Abstract
Thrombectomy is a common procedure performed to declot thrombosed dialysis arteriovenous fistula (AVF) or arteriovenous graft (AVG). Complications associated with access thrombectomy like pulmonary embolism have been reported, but paradoxical embolism is extremely rare. We report a case of a 74-year-old black man with past medical history significant for end-stage renal disease (ESRD), atrial fibrillation on anticoagulation with warfarin, who presented to our hospital with lethargy, aphasia, and right-sided hemiparesis following thrombectomy of a clotted AVG. Computed tomography (CT) scan of brain showed a hypodensity within the left posterior parietal lobe. INR was 2.0 on admission. Echocardiogram revealed a normal sized left atrium with no intracardiac thrombus, and bubble study showed the presence of right-to-left shunting. These findings suggest that the stroke occurred as a result of an embolus originating from the AVG. Paradoxical cerebral embolism is uncommon but can occur after thrombectomy of clotted vascular access in ESRD patients. Clinicians and patients should be aware of this serious and potentially fatal complication of vascular access procedure.
Highlights
Hemodialysis vascular accesses are commonly complicated by thrombosis
Thrombolysis using percutaneous endovascular techniques by means of mechanical devices such as balloons and catheters and thrombolytic agents has been the standard procedure in declotting of thrombosed dialysis vascular accesses in many centers [1]
A 74-year-old black man with history of end-stage renal disease maintained on hemodialysis for five years, coronary artery disease, peripheral vascular disease, atrial fibrillation on anticoagulation with warfarin, pacemaker placement for symptomatic bradycardia 10 years ago, diabetes mellitus, hypertension, and colon cancer was referred to an outpatient vascular access center for thrombosed right forearm loop graft, which has been in use for three years
Summary
We report a case of a 74-year-old black man with past medical history significant for end-stage renal disease (ESRD), atrial fibrillation on anticoagulation with warfarin, who presented to our hospital with lethargy, aphasia, and rightsided hemiparesis following thrombectomy of a clotted AVG. Echocardiogram revealed a normal sized left atrium with no intracardiac thrombus, and bubble study showed the presence of right-to-left shunting. These findings suggest that the stroke occurred as a result of an embolus originating from the AVG. Paradoxical cerebral embolism is uncommon but can occur after thrombectomy of clotted vascular access in ESRD patients. Clinicians and patients should be aware of this serious and potentially fatal complication of vascular access procedure
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