Superior Vena Cava Syndrome in a Kidney Transplant Recipient: Life-Threatening Complication of Arteriovenous Fistula

Introduction: While arteriovenous fistulas (AVFs) are the preferred vascular access for hemodialysis, they can lead to serious complications post-kidney transplant. We present a rare case of superior vena cava (SVC) syndrome developing in a kidney transplant recipient secondary to AVF-related venous hypertension, highlighting the diagnosis and management of access challenges in this population. Case Description: A 31-year-old male with ESRD due to ANCA-associated vasculitis status post deceased-donor kidney transplant, presented with an acute onset of right neck swelling, facial plethora, and dyspnea. The patient had previously undergone left AVF ligation for high-output heart failure. CT imaging demonstrated SVC obstruction proximally to the upper-extremity AVF. Urgent right AVF ligation resulted in immediate resolution of SVC syndrome symptoms. Postoperative ultrasound revealed extensive deep venous thrombosis of subclavian, axillary, and basilic veins, requiring indefinite anticoagulation. Remarkably, allograft function remained stable throughout with minimal proteinuria. Discussion: AVFs can cause life-threatening complications, including high-output cardiac failure and SVC syndrome, even in transplant recipients who no longer require dialysis. Long-term effects of AVF ligation following kidney transplantation are uncertain. The decision for AVF ligation requires careful consideration of future access needs versus current morbidity, especially in grafts with stable function. Post-ligation thrombosis, needing long-term anticoagulation, can further impose increased risk, requiring close monitoring. SVC syndrome represents a serious complication of AVFs post-kidney transplant. Ongoing vascular surveillance in stable transplant patients with patent AVF is needed, with consideration of ligation in selected cases with careful risk-benefit analysis. A coordinated, multidisciplinary approach is crucial for optimal outcomes in such challenging cases.Aneurysmal AVF and CT scan image of SVC syndrome with a clot in SVC marked by circle.