Subclavian steal syndrome in a hemodialysis patient after percutaneous transluminal angioplasty of arteriovenous access.

INTRODUCTION: We describe a hemodialysis patient who developed subclavian steal syndrome via an arteriovenous fistula after percutaneous transluminal angioplasty. CASE DESCRIPTION: A 55-year-old female with end-stage renal failure due to polycystic kidney disease had been treated with hemodialysis for 10 years. Because of an autologous arteriovenous fistula stenosis, percutaneous transluminal angioplasty was performed. After successful treatment with percutaneous transluminal angioplasty, the patient developed dizziness. Magnetic resonance imaging with angiography of the brain and neck revealed normal bilateral subclavian and carotid arteries. However, flow in the left vertebral artery was not detected in time-of-flight magnetic resonance angiography. The left vertebral artery showed completely reversed blood flow as detected by color duplex ultrasound. We also confirmed anterograde flow in the left vertebral artery by color duplex ultrasound with arteriovenous fistula compression. Arteriovenous flows before the arteriovenous fistula stenosis and post-percutaneous transluminal angioplasty were 1146 and 2239 mL/min, respectively. These findings suggested high-flow arteriovenous fistula led to the subclavian steal syndrome. The patient was subsequently treated by a flow reduction in the high-flow arteriovenous access using a modified graft inclusion technique. We decreased the arteriovenous fistula flow to 851 mL/min, which remained under 850 mL/min, 1 year later. The brain natriuretic peptide level and right-ventricular pressure also decreased after treatment. A modified graft inclusion technique was successful in decreasing the high flow of the arteriovenous fistula, and improved subclavian steal syndrome symptom and cardiac overload. CONCLUSION: This case shows that percutaneous transluminal angioplasty for an arteriovenous fistula may induce subclavian steal syndrome, and a modified graft inclusion technique was useful in improving the high flow of an arteriovenous fistula.

Inpatient venous access practices: PICC culture and the kidney patient.

PURPOSE: Depleted venous access is frequently cited as a reason for low fistula achievement. These quality assurance studies were designed to clarify the interactions between kidney disease, acuity of care and vascular access practices, and define the impact of nephrology intervention. METHODS: The inpatient population at an urban teaching hospital was surveyed three times between May 2010 and May 2012. Data were collected on limb protection and vascular access practices, as well as level of kidney function and level of care. RESULTS: Peripherally inserted central catheter (PICC) insertion consistently exceeded 30% in patients with chronic kidney disease; reasons for insertion were often poorly defined. More than 50% of patients had devices in the nondominant arm; use of limb protection bracelets was rare. An educational intervention designed to increase nephrologist awareness increased limb protection slightly, but did not affect the distribution of vascular access devices. CONCLUSIONS: PICC placement and invasion of the nondominant arm are both frequent in patients with abnormal kidney function, in spite of guidelines discouraging their use. The rate of PICC is higher than that of patients with normal kidney function. Current vascular access practices have substantial potential to affect future fistula rates. Effective vein protection may require participation of the entire medical community.