What is the evaluation and management of a dialysis (renal replacement therapy) patient with swelling in the access (vascular access) hand?

Evaluation and Management of Swelling in Dialysis Access Hand

For a dialysis patient with swelling in the access hand, fluoroscopy fistulography is the recommended diagnostic procedure, as it allows for both diagnosis and immediate intervention for the likely underlying central venous stenosis or occlusion. 1

Initial Assessment

• Swelling in a dialysis access arm often indicates central venous stenosis or occlusion, especially when accompanied by development of venous collaterals 1
• Temporarily avoid dialysis in the affected arm until the cause is determined to prevent further complications 2, 3
• Evaluate for:
  • Changes in access thrill or bruit (may indicate stenosis or thrombosis) 1
  • Duration of swelling (persistent swelling beyond 2 weeks requires venogram) 1
  • Presence of infiltration or hematoma (indicates need to rest the access) 1, 3
  • Signs of infection (erythema, warmth, tenderness) 3

Diagnostic Approach

First-line Imaging

• Fluoroscopy fistulography is the recommended initial imaging for patients with swelling in the extremity ipsilateral to the hemodialysis access 1
  • Allows for both diagnosis and immediate therapeutic intervention 1
  • Considered the reference standard for imaging dysfunctional dialysis access 1

Alternative/Complementary Imaging

• Duplex ultrasound can be used as an initial screening tool but may miss central venous stenoses 2, 4
• For suspected vascular steal syndrome (presenting with ischemic symptoms alongside swelling), both fluoroscopy fistulography and US duplex Doppler are recommended as complementary procedures 1

Management Strategy

Immediate Management

• Rest the affected access until swelling resolves 1, 3
• Elevate the arm to reduce swelling 2, 3
• Avoid cannulation of an infiltrated fistula as it carries high risk of further exacerbation and permanent access loss 1, 3
• Establish temporary alternative access (e.g., cuffed catheter) if dialysis is needed before swelling resolves 3

Definitive Treatment Based on Diagnosis

1. For central venous stenosis (most common cause of arm swelling):

   • Percutaneous transluminal angioplasty is the first-line treatment 1, 2
   • Consider stent placement for:
     • Refractory stenosis after high-pressure balloon angioplasty
     • Persistent abnormal hemodynamics post-angioplasty
     • Elastic venous recoil reducing vessel caliber >50%
     • Stenosis recurrence within 3 months 1

2. For infiltration or hematoma:

   • Rest the access until swelling resolves completely 1
   • Resume dialysis only when swelling has subsided and the course of the access is easily palpable 3

3. For vascular steal syndrome (if ischemic symptoms accompany swelling):

   • Complete arteriography from aortic arch to palmar arch is essential 1, 5
   • Treatment options depend on arteriography findings:
     • Angioplasty or stenting of culprit arterial lesions 1
     • Surgical revision may be needed in severe cases 5

Follow-up and Monitoring

• Regular monitoring of access function through physical examination at least monthly 3
• Surveillance for recurrent swelling, which may indicate restenosis 3
• For patients who underwent central venous stent placement, close monitoring is essential as swelling recurs in up to 59% of cases 6

Important Considerations

• Delay in treatment can lead to permanent loss of vascular access 2
• Patients with diabetes, hypertension, and peripheral arterial disease are at higher risk for complications including hand ischemia 7
• HeRO graft conversion may provide more durable results than stent deployment for patients with recurrent central venous stenosis and arm swelling 6