A 45-year-old man presented with increasing swelling and pain in his right arm over one month. He has a history of end stage renal disease and receives dialysis through a fistula in his right arm. Imaging showed a thrombus and stenosis in the fistula. He has multiple medical problems including HIV, hypertension, and hyperlipidemia. On examination, his right arm was edematous, erythematous, warm, and tender. He was diagnosed with a thrombosed arteriovenous fistula requiring surgical intervention.

1. John
Martinelli,
MSIII,
SGUSOM
DATE:
6/23/13
Case
2
Rotation:
Surgery/Anesthesia
Identifying
Data:
Mr.
D.L.
is
a
45-­‐year-­‐old
African-­‐American
gentleman,
English
speaking,
who
presented
to
the
NBIMC
ED
on
June
17,
2013.
Chief
Complaint:
Increasing
swelling
and
pain
in
right
arm
for
approximately
1
month.
History
of
Present
Illness:
Approximately
1
month
prior
to
our
evaluation,
D.L.
began
noticing
swelling
in
his
right
arm
that
has
progressively
worsened.
In
addition,
the
area
has
become
tender
to
touch.
Past
Medical
History:
End
Stage
Renal
Disease
(ESRD).
Dialysis
with
Fistula
access
for
approximately
2
years.
HIV(+).
Anti-­‐Retroviral
Therapy
(ART)
for
approximately
5
years.
Long-­‐standing
history
of
uncontrolled
Hypertension
and
Hyperlipidemia
for
at
least
15
years,
with
questionable
compliance
to
recommended
treatment.
Medications:
EMLA
–
for
dermal
pain
at
catheter
site,
topical
application
QD.
Kaletra
200mg/50mg
(Lopinavir/Ritonavir)
–
ART,
2
tabs
PO
BID.
Lac-­‐Hydrin
12%
-­‐
moisturizer
at
catheter
site,
topical
application
BID.
Plavix
75mg
–
for
prophylaxis,
1
tab
PO
QD.
Famotidine
40mg
–
for
prophylaxis,
1
tab
PO
QD.
Hydralazine
50mg
–
AntiHT,
1
tab
PO
TID.
Metoprolol
XR
200mg
–
AntiHT,
1
tab
PO
QD.
Valsartan
160mg
–
AntiHT,
1
tab
PO
QD.
Allergies:
NKA,
NKDA
Family
History:
Mother:
(+)
HT
Father:
(+)
HT,
DM
Type
II,
CVD
Siblings:
Not
known
Social
History:
Mr.
D.L.
lives
in
state-­‐assisted
housing
and
claims
he
is
comfortable
and
has
adequate
facilities.
He
is
unemployed.
He
is
homosexual
and
currently
lives
with
his
partner.
He
believes
his
diet
is
good
and
tries
to
choose
healthy
foods.
He
does
drink
one
to
three
beers
a
week.
He
does
not
smoke
cigarettes.
He
has
a
previous
history
of
IV
drug
use
although
he
states
he
has
been
“clean
for
many
years”.
He
has
a
history
of
several
homosexual
partners.
He
has
been
HIV(+)
for
approximately
5
years.

2. Physical
Exam:
Vitals:
T:
97.5
BP:
145/88
P:
80
RR:
18
O2sat:
99
General:
AAO.
Appearance
is
moderately
distressed.
Eye:
PERRLA
(-­‐)APD,
EOM’s:
Full
(-­‐)Diplopia,
Conjunctiva:
Clear
(-­‐)Icterus
HENT:
Normocephalic,
Normal
Hearing,
Oral
Mucosa
moist.
Neck:
Non-­‐Tender,
(-­‐)Carotid
Bruit,
(-­‐)Jugular
Venous
Distension,
(-­‐)Lymphadenopathy,
(-­‐)Thyromegaly.
Respiratory:
Lungs
clear
to
auscultation,
non-­‐labored,
equal
breath
sounds,
symmetrical
chest
wall
expansion,
no
chest
wall
tenderness.
Cardiovascular:
Normal
rate
and
rhythm,
(-­‐)Murmurs,
(-­‐)Gallops,
Peripheral
Pulses
equal
in
all
extremities,
(-­‐)Peripheral
Edema.
Gastrointestinal:
Abdomen
soft
and
non-­‐tender,
no
distension,
no
organomegaly,
and
bowel
sounds
present.
Genitourinary:
(-­‐)Costovertebral
Tenderness,
(-­‐)Scrotal
Tenderness,
(-­‐)Inguinal
Tenderness
Lymphatics:
(-­‐)Lymphadenopathy
in
Neck,
Axilla,
Groin.
Musculoskeletal:
Right
arm
edematous,
erythematous,
warm,
induration,
tender
to
touch.
Decreased
range
of
motion.
Motor
Strength
1/5.
Integumentary:
Right
arm
warm,
not
intact.
Neurologic:
AAO
Time,
Place,
Person.
CN
exam
I-­‐XII
intact.
Normal
Deep
Tendon
Reflexes.
Psychiatric:
Cooperative,
Normal
Judgment,
Non-­‐Suicidal,
Appropriate
Mood
and
Affect.
Labs:
WBC:
8.9
Hgb:
10.9
(L)
Hct:
33.9
(L)
Plt:
113
(L)
Na:
141
K:
4.0
CO2:
34
Cl:
104
BUN:
42
(H)
Cr:
8.75
(H)
Review
of
Systems:
General:
Distressed
Appearance
Skin:
Right
Arm
with
Edema,
Erythema,
Induration,
Tenderness,
Warm
x
1
month
(as
noted
in
PE).
EENT:
(-­‐)
Pulmonary:
(-­‐)
Gastrointestinal:
(-­‐)
Genitourinary:
(-­‐)
Musculoskeletal:
(-­‐)
Neurologic:
(-­‐)
Hematologic:
(-­‐)
Endocrine:
(-­‐)
Psychiatric:
(-­‐)
Imaging:
Fistulogram
performed
in
OR
on
6/19/2013
confirming
thrombus
formation
and
stenosis.

3. Discussion:
Mr.
D.L.
is
a
longstanding
hemodialysis
patient
with
ESRD
associated
with
poorly
controlled
HT
as
well
as
Hyperlipidemia.
He
presented
to
the
NBIMC
ED
with
a
chief
complaint
of
worsening
swelling
and
pain
of
his
right
arm
over
a
period
of
approximately
one
month.
For
dialysis
access,
a
surgically
created
arteriovenous
fistula
was
previously
created
which
had
been
functioning
well.
At
the
time
of
presentation,
loss
of
patency
of
the
fistula
was
suspected
along
with
possible
abscess
formation
due
to
the
erythematous,
tender,
and
warm
nature
of
the
area.
However,
noting
the
normal
WBC
level,
abscess
formation
was
not
thought
to
be
a
strong
differential.
An
elevated
BUN
and
Cr
along
with
a
BUN/Cr
ratio
of
4.8
is
consistent
with
uncontrolled
intra-­‐renal
ESRD.
In
addition,
inadequate
fistula
patency
with
poor
dialysis
will
only
lead
to
more
aggressive
disease.
The
Hgb
and
Hct
levels
were
found
to
be
diminished
which
can
also
be
linked
to
ESRD
with
insufficient
EPO
production
and
hence
poor
erythropoiesis.
The
Plt
level
was
also
reduced
for
which
thrombus
consumption
of
platelets
can
be
a
contributing
factor.
Finally,
the
urgency
of
surgical
intervention
and
repair
is
key
so
to
reinstitute
proper
hemodialysis
quickly,
as
well
as
the
prevention
of
secondary
complications
such
as
thrombotic
events.
Differential
Diagnosis:
1. AV
Fistula
Thrombus
with
Stenosis
2. Abscess
formation
3. Cellulitis
Assessment:
Hemodialysis
AV
Fistula
Thrombosis
with
Stenosis
–
Right
Arm.
Pathophysiology
Thrombotic
factors
can
be
defined
by
Virchow’s
Triad
that
includes
Hemostasis,
Vascular
Endothelial
(Intima)
Injury,
and
Hypercoagulability.
The
environment
of
a
surgically
created
hemodialysis
AV
fistula
is
inherently
susceptible
to
thrombosis.
The
hemodynamics
within
the
fistula
can
lead
to
pooling
of
blood
or
stasis
over
time.
Turbulence
within
the
fistula,
hypertension,
hyperlipidemia,
and
multiple
weekly
hemodialysis
access
can
lead
to
intimal
endothelial
damage.
Therefore,
thrombus
formation
is
a
considerable
risk
factor
for
all
hemodialysis
patients
receiving
AV
Fistula
access.
Clinical
Features
Edema,
Erythema,
Induration,
Warmth,
Tenderness,
and
Pain
at
AV
Fistula
site.
Possible
reduced
function
of
limb
if
increased
pain
or
joint
involvement.
Diagnosis
Clinical
by
history,
appearance,
palpation,
pulse.
Doppler
Ultrasound.
Confirmed
with
Fistulogram.
Treatment
Thrombectomy
with
Balloon
Angioplasty/Fistuloplasty.
Risk
Factors
Related
to
Virchow’s
Triad
as
discussed.

4. Complications
Abscess,
Cellulitis,
Thrombotic
or
Embolic
events.
Renal
Failure
due
to
insufficient
dialysis.
Plan:
Fistulogram
and
CT
guided
Thrombectomy
with
Balloon
Angioplasty/Fistuloplasty
was
performed
on
6/19/13.
No
evidence
of
Abscess
formation.
Anesthesia
induction
with
Propofol
and
maintained
with
Desflurane.
IV
Fluids
0.9%
NaCl.
Patient
tolerated
procedure
well.