A 52-year-old woman with type 2 diabetes mellitus (DM2), hypertension, and end-stage renal disease (ESRD) due to diabetic nephropathy has been on renal replacement therapy (RRT) for the past 5 years. She was recently transitioned from peritoneal dialysis to hemodialysis (HD) because of frequent peritonitis and subsequent peritoneal membrane failure. There is a tunneled HD catheter in her left internal jugular (IJ) vein that is being used as HD access. A brachiocephalic arteriovenous fistula (AVF) was created in the left arm 8 weeks previously. She arrived at a dialysis unit reporting new-onset left arm swelling and pain.

Physical exam revealed moderate swelling in her left hand and through the entire arm. The new AVF surgical site appeared well, with no sign of localized swelling or erythema. There was audible bruit at the AVF, which appeared mature. There was no cyanosis or blanching of the left hand. Radial pulse was 2+ bilaterally. There was no facial or neck swelling. A dialysis catheter was used for treatment with good blood flow of ~350 ml/min with no issues. An urgent evaluation by vascular surgeon was arranged.

Figure 1. Chest X-ray showing the presence of a tunneled dialysis catheter placed in the left IJ.
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