Figure 1.

Figure 2.

Introduction

The gradual increased number and age of the population on dialysis runs parallel to the advances made in nephrological care, and makes us to wonder whether the number of patients with exhaustion of conventional vascular accesses will increase with the passing of time. Exhaustion of conventional vascular accesses for dialysis is rare. However, in their routine practice, most dialysis centers will eventually encounter patients with very few options and in poor condition.1 Patients who have been on dialysis through catheters for many years often show stenosis or occlusion of their central veins. Also, patients on dialysis through native or prosthetic vascular accesses often show exhaustion of the veins in the upper extremities. In these patients, vascular access is fairly limited, and if their current access fails the patients’ chances of eventually being unable to receive dialysis grow.2 This is the case of a woman with exhaustion of conventional vascular accesses who required emergency dialysis. The patient was successfully treated with andovascular revascularization of the central veins followed by the placement of a transient hemodialysis catheter.

Case report

This is the case of a 58-year-old woman with stage 5 kidney disease who has been on dialysis for a number of years. The patient has a past medical history of thrombosed native and prosthetic vascular accesses in both upper extremities, and multiple central venous catheters at both jugular an subclavian level. Also, the patient’s 2 femoral veins have already been used for this purpose too.

The Doppler echocardiography performed revealed the presence of an occlusion in both internal jugular veins, and femoral veins. The phlebography performed revealed the presence of an occlusion at the right confluence of the subclavian and internal jugular veins, innominate left venous trunk, and superior vena cava (figure 1A). Since an emergeny dialysis was required, an ultrasound-guided puncture of a patent segment was performed that confirmed the reduced caliber of the right internal jugular vein using a 18 G Abbocath catheter. Then, a phlebography performed through the catheter confirmed the occlusion of the right internal jugular vein (figure 1B). Afterwards, an 8-Fr introducer sheath was inserted with support from a 5-Fr 2 Cobra catheter and a 0.035 in hydrophilic guidewire The occlusion located at right internal jugular vein and superior vena cava level was crossed uneventfully and the guidewire was advanced towards the inferior vena cava. Then, the hydrophilic guidewire was exchanged for a 300 cm Amplatz extra-support guidewire. To allow the passage of the transient hemodialysis catheter, the balloon used in the angioplasty had 8 mm in diameter and 400 mm in length (figure 2A). Finally, the recanalization of the vessel was achieved(figure 2B). Afterwards, a transient 12-Fr Arrow catheter was placed 20 cm above the right atrium without any complications being reported (figure 2C).

Results

No procedural complications have been reported to this date. The patient remains on postoperative hemodialysis with good fluid dynamics through the catheter placed.

Discussion

The rate of patients with exhaustion of conventional vascular accesses is low. Estimating the prevalence of the problem is not easy, and there is no mortality data associated with this entity.3 The percentage of patients with exhaustion of conventional vascular accesses requiring a procedure is also hard tell. Shakarchi et al. proved that only 2 patients from a cohort of 97 patients referred due to complex vascular access actually had complete exhaustion of conventional vascular accesses.4 The arrival of new technologies and the chances of recovering vascular accesses using complex endovascular techniques for the management of patients considered untreatable can prevent these accesses from deteriorating to a point where these patients can be in a life-treatening situation.5

Conclusion

We reported the case of a patient with exhaustion of conventional vascular accesses who required emegency dialysis. The patient was treated successfuly via endovascular access through a central venous angioplasty that allowed the advancement of a transient hemodialysis catheter towards the right atrium. The endovascular revascularization of central veins for dialysis is a well known and accepted technique that can extend the life of vascular accesses in complex patients.

1. Inston N, Khawaja A, Mistry H, Jones R, Valenti D. Options for end stage vascular access: Translumbar catheter, arterial-arterial access or right atrial graft? J Vasc Access 2019:1129729819841153.

2. Rahman S, Kuban JD. Dialysis Catheter Placement in Patients With Exhausted Access. Tech Vasc Interv Radiol 2017;20(1):65-74.

3. Excerpts from the United States Renal Data System 1996 Annual Data Report. Am J Kidney Dis 1996;28(3 Suppl 2):S1-165.

4. Shakarchi JA, Nath J, McGrogan D, et al. End-stage vascular access failure: can we define and can we classify? Clin Kidney J 2015;8(5):590-3.

5. Vachharajani TJ, Agarwal AK, Asif A. Vascular access of last resort. Kidney Int 2018;93(4):797-802.

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Endovascular revascularization of central veins and subsequent cardiac catheterization for hemodialysis in a patient with exhaustion of conventional vascular accesses

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