Symptoms from acute subclavian vein thrombosis are often expressed for only a short time in patients without an AVF. Edema will be severely and continuously exacerbated from the additional limb blood flow of the AVF.13,14 Often the edema becomes chronic, and precludes accurate puncture of an ipsilateral access. Untreated venous hypertension from this combination may produce the typical symptoms of venous stasis: edema, hyperpigmentation and even ulceration. Therefore any treatment must include ligation of the access.

Although lymphatic disruption from an infraclavicular pocket incision is possible, this would be so rare as to be remarkable. The electrodes are usually inserted indirectly and do not require surgical exposure of the vein; this reduces the likelihood of injury to the lym- phaticchannelsintheaxillary-subclavianvascularsheath.Localizedswellinginthepocket would be a more likely complication than arm swelling.

There is no evidence for hypercoagulability. Since the electrodes pass through the SVC, obstruction there is theoretically possible. However, the absence of contralateral upper extremity edema or a swollen head fails to suggest SVC thrombosis. Replacing the device on the right complicates the issue immeasurably. In addition to incurring a real risk of SVC obstruction, it also places the remaining (right) upper extremity at risk for problems with subsequent hemoaccess.

The combination of a high flow AVF with probable subclavian vein obstruction suggests a rather poor prognosis for the left arm radiobasilic AVF. Thus, investigation of the etiology with a fistulagram and venogram is appropriate. [Q8: D] A DU should also be obtained, but since central vein visualization is poor it is inadequate to confirm the suspected diagnosis. Although unlikely, it is entirely possible that the device has nothing to do with the venous obstruction and that the outflow vein of the AVF may be stenotic from an intimal hyperplastic response in a different anatomic location more amenable to a salvage procedure. If this is a subclavian thrombosis, it may be a good opportunity to consider thrombolysis. However, even if the vein could be reopened, a subclavian vein angioplasty and/or stent has not proven a durable solution in this anatomic site.13 Finally, thrombolysis carries a small but real risk of intracranial hemorrhage, which would be less acceptable without a real benefit. Removal of the electrodes would be complicated and risky. Unfortunately, if the obstruction is not well collateralized, the left arm should be excluded from future access options.1,13,14,18

Question 9

The best choice is the right forearm loop prosthetic graft. [Q9: A] Either an IJ or femoral catheter site has significant clinical negatives, and fails to offer a durable solution in the face of numerous better options.

The right brachial to cephalic is probably a better option, but as presented in the question, ligation of the contralateral symptomatic radiobasilic AVF is not accomplished. As presented in the question, ligation of the contralateral symptomatic radiobasilic AVF is not accomplished. More importantly, the two proximal transposition options remain available for construction of subsequent hemoaccess.

LigationoftheleftradiobasilicAVFisessentialtocontrolthevenousobstructivesymptoms. While a jugular vein turn-down would offer preservation of the left radiobasilic