A Case of Acute Subclavian Artery Occlusion Presenting with Shunt Failure-Like Symptoms in a Patient on Hemodialysis

Introduction: Arteriovenous fistula (AVF) failure is a common complication in patients undergoing hemodialysis, typically characterized by the disappearance of a bruit or thrill. Herein, we report a case of acute subclavian artery occlusion presenting with the disappearance of the AVF bruit, which was initially difficult to distinguish from AVF failure. Case Description: An 80-year-old woman undergoing hemodialysis for three years for IgA nephropathy via left forearm AVF had a history of three previous percutaneous transluminal angioplasties. She presented with a sudden onset of pain in the left upper limb and disappearance of the AVF bruit. Initially, AVF failure was suspected; however, angiography revealed no significant stenosis or occlusion (Fig 1). Contrast-enhanced chest CT subsequently revealed that the symptoms were caused by thrombotic occlusion of the left subclavian artery (Fig 2). Emergency subclavian artery bypass surgery was performed, which led to improvement in pain and restored the AVF bruit. The patient continued hemodialysis therapy using an existing AVF. Discussion: The hallmark symptoms of acute subclavian artery occlusion include upper limb pain, paralysis, and pallor. Owing to the overlap in neurological symptoms, it is often misdiagnosed as acute ischemic stroke. However, no previous reports have documented acute subclavian artery occlusion occurring on the same side as the AVF in hemodialysis patients and misdiagnosed as AVF failure, as in this case. In hemodialysis patients, AVF bruit disappearance tends to be assessed as AVF failure. However, acute subclavian artery occlusion should be considered in the differential diagnosis when the AVF bruit disappears, accompanied by upper limb paralysis or pain.Fig 1. Left forearm AVF DSA ImageFig 2. Contrast-enhanced chest CT