Upper Extremity DVT Can Significantly Affect IJ Dialysis Catheter Access Pressure
Yes, upper extremity deep vein thrombosis (UEDVT) can cause hemodynamically significant stenoses or occlusions in major central veins, directly affecting internal jugular (IJ) dialysis catheter access pressure. 1
Mechanism of Impact on Dialysis Access Pressure
- UEDVT can precipitate high venous pressures secondary to increased flow resistance, directly affecting access pressure readings during dialysis 1
- Central venous stenosis or occlusion from UEDVT can occur in 5% to 50% of cases with vascular access, creating resistance to outflow 1
- The presence of stenoses in central venous outflow results in increased venous pressures during monitoring of the access 1
- Catheter-related thrombosis can take different forms: fibrin sheath, intraluminal thrombosis, and mural thrombosis (thrombus extending from the catheter into the vessel lumen) 2
Clinical Manifestations of UEDVT Affecting Dialysis Access
- Poor flows documented during hemodialysis are a common manifestation of UEDVT affecting dialysis access 1
- Inability to aspirate blood from the catheter despite ability to infuse (one-way obstruction) is a sign of UEDVT affecting the catheter 1
- Dampening of cardiac pulsatility or respiratory variation waveforms on Doppler examination indicates central venous obstruction 2
- Unilateral swelling indicates an obstructive process at the level of the brachiocephalic, subclavian, or axillary veins 2
- Pain in the supraclavicular space or neck may indicate catheter-related DVT 2
Risk Factors for UEDVT Affecting Dialysis Access
- Indwelling venous devices, such as dialysis catheters, are the highest risk factor for UEDVT 2, 1
- Previous thrombophlebitis increases risk of UEDVT 2
- Hypercoagulability is a significant risk factor 2
- Heart failure increases risk of UEDVT 2
- Cancer is associated with higher UEDVT risk 2
- Intensive care unit admissions increase risk 2
- Left-sided catheter placements have higher incidence of DVT than right-sided catheters 2
- Larger catheter size increases risk (5-Fr and 6-Fr PICCs have 2.74 and 7.40 times higher risk compared to 4-Fr PICCs, respectively) 3
Diagnostic Approach for UEDVT Affecting Dialysis Access
- Duplex ultrasound is the initial imaging modality of choice for suspected UEDVT 2
- Diagnostic signs on ultrasound include:
- For central veins that cannot be adequately assessed by ultrasound, CTV with contrast, MRV with contrast, or x-ray venogram with contrast may be necessary 2
Management Implications
- Percutaneous transluminal angioplasty (PTA) is the preferred treatment for central venous stenosis affecting dialysis access 1
- Anticoagulation is recommended for UEDVT if no contraindication is present 2
- Catheter-directed therapy (pharmacomechanical thrombolysis or mechanical thrombectomy) can be considered in appropriate candidates 2
- For catheter-related thrombosis, anticoagulation without thrombolysis is the treatment of choice 4
- Mandatory functioning catheters can remain in place with anticoagulant treatment, while non-essential catheters should be immediately removed 4
Prevention Strategies
- Use catheters made from less thrombogenic materials (silicone, second/third-generation polyurethane) 2, 1
- Use catheters with the minimum number of lumens required, as risk increases with number of lumens 2, 1
- Ensure proper catheter tip placement in the caudal superior vena cava 2, 1
- Prefer right-sided placements when possible, as left-sided placements are associated with higher incidence of DVT 2, 1
- Utilize ultrasound-guided placement to minimize endothelial damage 2, 1
- Consider pharmacological DVT prophylaxis during hospitalization, which shows a trend toward reduction in risk of catheter-related DVT 3