Downhill Varices Secondary to HeRO Graft‐Related SVC Syndrome

Abstract

Tunneled hemodialysis catheters are well-documented causes of benign central vein stenosis, which can be associated with proximal or downhill esophageal varices due to shunting of blood flow from the upper portion of the body through the esophageal venous plexuses. A majority of these cases remain asymptomatic. As a result, studies are largely limited to symptomatic patients, with incidence rates ranging from 16% to 29%. Recently, Hemodialysis Reliable Outflow (HeRO) graft has been introduced as an effective alternate hemodialysis access in catheter-dependent patients, especially in the presence of significant central venous occlusion. It differs from a conventional arteriovenous graft (AVG) by the fact that its venous outflow end is in the right atrium via one of the central veins, bypassing any significant occlusion upstream. Lower intervention rates and reduced incidence of bacteremia make it comparable to conventional tunneled catheters. However, the incidence of central vein occlusion and associated complications with HeRO grafts is unknown. We present the first case of gastrointestinal bleeding from downhill esophageal varices secondary to HeRO-graft-related SVC occlusion.

Bleeding ‘downhill’ esophageal varices associated with benign superior vena cava obstruction: case report and literature review

“…SVC obstruction diverts venous return from the head and upper torso through collaterals such as the azygous or innominate veins to bypass the obstruction. The proximal and mid esophageal veins drain into the azygous and innominate veins, and the increased pressure and collateralization result in the development of esophageal varices supplied from the superior aspect of the esophagus and extending distally [4]. …”

“…1963, USA [16], Savoy et al 2004, USA [17], Sundermann et al 1960, Germany [18], Johnson et al 1978 Canada [19]Thoracic Malignancy5Sclerotherapy (1), band ligation and superior vena cava stenting (1), surgical resection of cancer (1), supportive care (1), not reported (1)Yasar et al 2015, Turkey [20], Basaranoglu et al 1999, Turkey [21], Glanz et al 1982, USA [22], Pugliese 1973, USA [23], Snodgrass et al 1961, USA [24]Mediastinal Fibrosis5Conservative (2), steroids (1), Sengstaken-Blakemore tube (1), not reported (1)Papazian et al 1983, France [25], Palmer et al 1952, USA [26]Superior vena cava obstruction (not otherwise specified)4Conservative (3), not reported (1)Ibis et al 2007, Turkey [27], Fleig et al 1982, USA [28], Kelly et al 1982, USA [29]Thyroid goiter3Band ligation (1), Sengstaken-Blakemore tube (1), surgical resection of thyroid goiter (1)Tavakkoli at al. 2006, Iran [30], Ichikawa et al 1991, Japan [31]Behcet’s syndrome2Band ligation (1), supportive care (1)Calderwood et al 2008, USA [32], Maton et al 1985, USA [33]Upper extremity DVT2Band ligation, angioplasty, and superior vena cava stenting (1), conservative (1)Tincani et al 1998, Italy [34]Cirrhosis1Diagnosis at autopsyMalloy et al 2013, USA [35]Post Fontan cardiac surgery1Angioplasty and superior vena cava stentingTsokos et al 1998, Germany [36]Post thyroidectomy1SclerotherapyAreia et al 2006, Portugal [2]Pulmonary hypertension1Supportive carePillai et al 2013, USA [4]Hemodialysis reliable outflow (HeRO) graft associated1Band ligationMartorell et al 1955, Spain [37]Ligation of SVC1Not reported USA United States of America, SVC superior vena cava, DVT deep vein thrombosis …”

When the HeRO Becomes the Villain

“…This provides adequate flow so that the normal arterial inflow portion of the AV graft can be cannulated for hemodialysis not unlike any standard AV graft. Complications associated with HeRO grafts include right atrial clots and pulmonary emboli, infection, and gastrointestinal bleeding from downstream esophageal varices . This is the first case we are aware of reporting an uncoupling of HeRO graft components.…”

Active bleeding from downhill varices: case report and management

“…3). 2 In contrast, uphill varices occur secondary to increased portal pressure, leading to the development of collateral circulation. Increased blood flow in this collateral circulation at the gastroesophageal junction and resistance of the esophageal muscularis layer contribute to an increase in venous pressure.…”