Unilateral pleural effusion associated with ipsilateral arm and breast oedema: a rare complication of brachiocephalic and SVC stenosis in association with an arteriovenous fistula.

Sir,

Central venous stenosis has been a well-recognized complication of dialysis catheters for over 20 years. There is a much higher incidence of venous stenosis associated with subclavian versus internal jugular vein dialysis catheters [1]. The stenosis, however, is commonly asymptomatic until an ipsilateral arteriovenous fistula is formed. Arm oedema and, to a lesser extent, breast oedema are well-described complications [2-4]. It is extremely rare, however, to have an associated pleural effusion as well [5].

We present a case of massive right pleural effusion associated with right breast and arm oedema, as a consequence of a right brachiocephalic/superior vena cava (SVC) stenosis in a dialysis patient with an ipsilateral arteriovenous fistula.

A 60-year-old female haemodialysis patient presented with shortness of breath. A CXR revealed a massive right-sided pleural effusion with ipsilateral breast and arm oedema. Eight hundred and fifty millilitres of straw-coloured pleural fluid was drained and found to be a transudate. Cytology, culture and biochemical analysis failed to demonstrate a cause. Rapid re-accumulation of fluid resulted in a second admission 2 weeks later with a ‘white-out’ of her right hemithorax (Figure 1). A further 1000 ml of pleural fluid was drained, with similar findings to the first examination.

Fig. 1

Chest x-ray showing a ‘white-out’ of the right lung field. Note also the significant right breast and arm oedema. There is a kinked left internal jugular dialysis catheter at the level of the right brachiocephalic vein/superior vena cava.

Dialysis access was via a right basilic vein transposition and also a left internal jugular tunnelled dialysis catheter. This had been left in situ due to needling problems of the fistula. Imaging revealed a significant stenosis at the junction of the right brachiocephalic vein and SVC. A decision was made to perform caval venoplasty with stenting of the stenosis, which was radiologically successful. The dialysis catheter was removed prior to the procedure. The placement of the stent resulted in the resolution of her arm and breast oedema within 48 h. Furthermore, the symptoms of breathlessness resolved over the next 2 weeks. A subsequent CXR revealed clear pleural spaces (Figure 2).

Fig. 2

Post-venoplasty and -stenting of stenosis with clear lung fields and pleural spaces. Significant resolution of the subcutaneous oedema of breast and arm.

Her fistula is still working well and being used as dialysis access 10-month post-stent insertion.

Pleural fluid can enter the pleural cavity through three potential routes: capillaries in the parietal pleura, interstitial spaces via the visceral pleura or peritoneal cavity via the diaphragm. This fluid is normally removed by lymphatics in the visceral pleura. In our case, it is likely there was impaired lymphatic absorption as the high venous pressure, resulting from the brachiocephalic stenosis, would impair lymphatic drainage from the right thoracic duct. Additionally, it is possible that there was increased pleural fluid production due to increased venous pressure of the parietal pleural capillaries, which ultimately drain into the SVC.

In conclusion, the finding of a pleural effusion with ipsilateral arm and breast oedema in a dialysis patient with an arteriovenous fistula should prompt investigation for a central venous stenosis.

Conflict of interest statement. None declared.