- Case Report
- Open Access
An unusual case of arteriovenous fistula-related venous hypertension: sonographic detection of a culprit perforating vein with movie and compact review
© The Author(s) 2016
- Received: 26 March 2016
- Accepted: 21 July 2016
- Published: 3 October 2016
Venous hypertension is one of the critical complications of arteriovenous fistula (AV fistula). Here, we report an unusual variation of venous hypertension which was caused by retrograde outflow through a perforating vein of the elbow.
A 79-year-old man with diabetic nephropathy had an AV fistula created at his left proximal forearm 2 years before referral. Shortly after the creation of the AV fistula, he developed swelling of the left hand and forearm. Six months prior to the referral, persistent pain of the left hand developed, and he visited the nephrology unit. An anastomosis of the AV fistula was located 5 cm distal to the elbow. Inspection, palpation, and auscultation did not suggest outflow stenosis. Ultrasound showed mature upper arm venous outflow without stenosis. His proximal radial artery had been anastomosed side-to-end to a nearby proximal forearm superficial vein. Color Doppler analysis revealed a retrograde outflow through an antecubital perforating vein, which drained into the deep portion of the forearm and then disappeared. Superficial veins of the left forearm had been exhausted due to a previous attempt to create a wrist AV fistula. Given the above, it was suspected that the unusual retrograde outflow through the perforating vein caused venous hypertension by interfering with the venous return of the forearm, which had been dependent on deep veins. The patient subsequently underwent ligation of the perforating vein. The day after the operation, the pain disappeared and swelling improved. The dialysis treatments were continued without problems.
Retrograde outflow through a perforating vein can be a cause of venous hypertension in a patient with an AV fistula created using the proximal radial artery. Close sonographic examination of antecubital vessels should be done if a practitioner encounters unilateral whole forearm edema without apparent proximal outflow stenosis.
- Arteriovenous fistula
- Venous hypertension
- Perforating vein
- Deep communicating vein
- Vena mediana cubiti profunda
- Point-of-care ultrasound
Symptoms of AV fistula-related venous hypertension
Edema of the upper limb
Pain of the upper limb
A decreased range of upper limb joint motion
Ulceration, pigmentation, and dermatosclerosis of the upper limb
Superficial venous dilatation over the chest and shouldera
Sonographic blood flow parameters of the left brachial artery before and after the operation
Flow volume* (mL/min)
Unfortunately, we did not perform angiography in the present case, although venous hypertension is usually diagnosed by angiography. However, if the cause is obvious by symptoms, physical exams, and ultrasonography, angiography may not be necessarily required , especially when an angiography suite is not readily available, as in our case. Recently, the latest ultrasound equipment was markedly improved in terms of mobility, spatial resolution, and affordability . Indeed, the laptop ultrasound equipment used in our case has high-level portability, which enabled a prompt diagnosis during the initial outpatient visit. In addition, its spatial resolution was superior at least compared with our 64-slice CT system. Portable ultrasound is not only useful for preoperative vascular mapping for AV fistula  and procedural guidance for difficult vascular access cannulation , but is also effective for the diagnosis of access trouble, as demonstrated in our patient.
Retrograde outflow through a perforating vein can be a cause of venous hypertension in a patient with an AV fistula created using the proximal radial artery. Close sonographic examination of antecubital vessels should be done if a practitioner encounters unilateral whole forearm edema without apparent proximal outflow stenosis, especially when superficial forearm veins are exhausted.
TK performed the ultrasound examination and prepared the manuscript. KY and MO conducted the operation. NI helped to draft the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patient for the publication of this case report and any accompanying images.
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- Kukita K, Ohira S, Amano I, Naito H, Azuma N, Ikeda K, et al. 2011 update Japanese society for dialysis therapy guidelines of vascular access construction and repair for chronic hemodialysis. Ther Apher Dial. 2015;19 Suppl 1:1–39.View ArticlePubMedGoogle Scholar
- Haruguchi H. Diagnostic methods for vascular access. Tokyo: Chugai Igakusha; 2012. p. 207. Japanese.Google Scholar
- Kamata T, Ochiai M, Kadoya Y, Tomita M, Iehara N. A case of subclavian-brachiocephalic venous junction stenosis diagnosed by a supraclavicular ultrasound. J Jpn Soc Dial Ther. 2013;46:487–91. Japanese.View ArticleGoogle Scholar
- Gracz KC, Ing TS, Soung LS, Armbruster KF, Seim SK, Merkel FK. Proximal forearm fistula for maintenance hemodialysis. Kidney Int. 1977;11:71–5.View ArticlePubMedGoogle Scholar
- Palmes D, Kebschull L, Schaefer RM, Pelster F, Konner K. Perforating vein fistula is superior to forearm fistula in elderly haemodialysis patients with diabetes and arterial hypertension. Nephrol Dial Transplant. 2011;26:3309–14.View ArticlePubMedGoogle Scholar
- Lomonte C, Basile C. On the phenomenology of the perforating vein of the elbow. Semin Dial. 2009;22:300–3.View ArticlePubMedGoogle Scholar
- Bruns SD, Jennings WC. Proximal radial artery as inflow site for native arteriovenous fistula. J Am Coll Surg. 2003;197:58–63.View ArticlePubMedGoogle Scholar
- Moini M, Williams GM, Pourabbasi MS, Rasouli MR, Tarighi P, Mardanloo A, et al. Side-to-side arteriovenous fistula at the elbow with perforating vein ligation. J Vasc Surg. 2008;47:1274–8.View ArticlePubMedGoogle Scholar
- Scholz H. Arteriovenous access surgery. New York: Springer; 2015. p. 135.Google Scholar
- Padberg Jr FT, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: recognition and management. J Vasc Surg. 2008;48:55s–80s.View ArticlePubMedGoogle Scholar
- Konner K, Nonnast-Daniel B, Ritz E. The arteriovenous fistula. J Am Soc Nephrol. 2003;14:1669–80.View ArticlePubMedGoogle Scholar
- Ten Berge MG, Yo TI, Kerver A, de Smet AA, Kleinrensink GJ. Perforating veins: an anatomical approach to arteriovenous fistula performance in the forearm. Eur J Vasc Endovasc Surg. 2011;42:103–6.View ArticlePubMedGoogle Scholar
- Beathard GA, Settle SM, Shields MW. Salvage of the nonfunctioning arteriovenous fistula. Am J Kidney Dis. 1999;33:910–6.View ArticlePubMedGoogle Scholar
- Haruguchi H. Diagnostic methods for vascular access. Tokyo: Chugai Igakusha; 2012. p. 208. Japanese.Google Scholar
- Shafie S, Dickman E. Equipment, image archiving, and billing. In: Soni NJ, Artfield R, Kory P, editors. Point-of-care ultrasound. Philadelphia: Elsevier Saunders; 2015. p. 374–8.Google Scholar
- Ferring M, Claridge M, Smith SA, Wilmink T. Routine preoperative vascular ultrasound improves patency and use of arteriovenous fistulas for hemodialysis: a randomized trial. Clin J Am Soc Nephrol. 2010;5:2236–44.View ArticlePubMedPubMed CentralGoogle Scholar
- Kamata T, Tomita M, Iehara N. Ultrasound-guided cannulation of hemodialysis access. Ren Replace Ther. 2016;2:7. doi:10.1186/s41100-016-0019-1.View ArticleGoogle Scholar