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| CASE REPORT |
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| Year : 2022 | Volume
: 9
| Issue : 2 | Page : 200-202 |
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Acute forearm compartment syndrome postdialysis
Ankur Aggarwal, Manju Bharat N R, Sunder Narasimhan
Department of Vascular Surgery, Max Superspeciality Hospital, Sahibzada Ajit Singh Nagar, Punjab, India
| Date of Submission | 21-May-2021 |
| Date of Acceptance | 04-Nov-2021 |
| Date of Web Publication | 13-Jun-2022 |
Correspondence Address:
Ankur Aggarwal
Department of Vascular Surgery, Max Superspeciality Hospital, Sahibzada Ajit Singh Nagar, Punjab
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijves.ijves_56_21
Postdialysis compartment syndrome is a rare but very devastating condition which needs emergent diagnosis and treatment. This can happen due to bleeding from puncture site due to inadequately applied pressure/coagulopathy. This case report illustrates a case of postdialysis pseudoaneurysm formation followed by forearm compartment syndrome. The patient was managed by emergency forearm fasciotomy and skin grafting along with rotation flap. This diagnosis should always be kept in mind when evaluating a patient with sudden onset of pain and swelling postdialysis. This will help in salvage of the patient's upper limb as well as of the precious arteriovenous fistula.
Keywords: Dialysis access bleeding, forearm compartment syndrome, post dialysis compartment syndrome
How to cite this article:
Aggarwal A, Bharat N R M, Narasimhan S. Acute forearm compartment syndrome postdialysis. Indian J Vasc Endovasc Surg 2022;9:200-2 |
| Introduction | |  |
Compartment syndrome due to bleeding from dialysis access puncture site is a very rare phenomenon. Very few cases of acute compartment syndrome associated with dialysis access have been reported.[1],[2],[3],[4] It can lead to severe damage to forearm tissues and can rapidly worsen, leading to strictures and tissue loss. The pain may be ignored by medical personnel, especially if the compartment develops slowly because of formation of a pseudoaneurysm. Furthermore, the thrill in arteriovenous (AV) fistula may be reduced due to pressure in case of compartment syndrome. Often, this is mistakenly diagnosed as thrombosed AV fistula. The purpose of this case report is to document possibility of compartment syndrome due to bleeding from dialysis puncture site in AV fistula in a chronic kidney disease patient. Patient consent was obtained for this report and the images.
| Case Report | | |
A 53-year-old female with previous history of end-stage renal disease presented with severe pain in left forearm and hand for 4 days which started after a dialysis session. She also had sudden onset of swelling in the forearm despite pressure at presumed site of puncture during dialysis. Coagulation profile was normal and the patient was normotensive. The patient was on regular hemodialysis through the left radiocephalic AV fistula made 2 years back. Ultrasound and colour Doppler showed the presence of a pseudoaneursym in the forearm arising from the cephalic vein [Figure 1]. | Figure 1: (a) Pseudoaneurysm in colour Doppler; (b) Pseudoaneurysm in ultrasound
Click here to view |
Emergency left forearm fasciotomy by the Rowland incision was done. Brachial artery control was taken at the elbow and pseudoaneurysm was explored and clots were evacuated from subcutaneous and intermuscular planes [Figure 2]. The bleeding puncture site in the cephalic vein was repaired primarily with polypropylene suture 7-0. In view of severe muscle edema, the wound was left open [Figure 3]. Dialysis was continued after inserting a left internal jugular (IJV) tunnelled dialysis catheter, as the right IJV was occluded (previous history of cannulation). After 2 days, the patient had a blow out of the fistula in mid-forearm, which was repaired primarily. Thereafter, plastic surgeon was involved and the wound was closed with a rotation flap in upper 1/3 of forearm, and the remaining cover provided partially with primary closure and partially with skin grafting [Figure 4]. | Figure 4: Closure achieved with rotation flap, skin grafting and primary closure
Click here to view |
After 2 weeks, the wound completely healed [Figure 5] and dialysis was started through the same fistula and left side tunnelled line was removed. The patient, at present, is dialysing uneventfully through the left radiocephalic AV fistula.
| Discussion | | |
Compartment syndrome is a devastating condition if not treated promptly. Delay in recognition and in treatment can have catastrophic consequences for the patient. The chances of bleeding and compartment increase if the patient is on anticoagulation. Clinical features such as severe pain over the fistula with swelling and tenderness should ring a warning bell in the mind of the clinician about the possibility of a compartment syndrome in such patients although the incidence is very low.
Often, the delayed presentation of compartment syndrome due to formation of pseudoaneurysm makes it difficult to suspect and diagnose the problem. This case report brings to light that this diagnosis should always be at the back of the mind of the clinician when evaluating such a patient with pain at or proximal to the site of AV fistula.
Furthermore, the dialysis technicians and the nursing staff should be educated about this potential complication so that prompt diagnosis and emergent treatment is done, thus saving the patient from potential disability (especially upper limb loss) and from failure of AV fistula.
| Conclusion | | |
We conclude that compartment syndrome is a possible complication after dialysis which can have disastrous consequences. However, it can be treated effectively if recognized and treated early.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Acknowledgment
It is my pleasure to thank Dr. Sunder Narasimhan for his valuable support and inputs in managing this case and guiding me through this case and writing this case report. I would also like to thank Dr. Manju Bharat for constant help in creating this case report. Last, but not the least, I would like to thank my patient for allowing me to publish her details.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Reddy SP, Matta S, Handa A. Forearm compartment syndrome following puncture of haemodialysis access fistula. Eur J Vasc Endovasc Surg 2002;23:458-9.  |
| 2. | Pereira de Godoy JM, Meziara JC, Braile DM. Compartment syndrome in subcutaneous and skin tissue of a dialysis patient operated for creation of an AV fistula. Int Urol Nephrol 2005;37:437-8. |
| 3. | Wang KL, Li SY, Chuang CL, Chen TW, Chen JY. Subfascial hematoma progressed to arm compartment syndrome due to a nontransposed brachiobasilic fistula. Am J Kidney Dis 2006;48:990-2. |
| 4. | Lee WY, Yen TH, Lee SY. Acute forearm compartment syndrome associated with dialysis access bleeding. Nephrology (Carlton) 2012;17:665-6. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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