High Incidence of Subclavian Vein Stenosis at the Thoracic Outlet in Patients with Ipsilateral Upper Extremity Hemodialysis Access

Subclavian vein stenosis at the thoracic outlet in patients requiring hemodialysis may precipitate upper extremity edema and threaten hemodialysis access. This poses a challenging anatomic location, where external compression may occur on a high-flow subclavian vein. We aimed to investigate the incidence and severity of subclavian vein compression at the thoracic outlet in patients with ipsilateral upper extremity hemodialysis access. We conducted a retrospective analysis of all patients undergoing fistulogram from January 1, 2021 to December 31, 2021 at our institution. Inclusion criteria include age >18 years, central venogram performed during fistulogram, and presence of ipsilateral upper extremity arteriovenous fistula or graft. Subsequent fistulograms performed during the same calendar year were excluded. The subclavian vein was measured at the level of the thoracic outlet and proximal subclavian vein on post processed images. A total of 147 patients had a fistulogram with central venogram performed during the study period. Sixty-one patients (41.5%) had evidence of subclavian vein compression at the thoracic outlet as measured on venogram (Fig). The most common access was a brachial-based autogenous arteriovenous fistula (38 patients, 62.3%), while 13 patients (19.7%) had radial-based access and 11 (18.0%) had a graft-based access. There was no known history of prior ipsilateral catheter placement in 45 patients (73.8%). There were previous ipsilateral internal jugular catheters in 15 patients (24.6%) and a previous external jugular catheter in one patient (1.6%). Mild subclavian vein narrowing (<50%) was identified in 26 patients (43%), moderate narrowing (50%-69%) in 16 patients (26%), severe narrowing (70%-99%) in nine patients (15%), and occlusion in 10 patients (16%). There is a high incidence of subclavian vein stenosis at the thoracic outlet in patients with ipsilateral hemodialysis access without previous catheter placement. This raises the possibility of dialysis-associated venous thoracic outlet syndrome, leading to stenosis and occlusion. Recognition of this occurrence is critical to guide management for symptom relief and long-term hemodialysis patency.