Disclosures: Kevin Zheng, MD: No financial relationships or conflicts of interest

Case Diagnosis: Central Venous Stenosis

Case Description: A 71-year-old male presented to inpatient rehabilitation after right transfemoral amputation for critical limb ischemia. His past medical history is significant for coronary artery disease status post coronary bypass graft, heart failure with Automatic Implantable Cardioverter Defibrillators (AICD), and atrial fibrillation on rivaroxaban. Peri-operatively, the patient’s rivaroxaban was transitioned to heparin. Post-operative complications included non-painful left upper extremity (LUE) swelling. Color Doppler ultrasound (CDU) was negative for deep vein thrombosis (DVT).

Setting: VA HospitalAssessment/

Results: On admission to inpatient rehabilitation, the patient’s LUE swelling was improving, however, two days afterward he developed worsening LUE with no pain, weakness, or sensory changes. CDU and CT pulmonary embolism study were performed. Both studies were negative. After reviewing images further with radiology, it was noted that he had central venous stenosis (CVS) secondary to AICD leads. The patient’s LUE swelling improved with conservative management.

Discussion: CVS due to AICD is a known complication. The incidence of CVS from pacemakers and AICD ranges from 26% to 64%. Risk factors for developing CVS from AICD, found in some studies, include the number or type of leads, multiple procedures, and the sum diameters of leads. Pathophysiologically, CVS is due to transvenous leads causing chronic inflammation resulting in endothelial injury, intimal hyperplasia, and tissue fibrosis. Thus, CVS can mimic upper extremity DVT.

Conclusion: The incidence of upper extremity DVT after lower limb amputation is not well established in literature. Given the incidence of lower extremity DVT after lower limb amputation of 9-11%, it is imperative to rule out DVT when patients develop unilateral upper extremities edema. Patients after lower limb amputation require more use of their upper extremities for support and ADLs. It is important for physiatrists to be aware of other causes and management of unilateral lateral limb swelling to prevent delay in therapies and functional gains.

Level of Evidence: Level IV

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/central-venous-stenosis-secondary-to-aicd-leads-a-case-report/