Hemodialysis International 2020 CASE REPORT An unusual cause of subacute airway obstruction in a hemodialysis patient with brachio-cephalic arteriovenous fistula: A rare presentation of central venous occlusion Muhammad Izzuddin HAMZAN, 1 Ahmad Rizal HAMID, 2 Ahmad Sukari HALIM 2 , Arman Zaharil MAT SAAD 1,2,3 1 Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 2 Hospital Universiti Sains Malaysia, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan and 3 Management and Science University Medical Centre, Shah Alam, Selangor, Malaysia Abstract A young lady with an arteriovenous (AV) fistula on hemodialysis was referred for surgical manage- ment following a failed endovascular approach to relieve central venous occlusion. She had an obstructed left brachiocephalic vein with a history of numerous central vein catheter placements. Alternative routes for new arteriovenous fistula creation had been exhausted due to previous con- tralateral upper limb fistula rupture and ligation. To the best of our knowledge, no similar cases of airway obstruction in central venous occlusion occurring in hemodialysis patients with AV fistula have been reported. The importance of identifying the possible emergency red flags in hemodialy- sis patients with central venous occlusion is important to prevent unwanted consequences. Keywords: Central venous occlusion, Hemodialysis, AV fistula, Venous hypertension INTRODUCTION Central vein occlusion (CVO) is a known complication related to the use of central venous catheters in hemodi- alysis patients. The creation of an arteriovenous fistula (AVF) leads to an increase in blood flow 4 to 10-fold above the resting level. 1 CVO may lead to venous hyper- tension when collateral capacity is insufficient and results in swelling of the upper limbs, neck, and face. 1 Airway obstruction may occur in superior vena cava syndrome in which upper airway edema results from a reversal of flow in the superior vena cava, which leads to venous congestion of veins draining the tongue, posterior oro- pharynx, and larynx. 2,3 To the best of our knowledge, no similar cases of airway obstruction in central venous occlusion occurring in hemodialysis patients with arterio- venous fistula have been reported. The importance of identifying the possible emergency red flags in hemodial- ysis patients with CVO is important to prevent unwanted consequences. Here we present a case of a young lady Correspondence to: Ahmad Sukari Halim, Reconstructive Science Unit, Hospital Universiti Sains Malaysia and School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia. E-mail: ashalim@usm.my Disclosure of grants or other funding: There are no financial support and sponsorship directly or indirectly. Conflict of Interest: There are no conflict of interest. © 2020 International Society for Hemodialysis DOI:10.1111/hdi.12832 1