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Unilateral Breast Enlargement Due to a High-Flux Ipsilateral Hemodialysis Fistula

169 mary vessels moves centrifugally toward the axillary and internal mammary lymph nodes. Approximately 3 percent of the lymph from the breast flows to the internal mammary chain, whereas 97 percent directs to the axillary nodes (1). Thus, an imbalance between a highly vascularized arteriovenous system and poorly developed lymphatic tree could have also contributed to the edema. There still exists no clear definition when a fistula is considered of high-flow. The concept of using the ratio access flow to cardiac output (CO) has been proposed by Pandeya and Lindsay (2); they found that in chronic dialysis subjects, the average access blood flow (Qa) was 1.6 L/min and the average CO was 7.2 L/min, thus describing a normal average Qa /CO ratio of 22 %. Despite surgical correction of the access, the blood flow remained high at 3 L/minute. Published case reports describing high-output cardiac failure all consistently show high-flow AVF with Qa > 2 L/min and Qa/CO ratios greater than 30% to 35 %. More information is required to confirm the plausible concept that high-access flows with elevated Qa/CO ratios may represent a risk factor for heart failure. Most of the reported banding and surgical closure of AVF have occurred when patients developed symptoms of cardiac failure with Qa/CO ratios of > 40%. (3). Studies in upper arm fistulae suggest a normal mean Qa ranging from 1.13 to 1.72 L/min, 15% of patients presenting Qa > 2-2.5 L/min (2) . However, a high flux fistula can result in a hyper-dynamic state that can cause a steal syndrome and end up in high-output heart failure. Steal phenomena can occur in approximately 73% of fistulae and is usually asymptomatic, symptoms appearing when collateral or direct flow is not developed to offset the steal. In a hemodialysis AVF, blood is shunted from a high pressure artery into a low pressure vein, increasing systemic vascular volume (4). The increased cardiac output associated with these fistulae depends upon the size of the communication and the Unilateral breast enlargement due to a high-flux ipsilateral hemodialysis fistula