Cephalic arch stenosis is considered one of the commonest cause of dysfunction in a brachiocephalic fistula which involves the cephalic vein in the region of the cephalic arch prior to junction with the axillary vein.
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Epidemiology
Has an average reported prevalance of around 15% in all autogenous hemodialysis fistulas3. A haemodynamically significant cephalic arch stenosis have been reported in a high proportion (range ~30–77%) of dysfunctional brachiocephalic fistulas 1.
Pathology
Postulated causes include:
- extrinsic compression by the enclosing clavipectoral fascia where the sharp turn of the cephalic arch can cause turbulent flow
- high concentration of valves that may hypertrophy +/- may also lead to turbulent flow
- higher blood flow
- higher flow in brachiocephalic fistulas (vs radiocephalic fistulas) may be a reason why affects the former type
- higher flow within the cephalic arch can be secondary to greater arterial inflow (brachial artery vs radial artery) as well as alternative venous outflow seen in radiocephalic fistulas, such as through the median cubital vein to the basilic vein.
Radiographic features
Doppler ultrasound
Often there is increased blood flow velocities at cephalic arch region (some suggest a velocity of 4 m/s at with an insonation angle of 60° or a peak systolic velocity ratio between the stenosis and an adjacent normal segment of > 3 as an criteria for considering intervention.
CT angiography
Best assessed on venograpic phase as allows direct visualization of anatomy.
Treatment and prognosis
Vascular interventional treatment options can vary and include angioplasty, primary stent placement, transposition, and bypass 2.
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