Vassar Brothers Medical Center Poughkeepsie, NY, United States
Award: Presidential Poster Award
Sikder Hassan, MD1, Sahib B. Singh, MD1, Oluwafemi Ajibola, MD1, Shazia Choudry, MD1, Simona Meca, MD2 1Vassar Brothers Medical Center, Poughkeepsie, NY; 2Premier Medical Gastroenterology, Poughkeepsie, NY
Introduction: Superior vena cava (SVC) syndrome can occur from SVC stenosis after central venous catheter placement. Downhill esophageal varices (DEV) are rare.
Case Description/Methods: 54-year-old man with a history of end stage renal disease (ESRD) due to polycystic kidney, had hemodialysis (HD) via a PermCath and subsequently via left arm (LA) arteriovenous fistula (AVF) for 5 years, before having kidney transplant in 2018. He presented with hematemesis and melena. Also had LA and facial swelling with difficulty breathing when supine, occasional blurry vision, and hoarse voice. He was hypotensive and tachycardic. Examination was remarkable for LA swelling and AVF aneurysm with thrill and facial edema without any signs of portal hypertension. Labs notable for Hb of 9.1 g/dl, MCV of 91 fl, platelet of 229 X10(3)/mcl, BUN/Creatinine of 27/1.14 mg/dl, and normal liver function tests. A CT angiogram showed distal SVC high-grade stenosis with extensive collateralization via azygos system. An upper endoscopy (EGD) showed two columns of grade II-III varices in the mid esophagus from 27 to 33 cm with recent bleeding stigma (fibrin plug), therefore, variceal banding was done. Diagnosis was made as DEV due to SVC syndrome. It was evident that there was high flow towards left arm AVF, which was causing increased central venous pressure, contributing to the variceal bleeding. Therefore, ligation of the AVF was done. Intraoperative fistulogram showed extensive ectasia of the brachiobasilic AVF; also confirmed high-grade distal SVC stenosis with collateralization via azygos system. Pre-ligation SVC pressure was 31 mmHg within the proximal SVC, which dropped to 19 mmHg post-ligation. An upper EGD after a month showed complete resolution of varices.
Discussion: DEV without portal hypertension are seen resulting from SVC obstruction, due to excessive pressure caused by increased blood flow towards azygous vein. Usually found in the upper esophagus; DEV may involve its entirety depending on severity and obstruction site. DEV due to SVC obstruction in ESRD after dialysis catheter placement is rare. Intact AVF contributes to elevated pressure in the central venous system; therefore, consideration should be made to ligate it, along with variceal treatment in order to reverse underlying pathophysiology.
Figure: Initial upper EGD shows esophageal varices (A) and fibrin plug (B). Upper EGD after a month shows complete resolution of varices (C). AVF post ligation (D).
Sikder Hassan indicated no relevant financial relationships.
Sahib Singh indicated no relevant financial relationships.
Oluwafemi Ajibola indicated no relevant financial relationships.
Shazia Choudry indicated no relevant financial relationships.
Simona Meca indicated no relevant financial relationships.
Sikder Hassan, MD1, Sahib B. Singh, MD1, Oluwafemi Ajibola, MD1, Shazia Choudry, MD1, Simona Meca, MD2. P1392 - High Flow AVF Causing Downhill Esophageal Varices in a Patient With Benign SVC Stenosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.