Intracranial venous reflux without the central venous occlusive disease in a patient receiving hemodialysis through brachio-brachial arteriovenous fistula: A case report

Upper-limb arteriovenous fistula as a hemodialysis access among patients with end-stage renal disease (ESRD) has become a preferred type of vascular access. However, complications involving the central nervous system may occur. There have been no reported cases of internal jugular vein (IJV) regurgitation without central venous occlusive diseases (CVODs).We describe the case of a patient on HD who presented with symptomatic IJV regurgitation without CVODs. An 83-year-old man with ESRD receiving HD through a left upper-limb AVF presented with impaired consciousness and seizures. After recovery from unconsciousness, he became alert with cognitive impairment. The left subclavian arteriography revealed early filling of the left subclavian vein due to the AVF on the left brachium, with retrograde high-flow venous reflux to the left IJV, sigmoid and transverse sinuses, with the left central veins patent. All cerebral venous drainage procedures were dependent on the right IJV. The left internal carotid arteriography showed venous congestion of the left hemisphere. The flow of the left brachial artery was measured extremely high. Under compression of the left brachial artery to reduce the flow, the regurgitation persisted. With the findings that all cerebral venous return were in the right IJV, sacrificing the left IJV was thought to be acceptable. Left IJV ligation was performed, and the patient's cognitive function improved. The short-term outcome after IJV ligation may be positive in the patient who was confirmed to have a normal cerebral venous return route independent of the refluxed IJV.