Elective arteriovenous fistula ligation for prevention of lymphedema in a patient with breast cancer before ipsilateral axillary lymph node dissection: A case report

Abstract

Upper limb lymphedema (LE) may occur following radical treatment of breast cancer (BC), and may manifest more severely in patients with dialysis vascular access located on the ipsilateral limb. The present study reports a case of a 44-year-old female patient with patent arteriovenous fistula (AVF) in the left antecubital fossa following a third kidney transplant and the diagnosis of luminal B-like (human epidermal growth factor receptor 2-positive) BC of the left breast (clinical stage cT4bN2aM0), admitted to the Clinical Hospital of the Medical University of Silesia in Katowice (Poland) in October 2020. The patient received neoadjuvant systemic therapy, achieving partial regression of the tumor. Before a left-sided mastectomy with axillary lymph node dissection (ALND), the AVF was ligated. Following radiotherapy, trastuzumab treatment was continued for 18 cycles, along with hormonal therapy, and no upper limb LE developed. After 18 months, numerous metastases of the same biological subtype appeared in the area of the previously irradiated mastectomy scar. Palliative treatment was implemented and resulted in a complete objective response. First-line systemic treatment resulted in a partial response and disease control for 9 months. As of March 2025, the kidney graft function was stable (estimated glomerular filtration rate, 56.9 ml/min/1.73 m²) and second-line treatment with trastuzumab emtansine was terminated after 3 months due to symptomatic brain metastases. The upfront ligation of AVF located in the antecubital fossa decreased the risk of upper limb LE, which may occur during BC treatment, ALND and chest wall and axillary region radiotherapy.

Keywords: arteriovenous fistula; breast cancer; chronic kidney disease; lymphedema; vascular access.

Figure 1.

Ultrasound imaging and computed tomography of chest wall skin recurrence of breast cancer. Local recurrence of breast carcinoma (arrow) in the area of the mastectomy scar of the chest wall in (A) ultrasound imaging with 11 MHz linear probe and (B) contrast-enhanced computed tomography scan of the chest.

Figure 2.

Flowchart of the systemic literature review.