Dermatol Sinica, June 2006 145

* **

Peripheral Venous Hypertension Related to ArteriovenousFistula for Hemodialysis

- A Case Report -

Wen-Yu Chang Jiann-Woei Hwang* Hong-Tien Kuo** Gwo-Shing Chen Hsiu-Hui Chiu Chieh-Shan Wu

Venous hypertension is a significant problem for patients under chronic hemodialysis.Arterialization of the outflow venous system may induce this condition, and result in impairment ofarteriovenous access function, disabling upper extremity edema, violaceous discoloration and hyperpig-mentation, ulceration of the skin, and in advanced cases, gangrene formation of the fingers and neural-gia. Histologic features show thick-walled capillaries with plump endothelial cells in upper dermis,which are compatible with the pattern of stasis dermatitis by chronic venous insufficiency. Early aware-ness of these problems is crucial for dermatologists to prevent the extreme result of gangrene forma-tion.(Dermatol Sinica 24: 145-149, 2006)

Key words: Venous hypertension, Pseudo-Kaposi's sarcoma, Arteriovenous fistula

( 24: 145-149, 2006)

From the Departments of Dermatology, Cardiovascular Surgery,* Nephrology,** Kaohsiung Medical University HospitalAccepted for publication: December 02, 2005Reprint requests: Chieh-Shan Wu, M.D., Department of Dermatology, Kaohsiung Medical University. No. 100, Shih-Chuan 1stRd., Kaohsiung, Taiwan, R.O.C. TEL: 07-3208214 FAX: 07-3216580

146 Dermatol Sinica, June 2006

INTRODUCTIONVenous hypertension of the hand caused

by arteriovenous access in patients receivinghemodialysis was first described in 1975.1 Itcauses swelling, induration, hyperpigmentation,and even ulceration distal to the arteriovenousaccess. We herein report a case of venoushypertension which developed thirteen monthsafter arteriovenous access creation, as a rarecomplication in patients involved in chronichemodialysis program.

CASE REPORTA 69-year-old female visited our out-

patient-clinic in November 2004 for progressiveswelling and tingling sensation over her righthand for 4 months. She had an autologous arte-riovenous access placement over her left wristand has been receiving hemodialysis at a localhospital for 9 years for underlying end stagerenal disease with undetermined etiology. Pastmedical problems included hypertension, previ-ous gastric ulcer bleeding, and right ureteral andrenal transitional cell carcinoma. Due to gradualthinning of the arteriovenous shunt, she had a

right brachial artery expanded polytetrafluoreth-ylene (PTFE) arteriovenous shunt built overright upper arm at the local hospital and keptreceiving hemodialysis since June 2003. In July2003, she underwent radical cystectomy, bilat-eral nephroureterectomy, and paraaortic lymphnode dissection and received regular hemodial-ysis via the new PTFE shunt. Swelling, localheat and erythema over her right hand and fore-arm developed after hemodialysis. The patientthen abandoned the use of her right upper armshunt and returned to receive hemodialysis viathe previous left wrist graft. Erythema graduallysubsided with less swelling. However, she start-ed to notice progressive swelling, violaceouschange, and tingling sensation of right handsince July 2004.

On physical examination, severe handswelling, purple patches, and violaceous changeof right hand were observed (Fig. 1). The skintemperature of right hand was warmer than lefthand. In addition, several brownish papulesover forearm were also noted. Cellulitis or her-pes zoster was initially considered. Laboratoryexamination revealed slightly elevated C-reac-tive protein, 29.2 µg/ml (normal range <5µg/ml), and leukocyte count 9.38 x 103/ul (nor-mal range 4-10 x 103/ul). During the admissionin November 2004, we prescribed intravenousacyclovir 125mg along with prostaphyllin 2 g

Fig. 1 Swelling, induration, violaceous discoloration and ulcerationof right hand caused by arteriovenous access for hemodialysis

Fig. 2 Thick-walled capillaries with extravasated erythrocytes,hemosiderin deposits, and interstitial mononuclear inflam-matory infiltrate in the dermis (H&E stain, 200X).

Dermatol Sinica, June 2006 147

per day. We consulted cardiologists for vascularsurvey and peripheral vascular echography ofupper extremities, which showed adequate rightarm flow and no evidence of deep vein throm-bosis. The patient requested discharge after 3days due to personal preference for hemodialy-sis at previous hospital.

In December 2004, she visited our out-patient-clinic again with complaints of persistedswelling and severe neuralgia of her right palm.Incisional biopsy was taken from the violaceusdiscoloration on the dorsum of her right hand.Under the microscope, the epidermis and papil-lary dermis was unremarkable. Thick-walledcapillaries with plump endothelial cells,extravasated erythrocytes, hemosiderin depositsand mononuclear inflammatory infiltrates indermis were noticed (Fig. 2). The histologicalpattern is compatible with stasis dermatitis inpatients with chronic venous insufficiency.During readmission, leukocytosis (12 x 103/ul)with elevated C-reactive protein (53.1 g/ml)was found. We prescribed Unasyn® (ampicillinsodium/sulbactam sodium) 3 g per day withsupplement after hemodialysis, but the patient'scondition did not improve. Skin swabs for aero-bic and anaerobic cultures from the ulcerationswere negative. We arranged Tc-99m RBCs sub-

cutaneous radionuclide venography and Tc-99msulfur colloid lymphoscintigraphy for suspicionof poor venous or lymphatic return. The resultof venography revealed visualized intact deepvenous return without collateral venous forma-tion in the bilateral upper extremity over bloodflow (with tourniquet applied in the bilateralelbows and wrists) and blood pool (after remov-ing tourniquet in the bilateral elbows andwrists) study. Lymphoscintigraphy showed noovert evidence of lymphatic obstruction. Patientresponded poorly to antibiotic treatment and hercondition continued to deteriorate with worsen-ing of swelling, ulceration, neuralgia, and fever(38.5OC). Further elevation of C-reactive proteinlevel (91.8 g/ml) was also noted. Diagnosticangiography was then arranged due to highlysusceptible vascular problems despite the risk oflocal infection. After puncturing the arteriove-nous access, the angiography showed reverseflow, arterialization of the outflow vein, andpoor central venous drainage (Fig. 3a, 4).Diagnosis of venous hypertension caused byhemodialysis shunt was then established.Diffuse venous collaterals and poor distal arteri-al run-off with irregular contour were alsonoticed over right forearm and hand, possiblyrelated to long-standing edema (Fig. 3b). The

Fig. 3 Angiography of right upper arm. a: Reverse flow, arterializationof the outflow vein (arrow), and poor central venous drainage. b:Diffuse venous collaterals were also noticed over right forearm

Fig. 4 Illustration of the angiography. Reverse flow (arrow),instead of the normal venous flow (dotted arrow), resulted invenous hypertension.

148 Dermatol Sinica, June 2006

cardiac surgeon then performed horizontalsuture ligation of the graft. Two days after oper-ation, progression of swelling halted with for-mation of wrinkle on her right hand dorsum(Fig. 5). Follow-up C-reactive protein level alsodecreased to 13.7 g/ml. She was then dis-charged with topical silver sulfadiazine forwound care. After 6 months' follow-up, therehas been no recurrence of the swelling or ulcer-ation. Only residual hyperpigmentation wasobserved over her right hand.

DISCUSSIONProper creation of a well-functioning arte-

riovenous access for hemodialysis is vital inpatients involved in chronic hemodialysis pro-gram. Vascular complications of arteriovenousaccess construction for hemodialysis are rare.However, early recognition is crucial. Venoushypertension occurs in 0.1% to 0.5% of patientsand may develop after 1 to 2 years.2, 3 In ourpatient, venous hypertension occurred thirteenmonths after the creation of arteriovenousshunt.

The clinical findings of the complicationstart with edema of one or more fingers, and thethumb is often affected. The edema may extendto the whole hand and forearm. More developedstages are manifested by bluish discoloration ofthe fingers, cyanotic-like changes, and pigmen-

tation. In advanced cases, necrosis of skin, gan-grene change of the fingers and neuralgia mayoccur.4, 5 Eventually ulceration of the skin occurssimilar to that seen in chronic venous hyperten-sion related varicose ulceration of legs.5

The etiology of central venous stenosisrelated to hemodialysis is most often initiatedby placement of an indwelling catheter. Injuryto the venous wall leads to fibrotic reaction andthrombosis that may cause significant stenosisor complete occlusion of the subclavian vein. Ifthe access does not thrombose and the collateralcirculation around the area of central venousocclusion is not adequate, signs and symptomsof venous hypertension become apparent.6

Anatomically, venous hypertension canoccur in all configurations of upper extremityaccess due to arterialization of the veins.Increased venous pressures in the presence ofincompetent venous valves distally in the armlead to higher distal venous pressure and devel-opment of symptoms. This can also happen inprosthetic arteriovenous access when there isreversal of flow in the outflow vein due tovalvular incompetence in the vein distal to thevenous anastomosis. This may be the possibleetiology in our patient.6

The erythema, tenderness, swelling, skinnecrosis and neuralgia may lead to misdiag-noses related to certain infectious processessuch as cellulitis and herpes zoster.Antimicrobial treatment alone may be ineffec-tive, as in our case. It is necessary to distinguishlimb ischemia secondary to arterial insufficien-cy, which induces a similar picture but withoutthe edema. To identify these patients withvenous hypertension, a high index of suspicionis required. Physical examinations such as pal-pation and auscultation may indicate the direc-tion of blood flow. Venous duplex ultrasound isa good screening tool for imaging of the centralvenous circulation for stenoses, dilated collater-als, and venous reflux. Unfortunately, someproximal lesions are unable to be adequatelyimaged secondary to poor ultrasound windows.6

The definitive diagnostic study remains inupper extremity angiography. Direct puncture of

Fig. 5 Upper: Skin necrosis with severe swelling, local heat anderythema before operation. Lower: Reduced swelling withwrinkle formation two days after operation.

Dermatol Sinica, June 2006 149

the arteriovenous access itself should includeimaging of the access, with particular attentionto the venous anastomosis, and the centralvenous circulation for detection of centralvenous occlusion or arterialization of vein.

Skin biopsy of the hyperpigmented mac-ules may be helpful, by revealing the findingsof stasis dermatitis-like lesions with thick-walled capillaries with plump endothelial cells,or pseudo-Kaposi's sarcoma with proliferationsof small vascular spaces and narrow vascularchannels lined by spindle cells in extremecases.7 Extravasated erythrocytes, hemosiderindeposits and mononuclear inflammatory infil-trates are common findings.

The primary goal of diagnosis and therapyof venous hypertension is symptomatic reliefwhile maintaining the functionality of theaccess. Mild forms of the complications, mostlydemonstrated by edema, may be treated by posi-tioning of the limb and employment of bandag-es. Ligation of the access and replacement atanother site has been proposed as a primarymode of the therapy, which decreases the flowinto the venous circulation and reduces armedema and sequelae of venous hypertension.Other choices of managing severe venoushypertension may include percutaneouscatheter-based transluminal angioplasty andintravascular stents placement, reconstruction ofthe central venous circulation with bypassingthe occlusive lesion to a patent vein with directcentral flow, and adjuncts of anticoagulationand antibiotics.6, 8

As the numbers of patients on hemodialy-sis increases, more arteriovenous accesses areconstructed. Venous hypertension will become acomplication which dermatologists mayencounter with rare but increasing frequency.This report highlights and documents angio-graphically a case of venous hypertension mas-querading as an infection. We would also like toemphasize the importance of diagnostic angiog-raphy due to poor window of peripheral vascu-lar echography over proximal shunts and insuf-ficient sensitivity of Tc-99m RBCs subcuta-neous radionuclide venography,.

REFERENCES1. Haimov M, Baez A, Neff M, et al.: Complications

of arteriovenous fistulas for hemodialysis. ArchSurg 110: 708-712, 1975.

2. Irvine C, Holt P: Hand venous hypertension com-plicating arterio-venous fistula construction forhaemodialysis. Clin Exp Dermatol 14: 289-290,1989.

3. Nakagawa Y, Ota K, Sato Y, et al.: Complicationsin blood access for hemodialysis. Artif Organs 18:283-288, 1994.

4. Knezevic W, Mastaglia FL: Neuropathy associatedwith Brescia-Cimino arteriovenous fistulas. ArchNeurol 41: 1184-1186, 1984.

5. Wood ML, Reilly GD, Smith GT: Ulceration ofthe hand secondary to a radial arteriovenous fistu-la: a model for varicose ulceration. Br Med J (ClinRes Ed) 287: 1167-1168, 1983.

6. Neville RF, Abularrage CJ, White PW, et al.:Venous hypertension associated with arteriove-nous hemodialysis access. Semin Vasc Surg 17:50-56, 2004.

7. Burnand KG, Clemenson G, Whimster I, et al.:The effect of sustained venous hypertension on theskin capillaries of the canine hind limb. Br J Surg69: 41-44, 1982.

8. Glanz S, Gordon DH, Butt KM, et al.: The role ofpercutaneous angioplasty in the management ofchronic hemodialysis fistulas. Ann Surg 206: 777-781, 1987.