Salvage of upper arm access graft in the presence of symptomatic subclavian vein thrombosis.

Dr. Josep M. Campistol, Nephrology Service, Hospital Clinic i Provincial, 170, Villarroel, E-08036 Barcelona (Spain) Dear Sir, The upper graft fistula using the expanded polytetra-fluoroethylene graft (Goret-Tex) is an excellent form of hemodialysis access when adequate forearm veins are no longer available [1]. Causes of failure include thrombosis, arterial stenosis, venous outflow stenosis, hypotension, infection, and more recently proximal central venous thrombosis or stenosis related to more widespread utilization of the subclavian vein catheters for acute-phase hemodialysis [2]. Furthermore, axillary-subclavian vein thrombosis has presented as a relatively benign lesion with a low incidence of associated pulmonary embolism [3]. Functional disability remains the major sequela related to the involved extremity, occurring in approximately 75% of affected patients [3]. We present herein a patient with proximal subclavian vein thrombosis ipsilateral to an upperextremity Gore-Tex graft hemoaccess, treated by surgery to salvage the graft and correct the functional disability. A 47-year-old white man affected with chronic renal failure secondary to nephronophthisis, and on maintenance hemodialysis since 1980. The patient has had multiple angioaccess problems, with several upper-extremity accesses (Cimino-Brescia fistula, Gore-Tex), many ofwhich had become infected or thrombosed and required removal. In July 1987, the patient was admitted because of thrombosis of the left GoreTex forearm, and a right jugular venous catheter was placed. A new hemoaccess was performed by a right Gore-Tex graft on the forearm. Two months later, the patient presented with insidious onset of massive right upper-extremity edema and pain. The graft functioned without problems. Physical examination disclosed the presence of collateral circulation on the right upper arm. A digital intravenous angiography showed occlusion of the right prox-