1. Patient has a tunneled hemodialysis catheter in her left internal jugular vein and has had multiple episodes of catheter dysfunction due to formation of a fibrin sheath fibrin sheath hemodialysis catheter has been removed left IJ

2. Fibrin sheath and left brachiocephalic vein have been dilated several times

3. Due to the long-term presence of the tunneled hemodialysis catheter there is a persistent stenosis in the left brachiocephalic vein This central venous stenosis. in combination with her new left upper arm fistula, is the etiology of her persistent left upper extremity swelling

4. A good management plan would be to remove the tunneled hemodialysis catheter from the left internal jugular vein and then to dilate (PTA) and stent the stenosis in the left brachiocephalic vein to alleviate the left arm edema. To do so requires moving the hemodialysis catheter to a new location. Ultrasound demonstrated that the right internal jugular vein is occluded. The right subclavian vein may be an option if the right upper extremity veins are not useable for future vascular access procedures. A right upper extremity venogram was performed.

5. Right elbow region basilic vein cephalic vein

6. Right upper arm veins basilic vein cephalic vein

7. Right shoulder region basilic vein cephalic vein subclavian vein

8. Moderate stenosis of mid-subclavian vein due to extrinsic compression of vein between 1 st rib and right clavicle

9. The right basilic vein is in decent shape and could be used for a future fistula or graft. Therefore, we would not want to jeopardize the right subclavian by using it for a new tunneled hemodialysis catheter. The next option would be to remove the current left-sided tunneled hemodialysis catheter and place a new tunneled hemodialysis catheter into a femoral vein. This option should be discussed with the patient.