Page 6 - Carotid and peripheral vascular interventions textbook
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                        Ipsilateral arm edema usually occurs after a high f ow   bleeding during repeated needle cannulation for dialysis,
                    AV f stula or graft is created in that extremity (Fig. 14-3).    can raise the infection risk.
                    Use of that access for dialysis frequently aggravates      SVC syndrome is the severe manifestation of CVD.
                    the edema more. Swelling, pain and tenderness in the     It is distinguished by edema of both upper extremities, the
                    extremity can resemble cellulitis. Development of tortuous,   neck and face with many dilated collaterals across the chest
                    aneurysmal dilatation of an AVF may exacerbate CVD.   and neck. Sometimes, the blood-f ow can be maintained
                    Prompt AV f stulogram and correction of stenosis can stop   via a dilated azygous vein. However, if unrelieved with
                    progressive deterioration and rupture of the aneurysm.   angioplasty or stenting, it may be life threatening and
                    In chronic CVD, visible, palpable and tortuous veins   may result in soft tissue edema of the neck with airway
                    across the extremity, neck and chest are developed to   compression.
                    divert blood-f ow centrally. Sometimes, the collaterals are
                    suff ciently large enough to divert blood-f ow to alleviate   DIAGNOSIS
                    the symptoms and signs of CVD, although in most cases
                    intervention is necessitated.                       The diagnosis of CVD can frequently be made
                        Signif cant decline in access blood-f ow, episodes of   or suspicious from a thorough history and physical
                    prolonged bleeding from needle sites following dialysis,   examination. Prior central venous catheter implantation
                    and raised venous pressures during hemodialysis are the   history, particularly if of multiple and long duration should
                    early signs of CVD. Consequently, CVD may reduce   warn about the potential for CVD. Presence of pacemaker
                    access blood-f ow and cause insuff cient dialysis. An AVF   or def brillator wires should warrant thorough assessment
                    generally stays patent even with low blood-f ow, but an   for the presence of CVD and its resolution before placing
                    AVG is more likely to thrombose. Thrombectomy of these   an AV f stula or graft on the ipsilateral side. Examination
                    accesses without attempting to diagnose and treat occult   revealing swelling of arm on the ipsilateral side and
                    CVD can be complicated by worsening of symptoms and   many dilated collaterals in the chest or neck indicates
                    recurrent thrombosis.                           obstruction to outf ow.
                        While infection may be a causative factor for CVD,      In patients who have not received central venous
                    CVD can also predispose to infection. In condition of   catheterization, other etiologies, such as pacemaker
                    venous congestion, access thrombosis with excessive   wires, thoracic outlet syndrome, hypercoagulopathy, or



                    Figure  14-3.  Right arm swelling secondary to right subclavian vein occlusion. A: Before endovascular intervention with a 6-Fr sheath
                    in the brachiobasilic AV graft at the forearm. B: After successful balloon angiopalsty 2 weeks, the right arm swelling subsided.
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