Severe Venous Hypertension Due to Central Venous Occlusion Leading to Arteriovenous Fistula Ligation: A Case Report

Central venous stenosis and occlusion are complications of hemodialysis vascular access.In patients with a functioning ipsilateral arteriovenous fistula (AVF), impaired venous outflow can cause severe venous hypertension.Endovascular treatment is first-line, but recurrence is common and management after repeated failure is not well defined.We report a 62-year-old right-handed woman on hemodialysis for five years whose left radiocephalic AVF failed and was replaced by a left humerocephalic AVF; a tunneled left internal jugular catheter was kept for approximately one year.She developed left upper limb edema due to a left brachiocephalic vein stenosis, which resolved after balloon angioplasty and recurred six months later; the same stenosis was dilated again.Four months later, she presented with diffuse limb edema, severe pain, and marked cyanosis of the hand, with preserved distal pulses.Fistulography showed complete occlusion of the left brachiocephalic vein.Because symptoms had recurred after two angioplasties and the patient did not wish a further attempt, the AVF was ligated.Within two days, pain disappeared, the edema regressed until the two limbs were comparable, and cyanosis regressed.A right humerobasilic AVF was created one month later, and the tunneled catheter was removed approximately three months after the ligation.At six months, the left limb remained free of edema and pain, and the new AVF was functional.Ligation with creation of a contralateral access may be considered as a salvage option in similar situations, at the cost of losing the access; a single case cannot establish its safety or superiority.