Case report: A PICC line-associated central occlusion complicating a brachiocephalic fistula.

A 72-year-old right-handed female patient was seen for dialysis access. She was dialyzing via a right IJ permacath for three months, had a BMI of 33, and had adequate vessels for a left brachiocephalic fistula, though the vessels were smaller and deep. There was no history of previous left arm swelling, left sided permacath, clavicular fracture nor pacemaker, but she did report a left arm PICC line during her hospitalization for initiation of dialysis. She was advised to have a left brachiocephalic fistula with delayed superficialization.

The initial procedure was performed uneventfully. On the second post-operative visit at five weeks she was found to have adequate growth and no complications other than excess depth. She was advised to proceed with the second stage superficialization.

On the day of the second surgery, 10 weeks after the initial operation, the patient was found to have mild arm swelling and prominent veins on the arm and shoulder. Suspecting interval development of an upper arm or central stenosis with the development of venous hypertension, an intraoperative venogram was performed at the onset of the procedure. On contrast injection, prominent venous collaterals were noted in the arm. Additional injections demonstrated a complete occlusion of the subclavian vein, with collaterals re-constituting the left IJ and innominant veins (images 1-4).

Attempts to past the subclavian obstruction from the cephalic arch were initially unsuccessful. Thinking that a basilic cutdown for an in-line subclavian recanalization might be more successful, a retrograde injection of the fistula into the arterial outflow with delayed venous-phase imaging demonstrated a basilic vein occlusion in the midarm (image # 5).

The subclavian was finally recanalized from the cephalic approach, was dilated, and stented (image # 6). Ultimately the cephalic arch was also stented (image # 7). The superficialization was then completed, but was complicated by brisk bleeding from all the collaterals formed to bypass the venous occlusions. The patient was kept overnight, but no transfusion was required.

Some lessons from this case:

First, in the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI, usually shortened to “DOQI”) Vascular Access Guidelines published in 1997, loss of central patency was identified as a critical problem. The DOQI 2006 update states that forearm and upper arm veins potentially usable for fistulas should not be used for venipuncture nor IV access, explicitly including PICC lines.
Far from being innocuous, PICC lines can cause serious venous damage and central stenosis or occlusion – 11-23 percent of the time in the literature. Curiously, no one in the hospitals in my area seems to be overly aware of this recommendation, and it is not usually enforced (image # 8).

Second, the history of having a PICC line in the extremity to be used for a fistula should have caused us to include an intra-operative venogram in the original operation. We might have been able to be more proactive.

Third, there is no reason for such a problem to remain undiscovered. Vascular-capable C-arm fluoroscopes are readily available in most hospitals, and it is easy enough to puncture the preliminary fistula in the operating room and shoot some contrast. If a problem is identified, it may be fixable on the spot (as in this case). If not, the operator has a judgment call whether to (1) ligate the preliminary fistula, thinking that the strategy was a mistake from the beginning and cannot be fixed; (2) abandon the superficialization for the time being, pending a recanalization by another operator, or from a different approach (perhaps a retrograde recanalization from a femoral vein or contralateral arm approach – this would have been my choice if I had been unable to open up the stenosis); or (3) go for broke with the superficialization in the face of central stenosis or occlusion, trusting in my relationship with the Lord. I don’t recommend the third choice, as the unrelieved prominent venous collaterals promise to bleed forever, and generally the surgeon starts to wish he had never been born before the surgery is done.

Fourth, re-establishing direct venous return to the heart and restoring central patency is possible with PTFE covered stents. We have a huge experience with central stents, and have found that 5 year patency rates are over 90% – if you can get a wire through it, you can stent it and keep it patent over the years.