NDT Plus Advance Access originally published online on February 15, 2008
NDT Plus 2008 1(2):131-132; doi:10.1093/ndtplus/sfn011
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Unilateral pleural effusion associated with ipsilateral arm and breast oedema: a rare complication of brachiocephalic and SVC stenosis in association with an arteriovenous fistula
1 Renal Unit
2 Department of Radiology, St James's University Hospital, Beckett Street, Leeds, UK E-mail: garycampbell73{at}hotmail.com
Sir,
Central venous stenosis has been a well-recognized complication of dialysis catheters for over 20 years. There is a much higher incidence of venous stenosis associated with subclavian versus internal jugular vein dialysis catheters [1]. The stenosis, however, is commonly asymptomatic until an ipsilateral arteriovenous fistula is formed. Arm oedema and, to a lesser extent, breast oedema are well-described complications [2–4]. It is extremely rare, however, to have an associated pleural effusion as well [5].
We present a case of massive right pleural effusion associated with right breast and arm oedema, as a consequence of a right brachiocephalic/superior vena cava (SVC) stenosis in a dialysis patient with an ipsilateral arteriovenous fistula.
A 60-year-old female haemodialysis patient presented with shortness of breath. A CXR revealed a massive right-sided pleural effusion with ipsilateral breast and arm oedema. Eight hundred and fifty millilitres of straw-coloured pleural fluid was drained and found to be a transudate. Cytology, culture and biochemical analysis failed to demonstrate a cause. Rapid re-accumulation of fluid resulted in a second admission 2 weeks later with a ‘white-out’ of her right hemithorax (Figure 1). A further 1000 ml of pleural fluid was drained, with similar findings to the first examination.
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Dialysis access was via a right basilic vein transposition and also a left internal jugular tunnelled dialysis catheter. This had been left in situ due to needling problems of the fistula. Imaging revealed a significant stenosis at the junction of the right brachiocephalic vein and SVC. A decision was made to perform caval venoplasty with stenting of the stenosis, which was radiologically successful. The dialysis catheter was removed prior to the procedure. The placement of the stent resulted in the resolution of her arm and breast oedema within 48 h. Furthermore, the symptoms of breathlessness resolved over the next 2 weeks. A subsequent CXR revealed clear pleural spaces (Figure 2).
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Her fistula is still working well and being used as dialysis access 10-month post-stent insertion.
Pleural fluid can enter the pleural cavity through three potential routes: capillaries in the parietal pleura, interstitial spaces via the visceral pleura or peritoneal cavity via the diaphragm. This fluid is normally removed by lymphatics in the visceral pleura. In our case, it is likely there was impaired lymphatic absorption as the high venous pressure, resulting from the brachiocephalic stenosis, would impair lymphatic drainage from the right thoracic duct. Additionally, it is possible that there was increased pleural fluid production due to increased venous pressure of the parietal pleural capillaries, which ultimately drain into the SVC.
In conclusion, the finding of a pleural effusion with ipsilateral arm and breast oedema in a dialysis patient with an arteriovenous fistula should prompt investigation for a central venous stenosis.
Conflict of interest statement. None declared.
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- Davis D, Petersen J, Feldman R, et al. Subclavian venous stenosis. A complication of subclavian dialysis. JAMA (1984) 252:3404–3406.
[Abstract/Free Full Text] - McNally PG, Brown CB, Moorhead PJ, et al. Unmasking of subclavian vein obstruction following creation of arteriovenous fistulae for haemodialysis. A problem following subclavian line dialysis? Nephrol Dial Transplant (1987) 1:258–260.
[Abstract/Free Full Text] - Agarwal AK, Patel BM, Haddad NJ. Central venous stenosis thrombosis: a nephrologist's perspective. Semin Dial (2007) 20:53–62.[CrossRef][Web of Science][Medline]
- Topf G, Jenkins P, Gutmann FD, et al. Unilateral breast enlargement, a complication on an arteriovenous fistula and coincidental subclavian vein occlusion. JAMA (1977) 237:571–572.
[Abstract/Free Full Text] - Wright RS, Quinones-Baldrich WJ, Anders AJ, et al. Pleural effusion associated with ipsilateral breast and arm edema as a complication of subclavian vein catheterization and arteriovenous fistula formation for haemodialysis. Chest (1994) 106:950–952.[CrossRef][Web of Science][Medline]
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