PMC5390919_01
Conventional plain radiographs and left upper limb digital subtraction angiography. (A) A chest radiograph obtained 3 years earlier had already shown the widespread increased radiodensity in the bilateral sternocostoclavicular regions as well as marked left clavicular hyperostosis, neither of which had been investigated. (B) Similar skeletal findings were confirmed at the referral as well. (C) Digital subtraction venogram injected via the drainage vein of the left forearm arteriovenous fistula failed to demonstrate the left subclavian vein despite the abundant dilated collaterals in the left shoulder area.
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AVF had been surgically created as a permanent vascular access just before initiating periodic HD. A conventional chest radiograph obtained at that time showed marked hyperostosis of the left clavicle (Figure 1A); however, this distinct finding was overlooked and had never been thoroughly investigated. A chest radiograph showed pronounced hyperostosis of the left clavicle (Figure 1B), whereas digital subtraction angiography (DSA) of the left upper limb revealed failed circulation in the ipsilateral subclavian vein with abundant collaterals (Figure 1C).
Thoracic computed tomography (CT) with contrast injection. A series of CT scans shown in alphabetical order (A to J) reveals marked hyperostosis in the ribs, sternum, and clavicles with well-developed ossification of the sternocostoclavicular ligaments. Note that the left clavicle and manubrioclavicular joint are predominantly affected. Despite the successful identification of the right subclavian vein (narrow arrows in B to D) and left innominate vein (arrowheads in G to J) with the contrast material, the left subclavian vein could not be visualized sufficiently in the corresponding area (middle arrows in D and E), although we did notice collateralization in the surrounding thoracic region (wide arrows), which was also identified in a coronal reconstructed image (K).
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Diagnostic thoracic computed tomography (CT) revealed marked ossification of the sternocostoclavicular joints with distinct bone overgrowth in the sternum and upper ribs as well as the left clavicle (Figure 2). Despite the injection of a contrast material, the left subclavian vein could not be observed, but we did notice collateralization in the surrounding thoracic region (Figure 2).