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Extrinsic compression of the left innominate vein in hemodialysis patients
Maxim Itkin1, Michael J Kraus, Scott O Trerotola
1Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104, USA.
Insights
Extrinsic compression of the left innominate vein is common in hemodialysis patients, affecting 44%. This condition, unlike intrinsic stenosis, is not linked to prior catheterization and may require stenting for effective treatment.
Area of Science:
- Vascular Surgery
- Nephrology
- Radiology
Background:
- Central venous stenosis is a frequent complication in patients undergoing hemodialysis.
- Intrinsic stenosis, often due to catheterization, is a well-known cause.
- Extrinsic compression of the left innominate vein is a less recognized etiology.
Purpose of the Study:
- To investigate the prevalence of extrinsic left innominate vein compression in hemodialysis patients.
- To compare extrinsic compression with intrinsic stenosis regarding causes and clinical significance.
- To evaluate the findings in patients undergoing diagnostic fistulography.
Main Methods:
- Retrospective review of 106 fistulograms from 48 hemodialysis patients.
- Grading of extrinsic compression of the left innominate vein.
- Assessment for intrinsic stenosis, collateral veins, and history of central venous catheterization.
Main Results:
- Extrinsic compression was observed in 44% of patients (21/48), with 6% experiencing severe compression.
- Intrinsic stenosis was found in 23% of patients (11/48), predominantly linked to prior catheterization.
- Collateral veins were present in 44% of patients; 52% of those with extrinsic compression and 91% with intrinsic stenosis had collaterals.
Conclusions:
- Extrinsic compression of the left innominate vein is a common and potentially significant finding in hemodialysis patients.
- Unlike intrinsic stenosis, extrinsic compression is not associated with previous central catheterization.
- Treatment may necessitate stent placement, as angioplasty alone can be insufficient due to elastic recoil.
Purpose:
Central venous stenosis is a common problem in hemodialysis patients. The most well known cause is intrinsic stenosis, usually a result of subclavian vein catheterization. A lesser-known cause is extrinsic compression of the left innominate vein. This study investigates the prevalence of this phenomenon in a series of patients undergoing diagnostic fistulography.
Materials And Methods:
One hundred six fistulograms of 48 patients were reviewed retrospectively. In reviewing the fistulograms, attention was paid to the central veins, which were graded for extrinsic compression of the left innominate vein. Presence of collaterals was noted, as well as the presence of any intrinsic stenosis of the left innominate or subclavian veins. Medical records were reviewed for a history of catheterization of the left-side venous system for hemodialysis or any other reason. The type of vascular access (native fistula, synthetic graft) and indication for the fistulogram were recorded.
Results:
Some degree of extrinsic compression was observed in 21 of 48 of patients (44%). Twelve of 48 patients (25%) had mild, six of 48 patients (13%) had moderate and three of 48 patients had (6%) severe compression. Among patients with any degree of extrinsic compression only four of 21 patients (19%) had previous left subclavian or jugular catheterization. Intrinsic stenosis was observed in 11 of 48 patients (23%). All but two of them had undergone previous left subclavian or jugular catheterization and two had concomitant extrinsic compression. Collaterals were seen in 21 of 48 patients (44%). Eleven of 21 patients (52%) with extrinsic compression showed collateral veins. Ten of 11 patients (91%) with intrinsic stenosis had collateral veins. All three patients with severe extrinsic compression were symptomatic and were treated with stent placement after angioplasty failed because of elastic recoil.
Conclusion:
Extrinsic compression is a common finding on diagnostic hemodialysis fistulography and may be hemodynamically significant. Unlike intrinsic stenosis, it is unrelated to previous central catheterization. Angioplasty alone may not be adequate for treatment and stent placement may be required.
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