserved for possible AVF creation. The permanent increase in the prevalence of end-stage renal failure, pacemaker insertion, and left-handed patients and the higher incidence of pacemaker needs in CRF patients than in the general population stresses the value of these data.
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Teaching point
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- Even if most nephrologists acknowledge that a pacemaker is a risk factor for CVS when AVF is created on the ipsilateral arm, only 11 case reports have been reported on the subject so far, stressing the need for a better shared experience in the medical community about such situations.
- It seems therefore critical to inform pacemaker implanters of the risk of CVS in our chronic renal failure patients in order for them to take into consideration the potential need for ulterior AVF when choosing the site of implantation of a pacemaker.
- Before arteriovenous fistula creation, patient's history in terms of central venous catheterism or pacemaker implantation must be carefully reviewed.
- In the case of a preceding pacemaker implantation, careful examination of the central venous system is mandatory, aimed at ruling out central venous stenosis if AVF is to be installed on the same arm side.
Conflict of interest statement. None declared.
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References
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