For patients requiring life-saving dialysis, access is everything. In this case overview, Dr. Noam Spinowitz treats a 78-year-old male patient with End Stage Renal Disease (ESRD) receiving dialysis and presenting arm swelling with central occlusion.
Consultation – History
Past Medical History:
- 78-year-old male
- HTN, DM Anemia, Hyperparathyroidism, Hyperlipidemia
- Left side pacemaker
- ESRD has been receiving dialysis through a right internal jugular vein permanent catheter since November 2021
- Right brachial-cephalic AVF creation January 19, 2022
Current Medications:
- Metoprolol
- Furosemide
- Januvia
- Atorvastatin
- Calcium Carbonate
- Sevalemer
- Ergocalciferol
- Flomax
Physical Examination – Current Condition
The patient presents for maturation of the right upper arm brachial-cephalic fistula.
Since the creation of the right arm AVF a month ago, the patient reports right arm swelling beginning from the wrist and extending to the axillary region. He also complains of pain in the upper arm.
On the physical exam, there is swelling appreciated with tension and pitting edema in the right forearm and upper arm. There is tenderness over the mid-body of the fistula within the upper arm over the bicep. There is poor thrill progression of the fistula through this area with multiple collateral vessels appreciated.
Patient Plan and Treatment
- Complete evaluation with fistulogram considering the presenting symptoms with concern for central venous occlusion
- Possible catheter change with central angioplasty
Central occlusion from right IJ catheter and left side pacemaker wires with multiple large collaterals draining across the neck and thyroid plexus of veins.
Procedure
Attempts to traverse the central occlusions from the fistula approach were not successful (Left).
The right IJ catheter was removed with plans for central venous angioplasty from the catheter approach to recanalize the subclavian-brachiocephalic vein junction from the fistula approach (Right).
Once the central occlusion was obliterated from the catheter approach, the wire was passed along with the balloon centrally from the fistula approach, and the central venous intervention, with angioplasty and stent placement, was performed from the fistula approach after a new catheter was exchanged (below L-R).
Follow-up Imaging
Antegrade flow seen from the right arm fistula with the disappearance of the previously seen retrograde collateral veins indicating the resolution of the stenosis and occlusion.
Right arm pressure was decreased; the swelling and painful symptoms began to resolve immediately.
Breakthrough, Minimally Invasive Treatments Performed in a Fully Equipped Outpatient Center
We Practice Collaboration of Care:
Dr. Spinowitz believes that coordination with the patient’s nephrologist and dialysis center is paramount to ensure complete care.
He is devoted to providing both clinical and service excellence in a caring culture.
Highly Trained, Board Certified Endovascular Specialists
Noam Spinowitz, MD – Interventional Nephrologist
Dr. Spinowitz specializes in the maintenance and management of vascular accesses for dialysis patients. He earned his MD from the Albert Einstein Medical College, completed an internal medicine residency at Montefiore Medical Center, and a nephrology fellowship at New York University. He is board certified in internal medicine and nephrology and is ASDIN-certified as an interventional nephrologist.
Dr. Spinowitz frequently uses advanced techniques to salvage accesses unable to be treated by other providers. He also pioneered treatments for access maturation and dialysis access steal syndrome. He is often asked to speak at conferences about his non-surgical approach to placing peritoneal dialysis catheters, saving patients from long recovery times, general anesthesia, and a hospital stay.
His patient care philosophy is and has always been, “patients come first.”
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