Management of Superior Vena Cava Occlusion Causing Bleeding “Downhill” Esophageal Varices in a Dialysis Patient
Pablo V. Uceda, MD, Jasmine L. Richmond, MS, Julio Peralta Rodriguez, MD, Hernán Vela, MD, Luis Vega Salvatierra, MD, Adelina Lozano Miranda, MD, Samuel S. Ahn, MD.
DFW Vascular Group, Dallas, TX, USA.
DEMOGRAPHICS: An 18 year-old woman on chronic hemodialysis for three years was admitted with hematemesis.
HISTORY: She had past history of mielomenigocele and developed urologic complications that caused end stage renal disease. She was on hemodialysis with a central venous catheter initially and then later with a left brachiocephalic fistula. Upon admission for hematemesis patient underwent upper endoscopy that revealed three columns of grade III esophageal varices throughout the esophagus with multiple red patches, strips, and evidence of bleeding that required banding. She was then evaluated with left arm fistulogram and venogram that revealed SVC occlusion from 1 cm above the right atrium to the junction with the brachiocephalic veins. There was a large azygous vein with downward flow.
PLAN: Endovascular repair of SVC occlusion was planned as treatment of “downhill” bleeding esophageal varices. This was done from a right femoral vein approach catheterizing the SVC stump and left arm access puncture to place a sheath in the left brachiocephalic vein as a reference point. A transseptal needle was used from below to cross the SVC occlusion into the left brachiocephalic vein; and after angioplasty a self expanding stent was deployed in the SVC and the left innominate vein. Final venogram revealed excellent flow from left brachiocephalic vein to SVC and right atrium without filling of the azygous vein. The patient was discharged the following day in satisfactory condition. She underwent upper endoscopy 6 weeks after the procedure that revealed grade II esophageal varices without evidence of bleeding.
DISCUSSION: The incidence of central vein occlusion in hemodialysis patients is reported to be 10-40% and is a known complication of tunneled dialysis catheters. Superior vena cava occlusion is associated with significant morbidity in these patients and is frequently associated with dysfunction of upper extremity dialysis access that may require ligation in severe cases. Esophageal bleeding due to “downhill” is a rare manifestation of SVC occlusion with only 38 cases reported in the literature. Of these, only 10 were caused by central venous catheters representing 0.4-11% of all esophageal varcies.1,2 Bleeding from “downhill” esophageal varices should be considered in the differential diagnosis of dialysis patients exposed to central venous catheters. We recommend aggressive endovascular treatment of SVC occlusion to preserve upper extremity access function and prevent bleeding.
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