A Case Report: Pulmonary Embolism (PE) in Hemodialysis Patients with Autogenous Arteriovenous Fistula (AVF) Occlusion during Ultrasonography

doi:10.21203/rs.3.rs-2244849/v1

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Case Report

A Case Report: Pulmonary Embolism (PE) in Hemodialysis Patients with Autogenous Arteriovenous Fistula (AVF) Occlusion during Ultrasonography

https://doi.org/10.21203/rs.3.rs-2244849/v1

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Backgrounds: Symptomatic pulmonary embolism is rare and fatal. We report a case of a patient with fatal pulmonary embolism during ultrasonography examination of autogenous arteriovenous fistula.

Case presentation: We present the case of a 53-year-old woman with end-stage renal disease (ESRD). The left forearm arteriovenous fistula is the vascular access. After had maintenance hemodialysis for about 9 years, the patient developed an aneurysm behind the anastomosis. She visited the doctor after finding that the arteriovenous fistula tremor disappeared. During the ultrasound examination, the patient lost consciousness. Pulmonary embolism was confirmed by enhanced CT. The patient was improved after tracheal intubation and active anticoagulation therapy. The follow-up angiography showed arteriovenous fistula anastomotic stenosis, autologous arteriovenous reconstruction surgery was performed.

Conclusions: Symptomatic and fatal pulmonary embolism was rarely during ultrasonography examination of autogenous arteriovenous fistula. Therefore, clinicians should pay attention to this possibility to provide timely and appropriate treatment.

Arteriovenous fistula

Hemodialysis

Pulmonary embolism

Ultrasonography

The incidence rate of end-stage renal disease (ESRD) is increasing year by year, and the prevalence rate of ESRD is about 0.07% in the world’s population[1]. Renal replacement therapy is required. At present, hemodialysis is still the first treatment option[2] and arteriovenous fistula (AVF) is the first choice for vascular access, which has longer duration of use and fewer complications than artificial blood vessels and catheters[3], but thrombosis remains the leading cause of dysfunction of native arteriovenous fistulas[4]. Local stenosis and sudden drop in blood pressure are two common mechanisms of the thrombosis. The thrombosis can be treated by mechanical compression of thrombus, percutaneous urokinase thrombolysis, and surgical thrombectomy[5]. Pulmonary embolism is common after thrombus shedding, and most patients are asymptomatic. Symptomatic pulmonary embolism is rare, while massive pulmonary embolism is fatal[6].

A 53-year-old woman hemodialysis patient had an office visit since the fistula tremor disappeared. Pulmonary embolism induced syncope occurred during the ultrasonography in the hemodialysis room.

This patient has been on maintenance hemodialysis for 9 years and has a history of liver cirrhosis. The initial access is internal jugular vein catheterization, followed by left forearm radial artery cephalic vein anastomosis, and arteriovenous fistula is the subsequent vascular access. After puncture, the patient developed an aneurysm 2–6 cm behind the anastomotic stoma. When the patient found that the tremor of the arteriovenous fistula disappeared, she visited the doctor. The physician in the hemodialysis room performed an ultrasonic exam. There was no blood flow signal from the anastomosis to about 3 cm behind the aneurysm. During ultrasonography, the patient lost consciousness with blue skin and lips. She was transferred to the emergency room. The oxygen saturation in the peripheral blood was 60%, the blood pressure dropped to 80/40 mmHg, and the heart rate dropped to 40 beats/min. Oxygen was inhaled by a mask. After that, the patient's consciousness gradually recovered, blood pressure and heart rate returned to normal, but the blood oxygen saturation was still at 70%. An open airway ventilator was used to assist exhalation, and the patient's blood oxygen saturation rose to 90%. D-Dimer 2.0 µg/ml (normal value 0–1µg/ml), fibrin degradation product 5.6 µg/ml (normal value 0–5µg/ml). The patient was admitted to the intensive care unit, and the blood gas analysis showed: PH 6.94 (normal value 7.35–7.45), partial pressure of carbon dioxide (PaCO2) 54.4mmHg (normal value 32–45 mmHg), partial pressure of Oxygen (PaO2) 126.2mmHg (normal value 83–108 mmHg), lactic acid 5.66mmol/L (normal value 0.5–1.6 mmHg). The pulmonary artery computed tomography angiography (CTA) on the second day showed right lower pulmonary artery branch and left pulmonary artery thrombosis (shown in Fig. 1–2). Considering the diagnosis of pulmonary embolism, dalteparin sodium 5000iu was administered subcutaneously every 12 hours. Bedside blood purification treatment after right femoral vein catheterization. Repeated coagulation tests showed D-dimer 8.4 µg/ml and fibrin degradation products 17.5 µg/ml. Three days later, the tracheal intubation was removed, the patient was transferred to the general ward, and continued to be given dalteparin sodium 5000iu, once a day, subcutaneously. On the 7th day, the patient developed right waist pain radiating to the left lower extremity, and pelvic CT showed hemorrhage of the right iliopsoas muscle (shown in Fig. 3). Considering the bleeding at the right femoral vein catheter, dalteparin was discontinued. Compression after femoral vein catheterization was removed.

On the 7th day of the course of the condition, the patient's left forearm arteriovenous fistula tremor appeared, and it was selected as the bedside hemodialysis access with a blood flow of 200ml/min. In order to further understand the arteriovenous fistula, digital subtraction angiography was performed, indicating that the anastomotic stoma was significantly narrowed. The contrast agent passed through in a linear manner, and the stenotic tumor-like expansion was seen behind the anastomosis. The reconstruction of the arteriovenous fistula was performed (shown in Fig. 4), and routine hemodialysis was performed after the operation.

Hemodialysis patients are at high risk of pulmonary embolism due to deep venous catheter removal, autologous arteriovenous fistula, artificial vascular arteriovenous fistula, and thrombus removal during surgery or digital subtraction angiography after thrombus removal. However, most of them are transient pulmonary arterial pressure rise, and fatal pulmonary embolism is rare[7]. Most of the reported clinical cases state that symptomatic and even fatal pulmonary embolism appear during the operation of arteriovenous fistula or interventional operation under digital subtraction angiography[8, 9].However, for this patient, after the internal fistula thrombosis, during the ultrasound examination, the thrombus fell off due to the extrusion of the ultrasound probe, which eventually led to fatal pulmonary embolism. Thanks for timely diagnosis, mask oxygen inhalation and ventilator, the patient ultimately had a good prognosis. Subsequent angiography also confirmed that the cause of thrombosis in the patient was the stenosis of the anastomosis and the aneurysm behind the anastomosis, and insufficient blood flow through the anastomosis, staying at the aneurysm, rather than passing quickly, led to the formation of thrombus. After the patient's vital signs stabilized, the next day's examination still found the presence of thrombus in both pulmonary arteries. After aggressive anticoagulation therapy, the patient's symptoms improved quickly, and without further treatment, the arteriovenous fistula became functional, but at the same time, we also found that anticoagulation therapy resulted in blood oozing at the femoral vein catheter leading to hematom. It has been reported that in the hemodialysis population, death from pulmonary embolism is lower than that of the general population, which is associated with better daily health concerns and routine dialysis anticoagulation[10]. Better attention to the structural abnormalities of the patient's arteriovenous fistula and timely intervention can effectively reduce the occurrence of fatal pulmonary embolism[7]. However, if pulmonary embolism does occur, timely and active treatment can save the patient's life.

Symptomatic and fatal pulmonary embolism was rarely during ultrasonography examination of autogenous arteriovenous fistula. Therefore, clinicians should pay attention to this possibility to provide timely and appropriate treatment.

ESRD

end-stage renal disease

AVF

arteriovenous fistula

CTA

computed tomography angiography

Acknowledgements

We appreciate the patient’s permission to publish this case.

Authors’ contributions

QHL and YCL made the conception and design of study. ZXH and ZH drafted the manuscript. DZH made analysis and interpretation of data. All authors read and approved the final manuscript.

Funding

None.

Availability of data and materials

The datasets used in this case are available from the corresponding author on reasonable request.

Ethics declarations

Ethical approval and consent to participate

This case report was carried out in accordance with the Declaration of Helsinki; Ethical Committee approval is waived for individual anonymized reports. The patient was informed about the availability and importance of the data, including the clinical data, images, and health information, described in this article.

Consent for publication

The patient signed a written informed consent to authorize publication of the present case report. Ethical Committee of Taizhou Second People’s Hospital approval was not required for a single case report.

Competing interests

The authors declare that they have no competing interests.

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No competing interests reported.

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A Case Report: Pulmonary Embolism (PE) in Hemodialysis Patients with Autogenous Arteriovenous Fistula (AVF) Occlusion during Ultrasonography

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