Can upper extremity Deep Vein Thrombosis (DVT) affect Continuous Veno-Venous Hemofiltration (CVVH) or access pressure from a dialysis line?

Upper Extremity DVT Can Affect CVVH and Access Pressure from Dialysis Lines

Yes, upper extremity deep vein thrombosis (UEDVT) can significantly affect Continuous Veno-Venous Hemofiltration (CVVH) and cause increased access pressure from dialysis lines. 1

Impact of UEDVT on Dialysis Access

• UEDVT can cause hemodynamically significant stenoses or occlusions in major central or intrathoracic veins (internal jugular, subclavian, brachiocephalic veins, or superior vena cava), degrading the function of arteriovenous (AV) access and resulting in ineffective hemodialysis 1
• Central venous stenosis or occlusion from UEDVT can occur in 5% to 50% of cases with vascular access 1
• UEDVT can precipitate high venous pressures secondary to increased flow resistance, directly affecting access pressure readings during CVVH 1
• The presence of stenoses in central venous outflow may result in increased venous pressures during monitoring of the access and increased AV access recirculation 1

Clinical Manifestations

• Patients with UEDVT affecting dialysis access typically present with:
  • Ipsilateral upper extremity edema (98% of cases) 2
  • Development of venous collaterals on chest wall and central ipsilateral extremity (71% of cases) 2
  • Pain in the affected extremity (63% of cases) 2
  • Prolonged bleeding after decannulation post dialysis 1
  • Poor flows documented during hemodialysis 1
  • Inability to aspirate blood from the catheter despite ability to infuse (one-way obstruction) 1

Risk Factors for UEDVT Affecting Dialysis Access

• Indwelling venous devices (catheters, dialysis lines) are the highest risk factor for UEDVT 1
• Central venous catheters (CVCs) are strongly associated with UEDVT development, with catheter-related thrombosis occurring at the CVC site 3
• Other risk factors include:
  • Previous thrombophlebitis 1
  • Hypercoagulability 1
  • Heart failure 1
  • Cancer 1
  • Intensive care unit admissions 1
  • Extrinsic compression 1

Diagnostic Approach for UEDVT Affecting Dialysis Access

• Duplex ultrasound is the initial imaging modality of choice for suspected UEDVT 1
• For central venous stenosis affecting dialysis access, diagnostic fistulography allows for angiographic visualization of culprit lesions 1
• Duplex US can suggest the presence of central venous stenosis when there is:
  • Absent respiratory variation in vessel diameter 1
  • Lack of polyphasic atrial waves 1
  • Depiction of regional venous collaterals 1
  • Poststenotic to prestenotic peak vein velocity ratio of 2.5 or greater 1

Management Implications

• Early detection and intervention can prevent complications and save the vascular access 4
• For catheter-related thrombosis affecting CVVH:
  • Anticoagulation is the treatment of choice 5
  • Mandatory functioning catheters can remain in place with anticoagulant treatment 5
  • Non-essential catheters should be immediately removed 5
• For central venous stenosis affecting dialysis access:
  • Percutaneous transluminal angioplasty (PTA) is the preferred treatment 1
  • A single intervention may facilitate both definitive diagnosis and treatment 1

Complications and Outcomes

• UEDVT in dialysis patients is associated with:
  • Higher risk of bleeding (adjusted HR 2.0) 6
  • Increased all-cause mortality (adjusted HR 2.4) 6
  • Potential pulmonary embolism (4% incidence) 2
• Dialysis patients have a significantly higher risk of VTE compared to the general population (adjusted HR 2.9) 6

Prevention Strategies

• Use catheters made from less thrombogenic materials (silicone, second/third-generation polyurethane) 1
• Use a catheter with the least number of lumens required, as risk of thrombosis increases with number of lumens 1
• Ensure proper catheter tip placement in the caudal superior vena cava 1
• Prefer right-sided placements when possible, as left-sided placements are associated with higher incidence of DVT 1
• Utilize ultrasound-guided placement to minimize endothelial damage 1