Dear Editor,

We report a 17-year-old male, with a case of chronic kidney disease and on thrice a week maintenance hemodialysis through right brachial arteriovenous fistula (AVF) for 12 months. He was admitted to the All India Institute of Medical Sciences, New Delhi, for live related renal transplantation. He had a single episode of vigorous sneeze followed by sudden onset of pain in the fistula arm at 10 cm proximal to the fistula anastomosis at the anterior aspect. Clinical evaluation revealed blood pressure of 140/90 mmHg and pulse of 80 beats per minute. Local examination revealed swelling and tenderness on the right upper arm, 10 cm proximal to the anastomosis. Bruit was present. Other systemic examination was unremarkable. He was immediately subjected to Doppler ultrasound of the arteriovenous system of the right arm. There was a circumferential asymmetrical wall thickening in the draining vein 10 cm above right elbow due to an intramural hematoma. Also there was a focal defect in the intima of the draining vein while it revealed normal arterialized flow (Fig. 1). There was edema in the surrounding soft tissue. The patient was managed with occlusive dressing for 4 hours intermittently for the next 2 days and resting of the AV fistula, with which pain and swelling subsided. There was no fever and no evidence of any infection and bruit and thrill continued to be heard. A day later, pre-transplant dialysis was done via femoral access and renal transplant surgery was successfully performed.


Figure 1. Doppler ultrasound of arteriovenous system of the right elbow and upper arm showing focal defect in intima of the draining vein.

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Our case highlights an unusual traumatic complication of AVF following a sneezing episode. Such a cause of intimal tear has never been reported. At first gesture, one laughs but for the patient, vascular access is an important issue. We thought it was better for him to proceed for transplant surgery.

Ultrasound is a noninvasive means of imaging for access complications (1). Though various optimized care protocols have shown to be effective in improving AVF patency (2), inevitable complications like in this case may occur. Nephrologists and dialysis care staff should be aware of such subtle complications of vascular access and their management, so as to avoid stress and trauma to a dialysis patient.


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  • 1
    Davidson I, Chan D, Dolmatch B et al. Duplex ultrasound evaluation for dialysis access selection and maintenance: a practical guide. J Vasc Access 2008;9:19.
  • 2
    Flu H, Breslau PJ, Krol-van Straaten JM, Hamming JF, Lardenoye JW. The effect of implementation of an optimized care protocol on the outcome of arteriovenous hemodialysis access surgery. J Vasc Surg 2008;48:65968.