Hemodialysis International 2015; 19:E6–E9
Access
Digital infarction in a hemodialysis patient due to embolism from a thrombosed brachial arteriovenous fistula Anupama YJ Department of Nephrology, Nanjappa Hospital, Shimoga, Karnataka, India
Abstract Acute onset of digital ischemia and infarction is an unusual complication in patients undergoing hemodialysis. This is a report of a patient on regular hemodialysis who presented with acute distal extremity ischemia, progressing to digital infarction and on evaluation was found to have thrombosis of brachial arteriovenous fistula with embolization to the distal arteries causing digital artery occlusion. Key words: Hemodialysis, thrombosed arteriovenous fistula, brachial, embolization, digital infarction
INTRODUCTION Digital gangrene is an unusual complication in patients undergoing hemodialysis. It is known to occur in less than 4% of patients and even then, it commonly follows arterial steal. Here, we report a case of digital ischemia and infarction that occurred due to embolism from a thrombosed brachial arteriovenous fistula (AVF).
CASE REPORT A 58-year-old lady with diabetes mellitus and chronic kidney disease stage 5 on regular dialysis with brachial AVF as access presented to the emergency room (ER) with history of generalized weakness and breathlessness. She had undergone dialysis 6 hours previously and had had a difficult cannulation. She had complained of pain in the left upper limb during dialysis, which was attributed to
Correspondence to: Anupama YJ, MD,DNB(Nephro), Department of Nephrology, Nanjappa Hospital, Kuvempu Road, Shimoga, Karnataka State 577201, India. E-mail: [email protected]
the difficult cannulation and the multiple pricks. This pain had worsened after the completion of dialysis and she complained of excruciating pain in the upper limb when she arrived at the ER. On evaluation, the left forearm was cold to touch and she complained of severe pain on slightest passive movement of the limb. The forearm was flaccid and active movements were not possible at the elbow and wrist joints. Bruit over the AVF was absent. Pulsations of brachial artery could be felt, while radial and ulnar artery pulsations were not palpable. Electrocardiogram revealed absent P waves, broad QRS complexes almost merging with the T waves suggestive of hyperkalemia (Figure 1). Her arterial blood gas analysis was suggestive of severe metabolic acidosis with pH 7.02, pCO2-26, pO2-124, HCO3-7.5 mmol/L. Serum potassium was 9.1 mmol/L. She was treated with emergency hemodialysis with femoral double lumen catheter as the access using potassium-free concentrate. She was then referred to the vascular surgeon for further management. However, the surgeon noted that while the limb was still paretic and cold to touch, both radial and ulnar artery pulsations were well felt. Patency of radial and ulnar arteries was confirmed on Doppler study of the arteries. There was complete occlusion of the cephalic vein and the AVF.
© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12256
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Digital infarction in a dialysis patient
Figure 1 Electrocardiogram of the patient at admission showing features suggestive of hyperkalemia.
Computed tomography angiogram of the left upper limb arteries also confirmed complete occlusion of the AVF and the post-fistula segment of the cephalic vein, while the radial and ulnar arteries were patent. There was complete cut-off of the contrast in all the digital arteries (Figure 2).
Surgical intervention was ruled out in view of the patency of the radial and ulnar arteries. She was treated with heparin infusion at the rate of 1000 units/hour and oral anticoagulants without substantial benefit. The ischemia remained at the digits and gradually the tips of all 5
Figure 2 Computed tomography angiogram of the left upper limb showing thrombosis of the AVF and the distal cephalic vein, patent forearm arteries and digital cut-off of the contrast.
Hemodialysis International 2015; 19:E6–E9
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YJ
Figure 3 Digital gangrene.
digits on the left hand turned gangrenous with the line of demarcation being confined to the level of distal interphalangeal joints on all digits (Figure 3). She discontinued hemodialysis and switched over to continuous ambulatory peritoneal dialysis.
DISCUSSION Limb ischemia in chronic hemodialysis patients is a rare phenomenon and is seen in less than 4% of hemodialysis patients.1 Hemodialysis access-induced distal ischemia (HAIDI) can occur acutely (1 month) after AVF placement.2 Chronic HAIDI is usually attributable to chronic steal with shunting of blood through the proximally placed low pressure AVF “stealing” away from the high pressure forearm arteries. In some cases, the distal arteries may be sclerosed or stenosed and allow lesser flow which contributes to the hypoperfusion.3 Chronic venous hypertension and massive limb edema causing pressure on the distal arteries is a less common cause. Acute hand ischemia occurring a few hours after arteriovenous access surgery is known to occur in a few cases and is a surgical emergency as untreated ischemia rapidly compromises limb function.4 Thromboembolism from AVF is the least common cause and very few cases are reported in the literature.5
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Thromboembolism usually involves dislodgement of thrombus from venous aneurysms or pseudoaneurysms. Lacombe reported 4 cases of severe digital ischemia resulting from embolization from a thrombosed AVF and recorded that all 4 patients had an aneurysm on the efferent vein.6 Rarely patients may have arterial pseudoaneurysms due to inadvertent arterial puncture during venous cannulation for hemodialysis.7 The risk is higher with brachial AVFs as the basilic and the cephalic veins are extremely close to the brachial artery. The presence of a tight downstream venous stenosis and repeated cannulations at the same site also facilitate venous aneurysm formation in hemodialysis accesses. These aneurysms or pseudoaneurysms predispose to thrombus formation due to loss of laminar flow and turbulence and hence should be avoided during cannulation to prevent embolism. In our patient, there was a small venous aneurysm that was stable with no recent increase in size. It was generally avoided during cannulation. On that day, there was difficulty in cannulating the AVF as the fistula was probably in the process of clotting and the aneurysm may also have been inadvertently pricked. The multiple cannulation attempts probably led to the dislodgement of a thrombus into the forearm arteries. Initially, patient had pulselessness involving the radial and ulnar vessels and there was complete flaccidity of right forearm, indicating ischemic paralysis of forearm muscles. The tissue ischemia may have caused the severe metabolic acidosis and acute hyperkalemia with cardiotoxicity. The dialysis was also probably inadequate due to the poor flow contributing to the acidosis. This was treated with emergency hemodialysis, which may have been beneficial to the patient as the thrombi in the forearm vessels appear to have lysed due to heparinization. Smaller fragments may have propagated distally to the digital arteries, which are end arteries limiting the extent of the ischemia to the digits. There are few treatment options for patients with distal limb ischemia. Amputation and loss of limb are the usual outcomes. Salvage of the limb can be attempted by catheter-directed thrombolytic therapy along with open repair.5 Percutaneous isolated limb thrombolysis has been tried with some success in a few cases.8 However, in general, peripheral arterial thromboembolic lesion responds poorly to thrombolytic therapy and was not tried in our patient.
CONCLUSIONS Digital ischemia due to embolic phenomenon following thrombosis of AVF is a rare event. Early diagnosis and urgent treatment with intra-access catheter-directed
Hemodialysis International 2015; 19:E6–E9
Digital infarction in a dialysis patient
thrombolysis may be beneficial in salvaging the limb. Prevention of formation of pseudoaneurysm by good venipuncture, rotation of puncture sites, and ensuring adequate hemostasis at the end of the dialysis session is essential to prevent such devastating complications.
ACKNOWLEDGMENTS I thank Dr Narendra G. Nishanimath, Consultant Cardiothoracic Surgeon, Nanjappa Lifecare, Shimoga, and Dr Uma Pandurangi, Consultant Radiologist, Medall Diagnostics, Shimoga, for their contribution to the management of this patient. Conflict of interest: None.
Manuscript received August 2014; revised October 2014.
REFERENCES 1 Tordoir JHM, Dammers R, van der Sande FM. Upper extremity ischemia and hemodialysis vascular access. Eur J Vasc Endovasc Surg. 2004; 27:1–5.
Hemodialysis International 2015; 19:E6–E9
2 Scheltinga MR, van Hoek F, Bruijninckx CMA. Time of onset in haemodialysis access-induced distal ischaemia (HAIDI) is related to the access type. Nephrol Dial Transplant. 2009; 24:3198–3204. 3 Leon C, Asif A. Arteriovenous access and hand pain: The distal hypoperfusion ischemic syndrome. Clin J Am Soc Nephrol. 2007; 2:175–183. 4 Lazarides MK, Staramos DN, Kopadis G, Maltezos C, Tzilalis VD, Georgiadis GS. Onset of arterial “steal” following proximal angioaccess: Immediate and delayed types. Nephrol Dial Transplant. 2003; 18:2387–2390. 5 Simosa HF, Mudumbi SV, Pomposelli FB, Schermerhorn ML. Distal digital embolization from a thrombosed aneurismal hemodialysis arteriovenous fistula: The benefit of a hybrid approach. Semin Dial. 2009; 22:93–96. 6 Lacombe M. Digital arterial embolism after thrombosis of arteriovenous fistula. Ann Cardiol Angeiol (Paris). 1993; 42:199–202. 7 Yildirim S, Nursal TZ, Yildirim T, Tarim A, Caliskan K. Brachial artery pseudoaneurysm: A rare complication after haemodialysis therapy. Acta Chir Belg. 2005; 105:190– 193. 8 Ali AT, Kalapatapu VR, Bledsoe S, Moursi MM, Eidt JF. Percutaneous isolated limb perfusion with thrombolytics for severe limb ischemia. Vasc Endovascular Surg. 2005; 39:491–497.
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Access
Digital infarction in a hemodialysis patient due to embolism from a thrombosed brachial arteriovenous fistula Anupama YJ Department of Nephrology, Nanjappa Hospital, Shimoga, Karnataka, India
Abstract Acute onset of digital ischemia and infarction is an unusual complication in patients undergoing hemodialysis. This is a report of a patient on regular hemodialysis who presented with acute distal extremity ischemia, progressing to digital infarction and on evaluation was found to have thrombosis of brachial arteriovenous fistula with embolization to the distal arteries causing digital artery occlusion. Key words: Hemodialysis, thrombosed arteriovenous fistula, brachial, embolization, digital infarction
INTRODUCTION Digital gangrene is an unusual complication in patients undergoing hemodialysis. It is known to occur in less than 4% of patients and even then, it commonly follows arterial steal. Here, we report a case of digital ischemia and infarction that occurred due to embolism from a thrombosed brachial arteriovenous fistula (AVF).
CASE REPORT A 58-year-old lady with diabetes mellitus and chronic kidney disease stage 5 on regular dialysis with brachial AVF as access presented to the emergency room (ER) with history of generalized weakness and breathlessness. She had undergone dialysis 6 hours previously and had had a difficult cannulation. She had complained of pain in the left upper limb during dialysis, which was attributed to
Correspondence to: Anupama YJ, MD,DNB(Nephro), Department of Nephrology, Nanjappa Hospital, Kuvempu Road, Shimoga, Karnataka State 577201, India. E-mail: [email protected]
the difficult cannulation and the multiple pricks. This pain had worsened after the completion of dialysis and she complained of excruciating pain in the upper limb when she arrived at the ER. On evaluation, the left forearm was cold to touch and she complained of severe pain on slightest passive movement of the limb. The forearm was flaccid and active movements were not possible at the elbow and wrist joints. Bruit over the AVF was absent. Pulsations of brachial artery could be felt, while radial and ulnar artery pulsations were not palpable. Electrocardiogram revealed absent P waves, broad QRS complexes almost merging with the T waves suggestive of hyperkalemia (Figure 1). Her arterial blood gas analysis was suggestive of severe metabolic acidosis with pH 7.02, pCO2-26, pO2-124, HCO3-7.5 mmol/L. Serum potassium was 9.1 mmol/L. She was treated with emergency hemodialysis with femoral double lumen catheter as the access using potassium-free concentrate. She was then referred to the vascular surgeon for further management. However, the surgeon noted that while the limb was still paretic and cold to touch, both radial and ulnar artery pulsations were well felt. Patency of radial and ulnar arteries was confirmed on Doppler study of the arteries. There was complete occlusion of the cephalic vein and the AVF.
© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12256
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Digital infarction in a dialysis patient
Figure 1 Electrocardiogram of the patient at admission showing features suggestive of hyperkalemia.
Computed tomography angiogram of the left upper limb arteries also confirmed complete occlusion of the AVF and the post-fistula segment of the cephalic vein, while the radial and ulnar arteries were patent. There was complete cut-off of the contrast in all the digital arteries (Figure 2).
Surgical intervention was ruled out in view of the patency of the radial and ulnar arteries. She was treated with heparin infusion at the rate of 1000 units/hour and oral anticoagulants without substantial benefit. The ischemia remained at the digits and gradually the tips of all 5
Figure 2 Computed tomography angiogram of the left upper limb showing thrombosis of the AVF and the distal cephalic vein, patent forearm arteries and digital cut-off of the contrast.
Hemodialysis International 2015; 19:E6–E9
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YJ
Figure 3 Digital gangrene.
digits on the left hand turned gangrenous with the line of demarcation being confined to the level of distal interphalangeal joints on all digits (Figure 3). She discontinued hemodialysis and switched over to continuous ambulatory peritoneal dialysis.
DISCUSSION Limb ischemia in chronic hemodialysis patients is a rare phenomenon and is seen in less than 4% of hemodialysis patients.1 Hemodialysis access-induced distal ischemia (HAIDI) can occur acutely (1 month) after AVF placement.2 Chronic HAIDI is usually attributable to chronic steal with shunting of blood through the proximally placed low pressure AVF “stealing” away from the high pressure forearm arteries. In some cases, the distal arteries may be sclerosed or stenosed and allow lesser flow which contributes to the hypoperfusion.3 Chronic venous hypertension and massive limb edema causing pressure on the distal arteries is a less common cause. Acute hand ischemia occurring a few hours after arteriovenous access surgery is known to occur in a few cases and is a surgical emergency as untreated ischemia rapidly compromises limb function.4 Thromboembolism from AVF is the least common cause and very few cases are reported in the literature.5
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Thromboembolism usually involves dislodgement of thrombus from venous aneurysms or pseudoaneurysms. Lacombe reported 4 cases of severe digital ischemia resulting from embolization from a thrombosed AVF and recorded that all 4 patients had an aneurysm on the efferent vein.6 Rarely patients may have arterial pseudoaneurysms due to inadvertent arterial puncture during venous cannulation for hemodialysis.7 The risk is higher with brachial AVFs as the basilic and the cephalic veins are extremely close to the brachial artery. The presence of a tight downstream venous stenosis and repeated cannulations at the same site also facilitate venous aneurysm formation in hemodialysis accesses. These aneurysms or pseudoaneurysms predispose to thrombus formation due to loss of laminar flow and turbulence and hence should be avoided during cannulation to prevent embolism. In our patient, there was a small venous aneurysm that was stable with no recent increase in size. It was generally avoided during cannulation. On that day, there was difficulty in cannulating the AVF as the fistula was probably in the process of clotting and the aneurysm may also have been inadvertently pricked. The multiple cannulation attempts probably led to the dislodgement of a thrombus into the forearm arteries. Initially, patient had pulselessness involving the radial and ulnar vessels and there was complete flaccidity of right forearm, indicating ischemic paralysis of forearm muscles. The tissue ischemia may have caused the severe metabolic acidosis and acute hyperkalemia with cardiotoxicity. The dialysis was also probably inadequate due to the poor flow contributing to the acidosis. This was treated with emergency hemodialysis, which may have been beneficial to the patient as the thrombi in the forearm vessels appear to have lysed due to heparinization. Smaller fragments may have propagated distally to the digital arteries, which are end arteries limiting the extent of the ischemia to the digits. There are few treatment options for patients with distal limb ischemia. Amputation and loss of limb are the usual outcomes. Salvage of the limb can be attempted by catheter-directed thrombolytic therapy along with open repair.5 Percutaneous isolated limb thrombolysis has been tried with some success in a few cases.8 However, in general, peripheral arterial thromboembolic lesion responds poorly to thrombolytic therapy and was not tried in our patient.
CONCLUSIONS Digital ischemia due to embolic phenomenon following thrombosis of AVF is a rare event. Early diagnosis and urgent treatment with intra-access catheter-directed
Hemodialysis International 2015; 19:E6–E9
Digital infarction in a dialysis patient
thrombolysis may be beneficial in salvaging the limb. Prevention of formation of pseudoaneurysm by good venipuncture, rotation of puncture sites, and ensuring adequate hemostasis at the end of the dialysis session is essential to prevent such devastating complications.
ACKNOWLEDGMENTS I thank Dr Narendra G. Nishanimath, Consultant Cardiothoracic Surgeon, Nanjappa Lifecare, Shimoga, and Dr Uma Pandurangi, Consultant Radiologist, Medall Diagnostics, Shimoga, for their contribution to the management of this patient. Conflict of interest: None.
Manuscript received August 2014; revised October 2014.
REFERENCES 1 Tordoir JHM, Dammers R, van der Sande FM. Upper extremity ischemia and hemodialysis vascular access. Eur J Vasc Endovasc Surg. 2004; 27:1–5.
Hemodialysis International 2015; 19:E6–E9
2 Scheltinga MR, van Hoek F, Bruijninckx CMA. Time of onset in haemodialysis access-induced distal ischaemia (HAIDI) is related to the access type. Nephrol Dial Transplant. 2009; 24:3198–3204. 3 Leon C, Asif A. Arteriovenous access and hand pain: The distal hypoperfusion ischemic syndrome. Clin J Am Soc Nephrol. 2007; 2:175–183. 4 Lazarides MK, Staramos DN, Kopadis G, Maltezos C, Tzilalis VD, Georgiadis GS. Onset of arterial “steal” following proximal angioaccess: Immediate and delayed types. Nephrol Dial Transplant. 2003; 18:2387–2390. 5 Simosa HF, Mudumbi SV, Pomposelli FB, Schermerhorn ML. Distal digital embolization from a thrombosed aneurismal hemodialysis arteriovenous fistula: The benefit of a hybrid approach. Semin Dial. 2009; 22:93–96. 6 Lacombe M. Digital arterial embolism after thrombosis of arteriovenous fistula. Ann Cardiol Angeiol (Paris). 1993; 42:199–202. 7 Yildirim S, Nursal TZ, Yildirim T, Tarim A, Caliskan K. Brachial artery pseudoaneurysm: A rare complication after haemodialysis therapy. Acta Chir Belg. 2005; 105:190– 193. 8 Ali AT, Kalapatapu VR, Bledsoe S, Moursi MM, Eidt JF. Percutaneous isolated limb perfusion with thrombolytics for severe limb ischemia. Vasc Endovascular Surg. 2005; 39:491–497.
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