Presentation
End stage renal disease (ESRD) on hemodialysis (HD) with left arterio-venous fistula (AVF; left brachiocephalic). Noted swelling with use post dialysis, tenderness with present thrill.
Patient Data
Heteroechogenic partially occluding soft solid material (thrombus) is noted within the left upper arm medial segment of the cephalic vein with the mentioned material adhering within the venous walls focally and sparing a luminal central portion (6.1 mm in diameter). There is moderate (24.4 mm) fusiform dilatation of the cephalic vein proximal to the fistulation point.
Accompanying the intraluminal venous filling defect and the moderate fusiform venous dilatation, are multiple areas (two) of complete kinking/coiling of the left cephalic vein and the left subclavian vein ipsilaterally with the subclavian venous coiling (at the level of the veno-axillary junction) showing 3600 turn with characteristic ribbon shape appearance.
Case Discussion
Proximal to the left brachiocephalic fistula/anastomosis site, is a partially occluding thrombus (~75% occlusion) resulting in moderate fusiform pseudoaneurysmal change at the thrombosis site and moderate phlebectasia at the veno-axillary subclavian junction.
Kinking/coiling of the left subclavian and the left cephalic veins noted as such may lead to vascular stenosis, aneurysms and/or pseudoaneurysms 2. The brachiocephalic fistula point is normal and shows a normal pulsatile flow pattern with turbulent mixed venous and arterial flow pattern. Mild subcutaneous tissue edema of the left upper extremity is noted.
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