Central Venous Reflux, a Rare Cause of Neurological Manifestations in Hemodialysis Patients: A Case Report and Literature Review

[Risk Factors associated with Central Vein Stenosis Development in Hemodialysis Vascular Access among Patients with Normal Preoperative Venography]

Purpose

We aimed to discover risk factors for central vein stenosis (CVS) in hemodialysis patients with normal preoperative venography.

Materials and Methods

Among the 411 individuals who underwent upper arm venography for hemodialysis access evaluation in 2017, we reviewed venography and medical record data from 349 patients with normal preoperative venography who subsequently underwent arteriovenous fistula creation. We compared the data between patients with and without CVS development.

Results

Among the 349 patients, 22 (6.3%) developed CVS during a median 20.9-month follow-up. The development of CVS appeared to be associated with preoperative venography findings (the presence of collateral vessels and cephalic arch stenosis), location of hemodialysis access, and history and duration of ipsilateral hemodialysis catheter placement (p < 0.05). Multivariate analysis identified two or more collateral vessels on venography, left-sided arteriovenous fistula, and a previous history of ipsilateral hemodialysis catheter placement as independent risk factors for CVS development (p < 0.05).

Conclusion

Even in patients with normal preoperative venography findings, there is an increased possibility of CVS development after arteriovenous fistula creation if they have more than two collateral vessels on venography, a left-sided arteriovenous fistula, or a history of ipsilateral hemodialysis catheter placement.

A rare hemodialysis vascular access complication-Internal jugular vein reflux

Hemodialysis (HD) arteriovenous fistulas commonly present with late vascular access complications, but are rarely in association with internal jugular vein (IJV) reflux. We reported two patients who had severe and mild IJV reflux, respectively. Case 1 was a 48-year-old male with end-stage renal disease (ESRD) who had been treated with HD for 5 years. He presented with persistent headaches, nausea, and vomiting. Combined with all the examinations, it was revealed severe IJV reflux, brachiocephalic vein stenosis, high-flow vascular access, and IJV valve dysfunction. Case 2 was a 59-year-old female with ESRD who had constructed an AVF for 4 months and had been on HD for only 1 day. She presented with dizziness and nausea after the first hemodialysis and duplex ultrasonography showed slightly continuous IJV reflux, high-flow vascular access, and IJV valve dysfunction. Furthermore, we reviewed 16 case reports to identify the characteristics of IJV reflux in HD patients. IJV reflux in HD patients may be caused by high-flow access, central venous stenosis or occlusion, and valve dysfunction. Severe IJV reflux can develop neurological symptoms secondary to intracranial venous reflux in this article. Etiological treatment is helpful for these patients, but there is a risk of recurrence.

Retrograde Flow Into the Internal Jugular Vein in a Hemodialysis Patient Mimicking Dural Arteriovenous Fistula: A Case Report

Arterial spin labeling (ASL) and three-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) are sensitive tools to detect dural arteriovenous fistula (DAVF), but hyperintensity in these images is also caused by jugular venous reflux. We present a case of a patient with renal failure on hemodialysis with retrograde flow into the internal jugular vein (IJV) mimicking DAVF. A 74-year-old man with a radial arteriovenous fistula for hemodialysis experienced transient dizziness. The TOF MRA and ASL revealed high signal intensity, suggesting the presence of a DAVF in the left transverse and sigmoid sinuses and the IJV. Digital subtraction angiography (DSA) revealed no evidence of a DAVF but showed retrograde flow into the IJV via his radial shunt. In hemodialysis patients, a high-flow shunt can cause fast retrograde flow into the dural sinuses and might lead to intracranial hypertension. The ASL images are useful for early detection and careful observation.

Bilateral Dilated Superior Ophthalmic Veins in a Patient With an Arteriovenous Dialysis Fistula

A 64-year-old man presented with 4 months of diplopia. He had end-stage renal disease requiring a cephalic transposition brachiocephalic fistula that was no longer in use following successful renal transplantation. On presentation, he had bilateral proptosis, extraocular movement restriction, chemosis, tortuous episcleral vessels, and caruncular injection. Non-contrast CT of the orbits demonstrated dilation of both superior ophthalmic veins, and CT angiography showed asymmetric enlargement of both cavernous sinuses and superior ophthalmic veins. A carotid-cavernous fistula was suspected, but cerebral angiography revealed shunting from the old fistula with intracranial drainage and cerebral venous hypertension. Aberrant retrograde drainage resulted from anatomical compression of the left brachiocephalic vein. The fistula was ligated, and at 1-week follow-up, the patient had marked improvement in extraocular movements and orbital congestion with near complete resolution of diplopia. Postoperative CT angiography obtained 2 months later demonstrated decreased size of both superior ophthalmic veins, consistent with improvement of venous hypertension.

Cerebral hemorrhage due to intracranial venous reflux associated with left brachiocephalic vein occlusion in a hemodialysis patient

Background:

Although central venous occlusion is sometimes seen in hemodialysis (HD) patients, neurological symptoms due to intracranial venous reflux (IVR) are extremely rare.

Case Description:

We present a case of a 73-year-old woman with cerebral hemorrhage due to IVR associated with HD. She presented with lightheadedness and alexia, and was diagnosed with subcortical hemorrhage. Venography through the arteriovenous graft showed occlusion of the left brachiocephalic vein (BCV) and IVR through the internal jugular vein (IJV). It is extremely rare that IVR occurs and causes neurological symptoms. This is because that there is the presence of a valve in the IJV and the communication between the right and left veins through the anterior jugular vein and thyroid vein. Percutaneous transluminal angioplasty for the left obstructive BCV was performed, but the obstructive lesion was only slightly improved. Hence, shunt ligation was performed.

Conclusion:

When IVR is found in HD patients, central veins should be confirmed. Early diagnosis and therapeutic intervention are desirable when neurological symptoms are present.

Endovascular Treatment of Cerebral Venous Circulation Dysfunction Caused by Hemodialysis Shunt: A Case Report

Objective

Central venous disease, defined as ≥50% stenosis or obstruction of central veins, is one of many life-threatening complications faced by patients on hemodialysis. It often presents as upper limb edema to the arteriovenous (AV) shunt for hemodialysis, although neurological symptoms are rare. We report a case of central venous disease with neurological symptoms associated with endovascular therapy.

Case Presentation

A 79-year-old man presented with status epilepticus. His past medical history included rectal carcinoma when he was 69 years old and indication for hemodialysis when he was 79 years old. However, he had no history of neurological disease or epilepsy. On arrival at our facility, CT perfusion revealed venous circulation dysfunction on the left cerebral hemisphere. DSA demonstrated regurgitation from the AV shunt on left upper limb to the cerebral veins and obstruction of the left subclavian vein. Ligation of the causal AV shunt was deemed difficult due to surrounding edema; therefore, endovascular transarterial coil embolization was performed. After completely occluding the AV shunt, patient's condition improved significantly. The patient was discharged 3 days later without neurologic symptoms, with no recurrence of epilepsy was observed to date.

Conclusion

Coil embolization of causal AV shunt significantly improved the neurological symptoms of central venous disease.

Trigeminal neuralgia due to intracranial venous reflux following central venous disease in a patient on hemodialysis: A case report

Background:

A wide variety of conditions can cause trigeminal neuralgia (TN).

Case Description:

We describe a rare case of a 77-year-old female patient on hemodialysis presenting with severe TN on the right side of the face for several weeks. She underwent multiple revisions using catheter for brachiocephalic venous stenosis over 6 years after a therapeutic arteriovenous fistula (AVF) was created in the left forearm. Her facial pain was consistent with Type 1 TN and remained intractable even after carbamazepine treatment. The initial magnetic resonance imaging did not demonstrate arterial compression on the right trigeminal nerve; instead, the vein adjacent to the right trigeminal nerve showed a hyperintense signal. In addition, the contralateral cortical veins and transverse sigmoid sinus were dilated. Angiography from the left brachial artery revealed intracranial venous reflux (IVR) through the left jugular vein due to an occluded brachiocephalic vein. Her pain was relieved immediately after her left upper arm was compressed with a sphygmomanometer to decrease the shunt. Surgical elimination of the AVF on the left forearm resulted in complete resolution of TN. Postoperative radiological examination revealed the resolution of IVR, and her TN has not recurred by her 6-month follow-up.

Conclusion:

The radiological diagnosis of IVR might be complicated because the true causative lesion for focal neurological symptoms might be remotely located. IVR following central venous disease should be a differential when patients on hemodialysis present neurological symptoms.

Intracranial venous reflux without the central venous occlusive disease in a patient receiving hemodialysis through brachio-brachial arteriovenous fistula: A case report

Background

Upper-limb arteriovenous fistula as a hemodialysis access among patients with end-stage renal disease (ESRD) has become a preferred type of vascular access. However, complications involving the central nervous system may occur. There have been no reported cases of internal jugular vein (IJV) regurgitation without central venous occlusive diseases (CVODs).We describe the case of a patient on HD who presented with symptomatic IJV regurgitation without CVODs.

Case Description

An 83-year-old man with ESRD receiving HD through a left upper-limb AVF presented with impaired consciousness and seizures. After recovery from unconsciousness, he became alert with cognitive impairment. The left subclavian arteriography revealed early filling of the left subclavian vein due to the AVF on the left brachium, with retrograde high-flow venous reflux to the left IJV, sigmoid and transverse sinuses, with the left central veins patent. All cerebral venous drainage procedures were dependent on the right IJV. The left internal carotid arteriography showed venous congestion of the left hemisphere. The flow of the left brachial artery was measured extremely high. Under compression of the left brachial artery to reduce the flow, the regurgitation persisted. With the findings that all cerebral venous return were in the right IJV, sacrificing the left IJV was thought to be acceptable. Left IJV ligation was performed, and the patient's cognitive function improved.

Conclusion

The short-term outcome after IJV ligation may be positive in the patient who was confirmed to have a normal cerebral venous return route independent of the refluxed IJV.