Case Description
A 68-year-old woman was seen at the dialysis department with progressive dyspnea over the last 3 weeks. Furthermore, she noticed progressive edema of the left arm. Her medical history included dermatomyositis and thrombotic microangiopathy resulting in ESKD. Her dermatomyositis was treated with rituximab and prednisone, and she was currently in remission.
Fifteen months before presentation, she started hemodialysis via a central venous catheter in the right internal jugular vein. Because she developed a catheter-associated thrombosis, a central venous catheter was placed in the left internal jugular vein and therapeutic anticoagulation was started. After 6 weeks, ultrasound showed reduction of the thrombus in the right internal jugular vein (from 4 to 2.4 cm); the left internal jugular vein was open. The blood flow was 300 ml/min during dialysis. We continued anticoagulation for a total of 3 months. Six months before presentation, a brachiocephalic arteriovenous fistula (BCAVF) in her left upper arm was created. After maturation, the blood flow was 1400 ml/min.
Chest radiography revealed left-sided pleural effusion (Figure 1A). Thoracocentesis was performed and 5.5 L of pleural fluid was drained. Analysis revealed a transudate according to Light criteria (pleural-fluid protein/serum total protein ratio of 0.27, and a pleural-fluid lactate dehydrogenase/serum lactate dehydrogenase ratio of 0.4). Culture and cytologic examination were negative. Venography of the left arm demonstrated an obstruction in the left brachiocephalic vein (solid arrow in Figure 1B) and backflow into the accessory hemiazygos vein (dashed arrow in Figure 1B). Despite two thoracenteses, the pleural effusion recurred.
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Figure 1.: Radiological images. (A) Unilateral pleural effusion. (B) Venography of the left arm demonstrating obstruction in the left brachiocephalic vein (solid arrow) and backflow into the accessory hemiazygos vein (dashed arrow). (C) After ligation of a brachiocephalic arteriovenous fistula, she had no recurrence of the pleural effusion. Arrow shows the peritoneal dialysis catheter.
We hypothesized that the BCAVF combined with the obstruction of the brachiocephalic vein resulted in increased left-sided pleural hydrostatic pressure via the accessory hemiazygos vein. Consequently, increased formation of pleural fluid occurs and decreased lymphatic clearance is noted. Therefore, we performed ligation of the BCAVF and, in the same procedure, a peritoneal dialysis catheter was inserted to start peritoneal dialysis. She had no recurrence of the pleural effusion since that time (Figure 1C).
Obstruction of the brachiocephalic vein as a result of central venous catheter is an extremely rare cause of unilateral pleural effusion. It has only been published three times previously (12–3). In two of the cases, removal of the central venous catheter gave resolution of the effusion (1,2). In the third case, the arteriovenous fistula was ligated and, in the same procedure, a kidney transplantation was performed (3). This caused immediate resolution of the pleural effusion.
This case, along with others, illustrates the long-term complications that may occur due to hemodialysis catheter-related central venous thrombosis. Clinicians should be aware of this complication and understand its pathophysiology.
Teaching Points
- Pleural transudative effusion in a patient on hemodialysis is often caused by heart failure or fluid overload.
- Left-sided unilateral pleural transudative effusion may also be caused by an arteriovenous fistula in a patient on hemodialysis who has an obstruction of the brachiocephalic vein due to catheter-related thrombosis resulting in increased pleural hydrostatic pressure.
- Ligation of the arteriovenous fistula prevents recurrence of pleural effusion.
Disclosures
All authors have nothing to disclose.
Funding
None.
Acknowledgments
Informed consent was obtained from the patient.
Author Contributions
A.C. Abrahams reviewed and edited the manuscript; and E.M. Spithoven wrote the original draft.
References
1. Muthuswamy P, Alausa M, Reilly B: Clinical problem-solving. The effusion that would not go away. N Engl J Med 345: 756–759, 2001
2. Porcel JM: Unilateral
pleural effusion secondary to brachiocephalic venous thrombosis: A rare complication of central vein catheterization. Respiration 69: 569, 2002
3. Wright RS, Quinones-Baldrich WJ, Anders AJ, Danovitch GM:
Pleural effusion associated with ipsilateral breast and arm edema as a complication of subclavian vein catheterization and
arteriovenous fistula formation for hemodialysis. Chest 106: 950–952, 1994
