Facial asymmetry as a clinical manifestation of central venous stenosis ina hemodialysis patient

A haemodialysis patient had an arterio-venous fistula as vascular access fo r hemodialysis. Soon after the fistula was created, he developed progressiv e edema of the right upper limb and right hemifacies, due to stenosis of th e innomate vein. The patient had carried several subclavian and jugular vei n cannulas as temporary access for haemodialysis in the past. Diagnosis of the stenosis with fistulography permitted correction with an angioplastic p roccedure and stent insertion, survival of the fistula for two years, and d ramatic improvement of the facial edema. Two years later there was recurren ce of the edema with only a slight decrease in Kt/V: with concomitant detec tion of increased venous pressures during the haemodialysis sesions. A seco nd fistulography showed obstructive thrombosis of the stent prothesis and m arked development of colateral veins, through wich bloodreturned. A new fis tula was placed in the contralateral arm and the previous fistula was close d with spectacular improvement of the edema and complete dissappearance of the colateral circulation.