Ulcerating Stasis Dermatitis of the Forearm Associated With Arteriovenous Graft and Central Vein Stenosis

Stasis dermatitis is a pathologic condition of the skin that most commonly occurs in the lower limb, where it is caused by chronic venous insufficiency. Stasis dermatitis of the upper limb is rare. Clinical manifestations usually include finger and hand edema and limited mobility. Venous gangrene may be observed in advanced stages of stasis dermatitis.^1–5 A case of severe ulceration of the forearm in a patient with AV graft and CVS is reported herein.

A 45-year-old African male, resident in Angola, presented to the emergency department with an ulcer encompassing the entire left forearm (Figure 1A, 1B). The patient indicated that the ulcer appeared 7 months before. It began with a small spontaneous wound on the dorsal aspect of the left forearm that progressively increased in dimensions. Past medical history comprised arterial hypertension and chronic kidney disease, including an 8-year history of hemodialysis treatment. The patient had previously undergone treatment in a low-income country and did not present with a detailed medical history. Vascular access consisted of a left brachial-basilic AV graft constructed 4 years previously. The patient also indicated prior treatment with a right jugular internal vein catheter during maturation of the access. At Doppler ultrasound, biphasic fluxes in the radial and cubital artery were identified, with no subcutaneous abscess near the AV graft. Empiric antibiotic therapy with vancomycin and gentamicin was initiated owing to the extensive soft tissue ulceration, followed by colistin and piperacillin/tazobactam after swab culture identification of Enterobacter cloacae, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Central vein stenosis was suspected, and stenosis of the left brachiocephalic vein was documented at angiography. Angioplasty was performed to resolve the stenosis.

One month after hospital admission, ligation of the fistula and wound debridement were performed. Two weeks later, the patient underwent split-thickness skin grafting to achieve soft tissue coverage (Figure 2). The patient was discharged from the hospital 2 months after admission with good healing of the wound (Figure 3A, 3B).

Stasis dermatitis is a manifestation of venous stasis syndrome, a skin condition that progresses from edema to ulcer development owing to venous insufficiency. The pathophysiology of stasis dermatitis in patients with an AV graft receiving hemodialysis is thought to be related to venous hypertension caused by the fistula, which eventually results in varix-like venous dilatation. Arteriovenous graft can also induce intimal thickening and turbulent flow, which sometimes cause venous thrombosis and/or stenosis distal to the fistula, most commonly at the axillary or subclavian vein. If the obstruction is located at the brachiocephalic trunk, CVS may occur. Central vein stenosis (referring to the major intrathoracic veins, including the subclavian vein, the innominate vein, and the SVC in the upper trunk and iliac veins as well as the inferior vena cava in the lower trunk) is a common complication of the CVC placement.⁶ It is often asymptomatic in patients who are not on dialysis, but it can result in edema of the ipsilateral extremity when challenged by increased flow from an AVF or AV graft.⁷ Historically, more than 90% of cases of SVC syndrome were associated with malignancy.⁸ Currently, however, approximately 40% of instances of SVC syndrome occur secondary to a benign etiology, with 71% of these attributed to intravascular devices.⁹ The most frequent signs and symptoms of SVC syndrome are swelling of the face or neck (82%) and swelling of the upper extremity (68%); an ulcer of the hand or forearm is not commonly reported.⁹ There is some consistent evidence linking artificial AVF with circulatory insufficiency, gangrene, thrombosis, and venous hypertension in patients receiving hemodialysis. The authors found 11 published reports associating the etiology of an upper limb ulcer with AV access, with Haimov et al reporting 4 cases.^{2,4,5,10–14} Only 1 study reported a forearm ulcer.²

The current case is of an atypical severe presentation of stasis dermatitis complicated by wound infection. Empiric antibiotherapy with piperacillin/tazobactam plus vancomycin is a proposed treatment to be initiated in patients who present with severe soft tissue infection.¹⁵ Stasis dermatitis may be caused by venous hypertension resulting from the AV graft and CVS, whereas steal syndrome (ie, hemodialysis access-related hand ischemia) may contribute to hemodynamic imbalance. In this case, there was a strong temporal correlation between angioplasty of the central stenosis, ligation of the AVF, and dramatic improvement of the ulcer, which was completely healed 2 months after hospital admission. This case report is the second description of a forearm ulcer as a possible complication of an AV access and, to the authors’ knowledge, is the most severe case reported in the literature to date. The differential diagnosis of extensive ulcer of the forearm must include neoplasms, cellulitis, and/or deep tissue infection with secondary ulceration, but it is also important to maintain suspicion for venous stasis syndrome as a rare but possible cause of these lesions. Differential diagnosis in such cases also requires a thorough clinical history, collection of microbiologic and pathologic samples for analysis, and performance of imaging tests such as computed tomography and Doppler ultrasound evaluation.

The patient could not provide a detailed past medical history, which contributed to a delay in the diagnosis and adequate treatment.

Stasis dermatitis remains a rare etiology for an ulcer on the upper limb; however, providers should still consider stasis dermatitis during the differential diagnosis of the ulcer, especially for those with risk factors for CVS--as it is with the placement of CVC.