Hemoptysis after percutaneous transluminal angioplasty for left stenotic brachiocephalic vein in a patient on maintenance hemodialysis

A 68-year-old female with pyonephrosis had been on maintenance hemodialysis due to end-stage renal disease (ESRD) for 25 years. Arteriovenous fistula (AVF) developed in the left forearm and swelling of the left limb appeared in 2010. Therefore, we performed percutaneous transluminal angioplasty (PTA) employing a balloon for the left stenotic brachiocephalic vein, based on a diagnosis of venous hypertension. At this time, venous hypertension was recurrent, and we again performed PTA with angiography using a 9-mm semi-compliant PTA balloon at the same site. However, the patient suffered massive hemoptysis just after the procedure and progressed to respiratory failure. CT scan showed reticular shadows in both lung fields, yielding a diagnosis of diffuse alveolar hemorrhage (DAH). As the hemoptysis was not continuous, we treated her with hemostatic agents and oxygenation. In addition, we created an AVF in the right forearm after closing the one in the left arm. The causes of DAH are well known and include not only non-immunological factors, such as heart failure, tumor, and pulmonary hypertension, but also immunological factors such as vasculitis syndrome and collagen diseases. On the other hand, there are no reports of DAH in an ESRD patient undergoing PTA. In conclusion, DAH might be caused by elevation of intra-alveolar capillary pressure due to the release of overflow capacity into the right-sided flows by PTA. We need to consider the optimal choice of therapy for long-term hemodialysis patients with multiple complications.