Management of Post-access Venous Hypertension in Haemodialysis Patients

Abstract

Summary V enous Hypertension is a significant problem for the patients on regular haemodialysis that result in disabling upper extremity oedema and impairment of arteriovenous access function. The problem seems to be increasing in clinical importance as the ability to care medically for patients on haemodialysis continues to improve, resulting in patients living longer. This may be due to an actual increase in incidence of, or a greater awareness and recognition of, the problem (Elseviers et al., 2003). Venous hypertension after access construction is due to central venous stenosis or occlusion or valvular incompetence in the more peripheral arm veins with retrograde flow. The exact incidence of central venous lesions in the haemodialysis population is unknown. It is estimated that between 5% and 20% of haemodialysis patients develop central venous stenosis. The incidence of significant (>50%) central venous stenosis following subclavian vein catheter placement is 42% to 50%; it is 10% in patients with internal jugular catheters (Dosluoglu et al., 2010). Several factors have an impact on the development of central venous lesions, including longer catheter indwelling times, multiple catheterizations, and longer functioning ipsilateral AV access after ipsilateral catheter placement (Dosluoglu et al., 2010). With the presence of central venous stenosis and ipsilateral dialysis access creation, the patient may remain asymptomatic owing to good collateral development, the access may thrombose owing to poor outflow, or the patient may experience a rapid onset of venous hypertension, with arm swelling and pain. The arm swelling can lead to cyanosis and even ulcerations in extreme cases (Dosluoglu et al., 2010). The NKF-KDOQI (The National Kidney Foundation Kidney Disease Outcomes Quality Initiative) guidelines recommend prompt treatment of central vein occlusions in haemodialysis patients when suspected preferably by endovascular minimally invasive techniques (Dosluoglu et al., 2010). To address outflow obstruction leading to venous hypertension after an access has been placed, there are a variety of potentially feasible options, including access sacrifice, endovascular treatments to recanalize the occluded central vein, and venovenous bypass. Ligation of the access, though successful at relieving symptoms, results in loss of the limb for dialysis access (Sidawy et al., 2002).