Teaching Case

Venous congestion of right arm. History of hemodialysis.

Patient has been on chronic hemodialysis for a couple of years. Recurrent swelling of the right shunt arm had occurred and underwent repeat PTA in an other institution. Result of PTA never lasted long. Now the patient presents with massive swelling of his right arm, venous ulceration at his hand and severe pain. Angiography (Fig. 1) revealed tight subclavian venous stenosis close to the junction to the jugular vein. Remarkably, no major collateral pathways are opacified.

After antegrade punction of the shunt-draining brachial cephalic vein, the stenosis is passed and a 14 mm wide 30 mm long Wallstent was inserted into the stenosis (Fig. 2 a). A short stent was choosen to avoid overstenting of the jugular vein. Due to the shortness of the stent and the rigidity of the stenosis, however, the stent did not place nicely within the brachiocpehalic vein but touches the medial wall of the brachiocephalic vein. This presented a potential risk for stent thrombosis and limited flow. Thus a second but longer Wallstent was implanted through the first that was adapted to the brachiocephalic and subclavian vein (Fig. 2 b). The junction with the jugular vein, however, was covered now. Primary stenting is an option to improve primary patency of percutaneous treatment of central veins. Reobstruction of stents in dialysis patients is frequent but responds sufficiently to percutaneous revision. Overall shunt function can be preserved for a longer period. Technically, stent placement into the right subclavian vein can be challenging because these stenoses are frequently stiff and rigid that may lead to deformation of the stent. Furthermore bony landmarks around the implantation site may compress the vein also. Sometimes, it is therefore mandatory to place a longer stent within both the subclavian and the brachiocephalic vein keeping the stenosis within the center of the stent.