Central vein stenosis in hemodialysis patients during COVID pandemic: A case series analysis

Abstract

End-stage kidney disease (ESKD) patients who were on maintenance hemodialysis require a stable, permanent vascular access as a lifeline. Venous mapping during prearteriovenous fistula (AVF) construction does not include central vein assessment. The guidelines on angiographic assessment of central veins during pre-AVF construction are yet to be streamlined. Moreover, during COVID pandemic, assess difficulty in catheterization laboratory and interventional radiology created devastating situation. We report 15 ESKD cases of central venous stenosis presented during the COVID pandemic time from February 2020 to July 2021. Patients' basic details were collected and initial clinical examination findings were recorded; they were subjected to Doppler and fistulogram. After the combined decision of nephrologist, interventional cardiologist, and vascular surgeon, the management (fistula closure/repair) was planned. Of 15 patients, 13 were males. Basic disease is chronic glomerulonephritis in 9, diabetic nephropathy in 4, and chronic interstitial nephritis in 2. Average number of central vein cannulation prior to AVF creation was 2.6. The median time to the development of symptoms after fistula creation was 13 months. Major initial symptoms were swelling of the upper limb in 4, dilatation of outflow veins in 5, swelling and dilatation in 2, poor flow during dialysis in 3, and dilatation of neck and chest vein in 1. Arm elevation test was positive in most of the cases. On Doppler assessment, dilated veins (>12 mm) with high outflow (>2000 ml/min) in 5, 4 patients showed low flow (<400 ml/min), and six patients showed normal findings. In fistulogram, the common location of stenosis/thrombosis was brachiocephalic vein (BV) in 5 and subclavian vein (SC) in 3, BV vein + SC vein in 4, and superior vena cava in 3. Out of 15, 3 underwent balloon dilatation, 7 underwent fistula closure, 1 no intervention done, 3 lost to follow-up, and 1 expired. This is the first case series of central vein stenosis (CVS) brought in light during COVID pandemic. CVS is a serious issue, which might result in permanent vascular access failure. Further study is needed on impact of previous central vein catheterization leading to stenosis and role of pre-AVF creation angiographic assessment to avoid this type of devastating AVF complication.