Quiz Page March 2006

A 48-year-old woman with a left upper-arm brachiocephalic vein fistula access experienced several episodes of prolonged bleeding after hemodialysis. During a 7-month period, she underwent 3 percutaneous angioplasties of a long, segmental, left-cephalic vein stenosis. At the time of the last intervention, 2 overlapping 9 × 80-mm and 9 × 60-mm stents were placed across the stenosis. After 6 months, recurrent clotting of the dialyzer developed (despite heparin) and Kt/V declined (from 1.8 to 1.2). Dynamic venous pressure readings at a blood flow of 200 mL/min were 155, 163, and 169 mm Hg on 3 consecutive treatments, respectively. A fistulogram was performed (Figure 49A, Figure 49B, Figure 49C).

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Figure 49A. Plain x-ray of the stents with the humerus at 90°.

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Figure 49B. Plain x-ray of the stents with the humerus abducted to 135°.

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Figure 49C. X-ray of the stents after injection of radiocontrast.

What is your diagnosis?

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Case provided by Ursula C. Brewster, MD, Hamid R. Mojibian, MD, John E. Aruny, MD, and Mark A. Perazella, MD, FACP, Departments of Medicine and Radiology, Yale University School of Medicine, New Haven, CT.

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