Case presentation

A 65-year-old right-hand-dominant man with end-stage renal disease (ESRD) on hemodialysis presented for vascular access planning. His medical history was significant for coronary artery disease status post right coronary artery (RCA) stent placement two years prior, subsequently found to be occluded within the stent on catheterization approximately one year later with left-to-right collaterals. He carried a diagnosis of ischemic cardiomyopathy with a left ventricular ejection fraction (LVEF) of 40-45% and multivessel coronary artery disease. Additional comorbidities included severe chronic obstructive pulmonary disease (COPD) with chronic hypoxemic respiratory failure requiring home oxygen.

Approximately three months prior to AVF creation, the patient developed sustained ventricular tachycardia and acute kidney injury requiring initiation of hemodialysis. A single-chamber transvenous ICD was implanted approximately two months prior to AVF creation via the left subclavian vein. A right internal jugular vein hemodialysis catheter was placed during the same hospitalization.

Preoperative venous mapping, performed approximately two weeks prior to AVF creation, demonstrated a left basilic vein of at least 6 mm above the elbow--superior to the right-sided options (right basilic 2 mm, right cephalic 3 mm). The left cephalic vein measured approximately 4-5 mm. Given the inadequacy of right-sided venous conduits, a left upper extremity AVF was created between the median cubital vein and brachial artery on Day 1, ipsilateral to the transvenous ICD.

At Day 89, the patient was evaluated for AVF maturation. On examination, the fistula had not matured, and the patient reported worsening left upper extremity swelling. Duplex ultrasound demonstrated a patent left upper extremity AVF with a maximum volume flow of 589 mL/min. The AVF was located 3.8-5.8 mm beneath the skin surface, with a peak systolic velocity of 344.2 cm/s at the anastomosis. Subcutaneous edema was present near the anastomosis without evidence of perigraft fluid or hematoma. Fistulography demonstrated a patent arteriovenous anastomosis with outflow through the cephalic and basilic veins without hemodynamically significant stenosis (Figure 1). Central venography confirmed widely patent axillary, subclavian, brachiocephalic, and superior vena cava segments despite the presence of the ipsilateral transvenous ICD lead, with no discrete central venous stenosis identified (Figure 2). Given the absence of a correctable stenotic lesion, continued surveillance was recommended with consideration of accessory vein embolization if maturation did not progress.

Figure 1: Day 89, AV fistula angiogram (peripheral)Peripheral fistulogram obtained at Month 3 (Day 89) demonstrating the arteriovenous (AV) anastomosis between the median cubital vein and brachial artery with outflow through the cephalic and basilic veins. The left brachial artery is visualized. No hemodynamically significant stenosis is identified in the peripheral venous outflow tract despite clinical immaturity of the fistula.

Figure 2: Day 89, AV fistula angiogram (central)Central venogram obtained at Month 3 (Day 89) showing the left cephalic vein, axillary vein, and subclavian vein draining into the superior vena cava (SVC).The transvenous implantable cardioverter defibrillator (ICD) lead and generator are visualized traversing the left subclavian vein. Despite the presence of the ipsilateral transvenous lead, no discrete central venous stenosis is identified. The lead-vein interface is annotated as the proposed region of hemodynamic disturbance; this mechanism was not directly measured.

At Day 201, the fistula remained immature despite continued observation. Repeat fistulography demonstrated widely patent central and peripheral venous outflow without evidence of hemodynamically significant stenosis. Clinical examination revealed a strong thrill near the antecubital fossa but minimal palpable thrill in the mid-upper arm. Fistulography and ultrasound identified two large accessory cephalic vein branches diverting flow from the primary outflow tract. Coil embolization of both accessory branches was performed, and the final fistulogram demonstrated improved flow through the cephalic vein with minimal residual flow through the embolized branches.

At Day 265, the patient returned for post-embolization follow-up. There was minimal improvement in left upper-extremity swelling, and the fistula remained unsuitable for dialysis use. Given the persistent failure to mature despite patent central veins and successful accessory vein embolization, the ipsilateral transvenous ICD lead was identified as a potential contributing factor. The decision was made to proceed with transvenous ICD extraction and transition to a subcutaneous ICD (S-ICD) to eliminate the intravascular lead as a source of hemodynamic perturbation.

At Day 299, the transvenous ICD was extracted, and a subcutaneous ICD was placed. The procedure was complicated by a small post-procedural hematoma at the abdominal generator site, which resolved with binder compression. The patient’s right-sided tunneled dialysis catheter was used for ongoing hemodialysis access during the interval of continued AVF maturation.

At Day 377, the patient reported marked improvement in left upper-extremity swelling. Repeat fistulography demonstrated a patent cephalic vein outflow tract throughout the distal, mid, and proximal segments, with widely patent venous confluence, subclavian vein, brachiocephalic vein, and superior vena cava. Only small residual proximal venous branches remained, and the AVF was cleared for hemodialysis use. Subsequent successful cannulation and sustained functional use were not available in the record reviewed. The clinical course is depicted in Figure 3.

Figure 3: Clinical timeline from AVF creation to clearance for hemodialysis useClinical timeline illustrating the patient's course from AVF creation (Day 1) to clearance for hemodialysis use (Day 377). Key milestones include duplex ultrasound and fistulography demonstrating patent central veins without angiographic stenosis (Day 89), accessory vein coil embolization (Day 201), persistent non-maturation despite intervention (Day 265), transvenous ICD extraction with subcutaneous ICD implantation (Day 299), and repeat fistulography demonstrating patent central venous outflow with subsequent clearance of the AVF for dialysis use (Day 377).