The Hulk Hand!—In a Hemodialysis Patient

A 35-year-old gentleman who was on maintenance hemodialysis for last 20 months presented with progressive swelling of the left upper limb. Initially, he had right nontunneled internal jugular vein (IJV) catheter followed by left nontunneled IJV catheter through which he received dialysis for 2 months. Further, his left brachiocephalic fistula (BCF) was created 18 months back. Since then, he was on regular thrice weekly dialysis through BCF. He started developing swelling of the left upper limb 8 months after fistula creation, which was gradually increasing. Blood flow was found to be normal during dialysis, examination suggestive of entire left upper limb swelling with thick induration. Doppler showed dilated outflow veins with high flow without any narrowing/stenosis of veins. Computed tomography venography done showed left brachiocephalic vein stenosis. He was found to have mega-fistula secondary to central vein stenosis which was managed successfully being discussed in this case report. Undiagnosed occult central venous stenosis in the prearteriovenous fistula (AVF) construction can manifest in various ways; one of them is as mega-fistula. It is the generalized aneurysmal dilatation of the entire outflow vessels of an AVF. Management option for this condition is limited depending on the etiology, fistula flow has to be reduced either by banding of the vessel or by fistula closure. Assessment of central veins before AVF construction and regular access surveillance in dialysis patients may prevent complications like these.