Parathyroidectomy in the presence of central venous stenosis

Hyperparathyroidism is common in the end-stage renal failure and may require surgical intervention. In addition, following multiple vascular access attempts central venous stenosis may occur. The results in high-volume venous blood flow through neck collaterals. Here, we describe a case of severe secondary hyperparathyroidism, high flow arteriovenous fistula and central venous occlusion unresponsive to radiological intervention. A four-gland exploration was undertaken and global parathyroidectomy was performed. Despite meticulous attention to haemostasis, blood loss was considerable from the skin edges although thyroid veins were easily controlled with a drop of 2.1 g/dl in haemoglobin. Postoperative hypocalcaemia requiring intravenous calcium occurred as expected from the severity of his bone disease (preoperative parathyroid hormone (PTH) 26 times the upper normal range). The patient recovered well, despite a small subcutaneous haematoma and remains asymptomatic.