Epistaxis as a Rare Complication of Catheter-Related Central Venous Stenosis Jin-Ju Tsai, MD, Ching-Chih Hsia, MD, Dong-Ming Tsai, MD, Wei-Tsung Chen,

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Epistaxis as a Rare Complication of Catheter-Related Central Venous Stenosis Jin-Ju Tsai, MD, Ching-Chih Hsia, MD, Dong-Ming Tsai, MD, Wei-Tsung Chen, MD, Yung-Hsuen Hsu, MD American Journal of Kidney Diseases Volume 53, Issue 3, Pages 555-559 (March 2009) DOI: 10.1053/j.ajkd.2008.08.025 Copyright © 2009 National Kidney Foundation, Inc. Terms and Conditions

Figure 1 Antegrade venography shows obstruction of the right subclavian vein (arrowhead). Shunted blood runs collaterally to the right external jugular vein (black arrow). Other collateral vessels and the right internal jugular vein are also evident (white arrow). American Journal of Kidney Diseases 2009 53, 555-559DOI: (10.1053/j.ajkd.2008.08.025) Copyright © 2009 National Kidney Foundation, Inc. Terms and Conditions

Figure 2 Head-and-neck first-pass contrast-enhanced magnetic resonance venography shows occlusion of the right subclavian vein. The venous return of the right arm is diverted to the right external jugular vein (f). The venous return then descends not only through the right internal jugular vein (e), but also through the cavernous sinus to the left external (i) and left internal (j) jugular veins. It finally flows to the left brachiocephalic vein (m). The left pterygoid plexus (h) also is markedly congested. a, right heart; b, pulmonary trunk; c, superior vena cava; d, right brachiocephalic vein; g, right and left cavernous sinuses; k, right and left superior and middle thyroid veins; l, left anterior jugular vein. American Journal of Kidney Diseases 2009 53, 555-559DOI: (10.1053/j.ajkd.2008.08.025) Copyright © 2009 National Kidney Foundation, Inc. Terms and Conditions

Figure 3 Normal antegrade venography through the right arm shows the contrast medium running from the axillary vein (a); joining the cephalic vein (b); draining into the right subclavian vein, right brachiocephalic vein (e), and superior vena cava (f); and finally terminating in the right atrium (g). c, dialysis catheter; d, subclavian vein. American Journal of Kidney Diseases 2009 53, 555-559DOI: (10.1053/j.ajkd.2008.08.025) Copyright © 2009 National Kidney Foundation, Inc. Terms and Conditions

Figure 4 Antegrade venography through the right arm of a patient with dialysis catheter–related superior vena cava (SVC) occlusion after removal of the tunneled catheter shows 2 collateral pathways to return blood to the inferior vena cava; 1 through the lateral thoracic vein (a) and the other through the vertebral venous plexus (e) and intercostal veins (d) to the azygos (g) and hemiazygos (h) system, thereby bypassing the obstructed SVC (f). b, obstructed orifice of the azygos vein entering into the SVC; c, axillary vein. American Journal of Kidney Diseases 2009 53, 555-559DOI: (10.1053/j.ajkd.2008.08.025) Copyright © 2009 National Kidney Foundation, Inc. Terms and Conditions