Vascular Access in Hemodialysis Patients with Central Venous Obstruction or Stenosis: One Center's Experience

Left innominate vein creation using left internal jugular vein tunneled to right internal jugular vein

BACKGROUND

Left innominate vein occlusion is a known complication of pacemaker and central venous catheter placement. For dialysis-dependent patients with an arteriovenous fistula (AVF), this can prevent successful hemodialysis and may require surgical intervention.

CASE REPORT

An 8-month-old male was diagnosed with hemolytic uremic syndrome and became dialysis-dependent at 11 months of age. After multiple vascular access and peritoneal dialysis complications, the patient had construction of a brachiobasalic AVF in his left arm at 13 years old. While waiting for the AVF to mature, an attempt to remove a previously placed left subclavian vein port-a-cath was unsuccessful and a follow-up imaging revealed that the vessel had become occluded. The fistula remained patent, but due to arm swelling and venous obstruction, his fistula was not accessible. Multiple attempts to percutaneously cross the left innominate vein were unsuccessful and the patient was referred for surgical intervention. At 15 years old, the patient was taken to the operating room for transposition of the left internal jugular vein (LIJ) to the right internal jugular vein (RIJ). The LIJ was transected under the mandible and anastomosed to the RIJ. Subsequently the patient underwent VWING insertion rather than venous transposition for constant site dialysis. Although he has required frequent transcatheter dilation of the LIJ-RIJ anastomosis, the patient was successfully dialyzed using this fistula for 5 years. The patient received a cadaveric renal transplant at 5 years 20 days.

CONCLUSIONS

In cases of left innominate vein stenosis, transposing the LIJ can create a new left innominate vein that can alleviate venous hypertension and preserve fistula function. This procedure avoids sternotomy and only requires one anastomosis.

Thigh arteriovenous grafts. Quantitative comparison with alternative options: A meta-analysis

Thigh arteriovenous grafts are required in a number of patients with exhausted upper extremity veins and comprise 1%-5% of the total access procedures performed. Alternative autogenous lower extremity options are the rarely used sapheno-tibial arteriovenous fistulae, the saphenous vein transpositions, and the femoral vein transpositions. The latter have proven to be the most durable lower limb access procedures, with low infection rates and their primary patency rates ranged from 74% up to 87% at 2 years. Synthetic thigh grafts are suitable for patients who are not good candidates for any upper limb or any autogenous lower limb access and their secondary patency rates ranged from 54% up to 83% at 2 years. Thigh grafts often get infected and their average weighed infection rate in 920 such grafts included in eight large series was 22.9%. A literature search was performed to evaluate thigh grafts compared with alternative options using meta-analysis. Lower limb accesses were found superior compared to HeRO^® device regarding 1-year primary failure rate (odds ratio = 0.28, confidence interval = 0.09-0.88, p = 0.03) and additionally autogenous lower limb accesses were found superior compared to thigh grafts regarding the 1-year primary failure rate (odds ratio = 6.54, confidence interval = 2.29-18.72, p = 0.0005).

Radiological Central Vein Treatment in Vascular Access

In the last decades, the percutaneous interventional approach for the treatment of central venous obstructions (CVO) has become increasingly popular as the treatment of first choice because of its minimal invasiveness and reported success rates. CVOs are caused by a diverse spectrum of diseases which can be broadly categorized into two principal eliciting genera, either benign or malignant obstructions. The large group of benign venous obstructions includes the increasing number of end-stage renal disease patients with vascular access related complications. Due to the invasiveness and complexity of thoracic surgery for benign CVOs, the less invasive percutaneous interventional therapy can generally be considered the preferred treatment option. Initially, the radiological intervention consisted of balloon angioplasty alone, subsequently additional stent placement was applied. This was advocated as either primary placement or secondary in cases of elastic recoil or residual stenosis after percutaneous transluminal angioplasty (PTA). The efficacy of angioplasty of CVO in patients with vascular accesses, either with or without stenting, has been addressed by various studies. Overall, reports indicate an initial technical and clinical success rate above 95% and satisfactory patency rates. However, systematic follow-up and frequent re-interventions are necessary to maintain vascular patency to achieve long-term success.

Primary and secondary patencies of transposed femoral vein fistulas are significantly greater than with the HeRO graft

Introduction

For access-challenged patients with bilateral upper extremity central venous stenosis, solutions include the Hemodialysis Reliable Outflow (HeRO) device or an autogenous AV fistula in the lower limb. We evaluated HeRO grafts and transpositions of the femoral vein in maintaining primary and secondary patency.

Methods

We retrospectively analyzed 40 patients with a HeRO device and 18 patients with superficial femoral artery to transposed femoral vein autogenous arteriovenous fistula (SFA-tFV). All patients had bilateral central venous obstruction. All procedures were outpatient performed by a single surgeon at one center between 2009-2015. Operative details, intraoperative flows, and flows at the first-week postoperative visit were analyzed, as were primary and secondary patency and intervention rates. Complications were compared between groups.

Results

The one-year cumulative primary patency was 30% for HeRO grafts and 79% for SFA-tFV fistulas (p = 0.0001); secondary patency was 71% for HeRO grafts and 93% for SFA-tFV fistulas (p = 0.03). To maintain patency, HeRO patients required a mean 2.1 interventions per year and thigh fistula patients required a mean 0.4 interventions per year. Thirty-seven percent of thigh fistula patients had a hematoma or seroma versus 5% of HeRO patients and 17% of thigh fistula patients experienced delayed wound healing versus 2.5% of HeRO patients (p<0.05). None of the thigh fistula patients had distal ischemia.

Conclusions

HeRO patients had lower primary and secondary patency rates versus thigh fistula patients and HeRO grafts required five-fold more interventions to maintain secondary patency. However, patients with thigh fistulas had significantly more wound healing problems. Thus, the SFA-tFV has become our access of choice for patients with bilateral central venous stenosis.

Straight configuration saphenous vein transposition to popliteal artery for vascular access

INTRODUCTION

The saphenous vein is commonly used as a vascular graft in peripheral artery surgery but rarely used for vascular access. The literature on straight configuration saphenous vein transposition to the popliteal artery is scarce. Here we present two cases of straight configuration saphenous vein transposition to the popliteal artery for vascular access, the surgical technique and respective follow-up.

CASE REPORT

Two young men, aged 29 and 36 years, were chosen for lower-limb vascular access for hemodialysis. The first patient was paraplegic since birth. He used his arms to move so upper extremity vascular access was avoided. The second patient presented with an infected upper extremity arteriovenous graft (AVG) and after multiple closed AVFs he had no more available arm veins. Both patients received autologous lower extremity straight configuration saphenous vein transpositions to the popliteal artery under spinal anesthesia in May and October 2012, respectively. Cannulation of the fistula was allowed after one month. There were no early complications. Slight swelling on the leg appeared in one of the patients. Both fistulas were still functional after 36 and 32 months, respectively.

CONCLUSIONS

The straight configuration saphenous vein transposition to popliteal artery is simple to perform, offers a long and straight segment for cannulation and may be a suitable autologous vascular access in selected patients.

[Exhaustion of vascular capital in patients on hemodialysis: what will be the outcome?]

Despite advances in the treatment of chronic renal failure, vascular access remains the weakest link in renal replacement therapy (RRT) and the leading cause of morbidity in patients on hemodialysis We report the case of a young female patient with chronic renal insufficiency secondary to vascular nephropathy on periodic hemodialysis and whose vascular capital was early exhausted due to iterative thromboses in arteriovenous fistulas and failure in peritoneal dialysis. Protein C deficiency was objectified. The patient underwent tunneled hemodialysis catheter insertion at the level of the right atrium via a right anterolateral thoracotomy with cannulation of the inferior vena cava, with poor functional outcome after three months of use. Since then she has been dialyzed using puncture of the external jugular veins.

Early cannulation graft Flixene™ for conventional and complex hemodialysis access creation

PURPOSE

The Flixene™ (Atrium™, Hudson, NH) is a trilaminate composite polytetrafluoroethylene (PTFE) graft that allows access within 72 hours. We evaluate our initial experience with this device for conventional and complex hemodialysis access creation.

METHODS

Retrospective review in end-stage renal disease (ESRD) patients who underwent access creation with Flixene from January 2013 to July 2014. For our analysis, the patients were divided in two groups: those with complex access configurations tunneled in the chest and/or abdominal wall (thoraco-abdominal wall access [TAWA]), and those tunneled in conventional sites (extremity access [EA]). Patient's demographics, indications, complications, reinterventions, patency rates and factors influencing outcomes were evaluated.

RESULTS

In 19 patients (54% men; mean age 44 years ± 18), 24 grafts were implanted, (13 EA [54%] vs. 11 TAWA), all patent after surgery. Central venous occlusive disease (CVOD) was present in all patients with TAWA and in 7/13 (54%) EA patients (p = 0.016). Early cannulation (within 72 hours) was successful in 12 EA and 5 TAWA grafts (p = 0.044). Complication rates including infection, thrombosis, bleeding and steal syndrome were 8/11 (73%) in TAWA and 5/13 (38%) in EA (p = 0.02). At 12 months, primary patency rates for EA and TAWA were 25% and 41%; secondary patency rates were 55% and 41%, respectively.

CONCLUSIONS

Early cannulation (EC) grafts are viable alternatives for conventional and complex access creation that allowed early cannulation (<72 hours) in 17 (70%) of our cases. Primary and secondary patency rates at 12 months were equivalent to data reported on ePTFE grafts.

Arteriovenous Access: Infection, Neuropathy, and Other Complications

Complications of vascular access lead to morbidity and may reduce quality of life. In this module, we review both infectious and noninfectious arteriovenous access complications including neuropathy, aneurysm, and high-output access. For the challenging patients who have developed many complications and are now nearing their last vascular access, we highlight some potentially novel approaches.

Patency and Complications of Translumbar Dialysis Catheters

Translumbar tunneled dialysis catheter (TLDC) is a temporary dialysis access for patients exhausted traditional access for dialysis. While few small studies reported successes with TLDC, additional studies are warranted to understand the short- and long-term patency and safety of TLDC. We conducted a retrospective analysis of adult patients who received TLDC for hemodialysis access from June 2006 to June 2013. Patient demographics, comorbid conditions, dialysis details, catheter insertion procedures and associated complications, catheter patency, and patient survival data were collected. Catheter patency was studied using Kaplan-Meier curve; catheter functionality was assessed with catheter intervals and catheter-related complications were used to estimate catheter safety. There were 84 TLDCs inserted in 28 patients with 28 primary insertions and 56 exchanges. All TLDC insertions were technically successful with good blood flow during dialysis (>300 ml/minute) and no immediate complications (major bleeding or clotting) were noted. The median number of days in place for initial catheter, secondary catheter, and total catheter were 65, 84, and 244 respectively. The catheter patency rate at 3, 6, and 12 months were 43%, 25%, and 7% respectively. The main complications were poor blood flow (40%) and catheter-related infection (36%), which led to 30.8% and 35.9% catheter removal, respectively. After translumbar catheter, 42.8% of the patients were successfully converted to another vascular access or peritoneal dialysis. This study data suggest that TLDC might serve as a safe, alternate access for dialysis patients in short-term who have exhausted conventional vascular access.

Endovascular salvage of a right brachial artery-right atrium hemodialysis graft using a covered endoprosthesis

Creation of a functional hemodialysis access in patients with exhausted peripheral access sites and concomitant central venous occlusive disease (CVOD) is a multifaceted challenge; often requiring complex, innovative solutions, not without their own complications. We present a 57-year-old hemodialysis patient with a history of hypercoagulable disorder and multiple failed arteriovenous accesses. Because of inadequate peripheral access sites and chronic occlusions in superior vena cava, brachiocephalic veins and inferior vena cava, in addition to multiple transhepatic catheter related issues; we decided to perform a right brachial artery to right atrium (RA) hemodialysis graft. The access was used without complications for 18 months at which point he had his first episode of thrombosis; open thrombectomy and percutaneous balloon angioplasty (PTA) at the atrial anastomosis were done with success. The following three months, he endured two more thrombectomies and PTAs. During the last intervention we performed an intravascular Ultrasound (IVUS) through the atrial anastomosis, which demonstrated stenosis; and the decision was made to extend the outflow anastomosis with a covered stent into the atrium. Therefore a 10 cm x 10 mm Viabahn stent-graft (W. L. Gore and Associates, Flagstaff, Ariz.) was deployed and post dilated with 8 mm balloon within the graft component. Repeat injection and Intravascular Ultrasound (IVUS) demonstrated significant improvement and free outflow. The brachial-RA hemodialysis graft could be use immediately and at 5 months has remained fully functional and no reinterventions have been necessary.

Alternative venous outflow by brachial to jugular vein vascular access for hemodialysis in the exhausted upper extremities

BACKGROUND

A shunt is usually created from the distal arm (wrist) to the proximal arm (axillary loop) as long as no central stenosis has occurred. Creating vascular access in a patient with central vein stenosis could induce venous hypertension in the upper extremities. In such patients, an ipsilateral internal jugular vein (IJV) as an arteriovenous (AV) outflow vein should be the last option for using a particular arm.

METHODS

Thirty-two patients who had AV hemodialysis access via a jugular vein were analyzed retrospectively from 2001 to 2011. All patients had an ipsilateral subclavian or axillary vein stenosis. The preserved IJV and innominate veins were preoperatively confirmed with Doppler echocardiography and contrast venography.

RESULTS

Mean age of the patients was 57.6 ± 12.3 years, and the mean follow-up period was 43.5 ± 27.4 months. Primary patency was 74%, 54%, 32%, 15% and 5% at 6 months, 1, 2, 3 and 4 years, respectively. Secondary patency was 97%, 93%, 93%, 89%, 79% and 72% at 6 months, 1, 2, 3, 4, and 5 years, respectively. One case of steal syndrome, 2 of seroma, 1 hematoma, 3 swollen arm, 2 infections, 1 pseudoaneurysm, 1 bleeding from puncture site, 8 stenoses and 13 thrombosis cases were noted.

CONCLUSIONS

A brachial-jugular AV graft showed satisfactory results in terms of patency and complication rate. The IJV could be a good outflow vein for an AV fistula if the IJV is preserved in patients with chronic renal failure who have subclavian or axillary vein stenosis or occlusion.

Bilateral Central Vein Stenosis: Options for Dialysis Access and Renal Replacement Therapy when all upper Extremity Access Possibilities have been Lost

Purpose

Patients with bilateral central vein stenosis present a unique challenge: treatment options are limited, largely unproven and associated with reputedly poor outcomes. Our aim was to compare patency rates of different access and renal replacement treatment (RRT) modalities in patients with bilateral central vein stenosis/occlusion.

Material and methods

Data on all patients presenting to a tertiary referral vascular access centre with end-stage vascular access (defined by bilateral central vein stenosis/occlusion with loss of upper limb access) over a 5-year period were included. 3, 6 and 12-month patencies of translumbar catheters (TLs), tunnelled femoral catheters (Fem), native long saphenous vein loops (SV), prosthetic mid-thigh loop grafts (ThGr), peritoneal dialysis (PD), and expedited donation after cardiac death (DCD) cadaveric renal transplants (Tx) via local allocation policies were compared using log-rank test. Kaplan–Meier survival analysis was used to estimate long-term access survival.

Results

One hundred forty-six vascular access modalities were attempted in 62 patients (62 Fem, 25 TL, 15 SV, 25 ThGr, 8 PD, 11 Tx). Median follow-up was 876±57 days. Three, 6 and 12-month primary-assisted patencies for each modality were as follows: Fem: 75.4%, 60% and 28%; TL: 88%, 65% and 50%; SV: 87.5%, 60% and 44.6%; ThGr: 64%, 38% and 23.5%; PD: 62.5%, 62.5% and 50%; Tx: 72.7%, 72.7% and 72.7%. SV had better secondary patency at 900 days (76.9%) than ThGr (49.2%) or Fem (35.8%) (p<0.01). No patients died as a result of loss of access.

Conclusion

Patients with bilateral central vein stenosis often require more than one vascular access modality to achieve a “personal access solution.” Native long saphenous vein loops provided the best long-term patency. Expedited renal transplantation with priority local allocation of DCD organs to patients with precarious vascular access provides a potential solution to this difficult problem.

Extra- and intrathoracic access

The most complex patients requiring vascular access are those with bilateral central vein occlusions. Endovascular repair of the central lesions when feasible allow upper extremity use for access. When endovascular repair is not feasible, femoral vein transposition should be the next choice. When lower limb access sites have been exhausted or are contraindicated as in obese patients and in patients with peripheral arterial obstructive disease, a range of extrathoracic "exotic" extra-anatomic access procedures as the necklace cross-chest arteriovenous (AV) grafts, the ipsilateral axillo-axillary loops, the brachial-jugular AV grafts, the axillo-femoral AV grafts or even intra-thoracic ones as the right atrial AV bypasses represent the vascular surgeon's last resort. The selection among those extra-anatomical chest-wall procedures should be based upon each patient's anatomy or patient-specific factors.

Midterm experience of ipsilateral axillary-axillary arteriovenous loop graft as tertiary access for haemodialysis

Objectives. To present a series of ipsilateral axillary artery to axillary vein loop arm grafts as an alternative vascular access procedure for haemodialysis in patients with difficult access. Design. Retrospective case series. Methods. Patients who underwent an axillary loop arteriovenous graft from September 2009 to September 2012 were included. Preoperative venous imaging to exclude central venous stenosis and to image arm/axillary veins was performed. A cuffed PTFE graft was anastomosed to the distal axillary artery and axillary vein and looped on the arm. Results. 25 procedures were performed on 22 patients. Median age was 51 years, with 9 males and 13 females. Median number of previous access procedures was 3 (range 0–7). Median followup was 16.4 months (range 1–35). At 3 months and 1 year, the primary and secondary patency rates were 70% and 72% and 36% and 37%, respectively. There were 11 radiological interventions in 6 grafts including 5 angioplasties and 6 thrombectomies. There were 19 surgical procedures in 10 grafts, including thrombectomy, revision, repair for bleeding, and excision. Conclusions. Our series demonstrates that the axillary loop arm graft yields acceptable early patency rates in a complex group of patients but to maintain graft patency required high rates of surgical and radiological intervention, in particular graft thrombectomy.

Transposition of cephalic vein to rescue hemodialysis access arteriovenous fistula and treat symptomatic central venous obstruction

It is known that stenosis or central venous obstruction affects 20 to 50% of patients who undergo placement of catheters in central veins. For patients who are given hemodialysis via upper limbs, this problem causes debilitating symptoms and increases the risk of loss of hemodialysis access. We report an atypical case of treatment of a dialysis patient with multiple comorbidities, severe swelling and pain in the right upper limb (RUL), few alternative sites for hemodialysis vascular access, a functioning brachiobasilic fistula in the RUL and severe venous hypertension in the same limb, secondary to central vein occlusion of the internal jugular vein and right brachiocephalic trunk. The alternative surgical treatment chosen was to transpose the RUL cephalic vein, forming a venous necklace at the anterior cervical region, bypassing the site of venous occlusion. In order to achieve this, we dissected the cephalic vein in the right arm to its junction with the axillary vein, devalved the cephalic vein and anastomosed it to the contralateral external jugular vein, providing venous drainage to the RUL, alleviating symptoms of venous hypertension and preserving function of the brachiobasilic fistula.

Killing Two Birds with One Stone: Subclavian Vein Bypass Graft for Relief of Venous Obstruction and Haemodialysis Access

Subclavian and brachio-cephalic vein stenosis or occlusion occurs, most commonly, as an iatrogenic complication of the placement of central venous catheter. This occurrence can cause ipsilateral arm swelling in a newly-created arteriovenous fistula (AVF). Critical central vein stenoses are often successfully managed by endovascular approach; occasionally, complete occlusion with symptomatic severe arm swelling and pain that does not respond to angioplasty requires ligation of the dialysis access. We report successful surgical management of an end-stage-renal-failure (ESRF) patient with symptomatic subclavian vein occlusion refractory to angioplasty in an ipsilateral arm with an existing functional brachio-basilic transposition arteriovenous fistula by performing a basilic to internal jugular vein (IJV) bypass graft, relieving both the arm swelling and salvaging the existing vascular access for future haemodialysis.

Successful early cannulation of a superficial femoral vein transposition angioaccess in a patient without other alternatives

Early cannulation of a native fistula is defined by Dialysis Outcomes and Practice Patterns Study and Kidney Disease Outcomes and Quality Initiative as between 2 and 12 weeks postoperatively. We present a case of a patient in whom anatomical and hematological barriers prevented early cannulation graft placement, and in whom temporary catheterization was not feasible as a result of central venous occlusion. Successful cannulation at the fifth postoperative day of a native angioaccess was performed and the reasons and challenges faced behind this choice under the circumstances were discussed.

Right intra-atrial catheter placement for hemodialysis in patients with multiple venous failure

The purpose of this study is to evaluate the efficacy and safety of direct right atrial catheter insertion for hemodialysis in patients with multiple venous access failure. We retrospectively evaluated the charts of 27 patients with multiple venous access failure who had intra-atrial dialysis catheter placement between October 2005 and October 2010 in our clinic. Permanent right atrial dialysis catheters were placed through a right anterior mini-thoracotomy under intratracheal general anesthesia in all patients. Demographics of the cases, the patency rates of hemodialysis via atrial catheterization, existence of any catheter thrombosis, and catheter-related infections were documented and used in statistical analysis. Seventeen women (63%) and 10 men (37%) with the mean age of 59.0 ± 7.1 years (47-71) were enrolled in this study. Chronic renal failure was diagnosed for the mean of 78.9 ± 24.3 months (33-130). Five patients (18.5%) died. Ventricular fibrillation and myocardial infarction were the causes of death in the early postoperative period in two patients. Two of the remaining three patients died because of cerebrovascular events, and one patient died because of an unknown cause. Ten patients (37%) had been using anticoagulate agents (warfarin) because of concomitant disorders such as deep vein thrombosis, operated valve disease, and arrhythmias. Catheter thrombosis and malfunction was determined in three cases (11.1%). Intra-atrial hemodialysis catheterization is a safe and effective life-saving measure for the patients with multiple venous failure and without any possibility of peritoneal dialysis or renal transplantation.

Aneurysm of the tibial-saphenous fistula in hemodialysis patient: the results of surgical treatment

Arteriovenous fistulas are widely used for hemodialysis patients with end-stage renal failure. Due to the lack of suitable veins because of the arteriovenous fistulas previously opened in the upper extremity, alternative access routes are being tested. Few complications of long-term alternative arteriovenous fistulas have been reported in the literature. We report the results of surgical repairs of aneurysms that occurred on anterior tibial-saphenous arteriovenous fistulas (along the vein) in patients with end-stage renal disease after 5 years on hemodialysis.

Lower extremity arteriovenous hemodialysis access: an important adjunct in select patients

Given the current survival rates of patients receiving hemodialysis, it has become increasingly common for patients to exhaust their upper extremity access options. Likewise, overzealous catheter use can lead to central venous occlusion or stenosis, further limiting the upper extremity access options. In these patients, use of the lower extremities for access is often required. Fortunately, there are a number of options available that have acceptable durability and utility. The purpose of this article is to review the various techniques available for placement of hemodialysis access in the lower extremity and discuss their results.

Vascular Access Flow Reduction for Arteriovenous Fistula Salvage in Symptomatic Patients with Central Venous Occlusion

Purpose

Vascular access patients with central vein (CV) stenosis or occlusion may have significant symptoms. Treatment is generally by balloon angioplasty, with or without stenting. However, CV lesions may not be correctable and when treated, tend to recur. Surgical bypass of CV obstruction is a major procedure and ligation of the access may leave the patient dependent on catheter dialysis. We review a precision inflow banding procedure to limit vascular access flow and pressure for symptomatic patients with CV obstruction while preserving access functionality.

Materials and Methods

All individuals with symptomatic CV occlusive disease who underwent an autogenous vascular access inflow restriction procedure by the two senior authors were identified. All had failed attempts to correct CV lesions by angioplasty and stent placement. A precision banding procedure was used for access inflow reduction with the addition of real-time intravascular flow monitoring.

Results

Twenty-two patients were identified. Ages were 22–72 years (mean=43 years). Nine patients (40.9%) were women, and 8 (36.4%) obese. Mean access flow was 1640 mL/minute before banding decreased to 820 mL/minute after banding (P<.01). All patients had access salvage. Swelling resolved promptly in 20 patients and was markedly improved in two individuals. Three patients underwent aneurysm repair with simultaneous inflow banding and decreased intra-access pressure after flow restriction. Two fistulas failed at eight and 13 months. Mean follow-up was 8 months.

Conclusions

The symptoms of hemodialysis vascular access patients associated with non-correctable central venous lesions resolved successfully and their access was maintained using a precision inflow banding procedure.

Translumbar central venous catheters for long-term haemodialysis

BACKGROUND

Vascular access for haemodialysis is achieved by tunnelled central venous catheter (CVC) in at least 23% of prevalent patients in the UK, Canada and the USA. Use of CVCs is associated with an increased incidence of venous stenosis that can progressively limit future vascular access routes. Lack of conventional venous access routes mandates the use of alternative strategies such as the translumbar approach.

METHODS

We retrospectively analysed patients at our centre requiring translumbar inferior vena caval CVCs (TesioCath) for haemodialysis in the period 1999-2008. Written and electronic records capturing dialysis adequacy and complications, hospital admissions and laboratory data were examined.

RESULTS

Thirty-nine pairs of translumbar CVCs were inserted in 26 patients with 15 864 catheter days follow-up, mean patient age 61.9 +/- 12.1 years, 31% diabetic, 15% with ischaemic heart disease. All insertions were successful. Insertion of one CVC was associated with a self-limiting retroperitoneal haematoma. No patients died of a catheter-related cause or through lack of vascular access. Cumulative assisted primary catheter site patency was 81% at 6 months and 73% at 1 year (median 18.5 months). Good dialysis adequacy was achieved throughout (mean single-pool Kt/V 1.5 +/- 0.4). The incidence of access-related infection was 2.84/1000 catheter days (exit site infection rate 2.02/1000 catheter days; catheter-related bacteraemia rate 0.82/1000 catheter days). Catheter dysfunction (need for thrombolytic infusion or catheter change) led to 0.88 admissions per 1000 catheter days.

CONCLUSION

Translumbar inferior vena caval CVCs can offer relatively safe and effective long-term haemodialysis access in patients with no other options.

Neurologic and ophthalmologic complications of vascular access in a hemodialysis patient

Patients on long-term hemodialysis undergo multiple interventions, including insertion of central catheters and arteriovenous anastomoses for creation of vascular access. The need for high-flow vessels to maintain hemodialysis efficiency leads to wear on the central veins and consequent stenosis and occlusion. In addition to local signs of impaired venous drainage, abnormal venous flow patterns involving the upper chest, face, and central nervous system might develop. We describe the first pediatric case of devastating intracranial hypertension presenting with visual loss in the eye contralateral to a high-flow vascular access in a patient on long-term hemodialysis. The literature on this rare complication of hemodialysis is reviewed.

Use of the internal mammary vein for access outflow in a hemodialysis fistula

A patient with occlusion of multiple central veins from both dialysis and nondialysis catheters required permanent access for hemodialysis. Magnetic resonance imaging showed a patent left innominate vein. He underwent creation of a left axillary artery to internal mammary vein transposition fistula using the basilic vein from his right arm. The fistula has required one revision for outflow stenosis and one for aneurysmal degeneration. It continues to function well 3 years after placement. The internal mammary vein is an option for outflow when permanent hemodialysis access has failed in the presence of a patent innominate vein with occluded or severely stenotic ipsilateral subclavian and jugular veins.

Care of the end-stage renal disease patient on dialysis in the ED

End-stage renal disease is a major public health problem. In the United States, more than 350,000 patients are being treated with either hemodialysis or continuous ambulatory peritoneal dialysis. Given the high burden of comorbidities in these patients, it is imperative that emergency physicians be aware of the complexities of caring for acute illnesses in this population. This article reviews the common medical problems that bring patients with end-stage renal disease to the emergency department, and their evaluation and management.

Central vein obstruction in vascular access

Central venous obstruction has become a major problem because of the frequent need for central venous catheters in haemodialysis patients. This article discusses the epidemiology and clinical features of central venous obstruction and the different surgical and interventional alternatives for its treatment.

Asdin Original Investigation: Complex Bypasses and Fistulas for Difficult Hemodialysis Access: A Prospective, Single-Center Experience

The purpose of this article is to describe several complex vascular access procedures and the outcomes achieved with them in 24 patients (mean age 60 years) undergoing hemodialysis in whom all other accesses had failed and neither peritoneal dialysis nor transplantation was possible. Patients underwent either a necklace bypass (n = 5), axillary loop (n = 1), contralateral internal jugular vein bypass (n = 6), femorofemoral crossover bypass (n = 1), superficial femoral vein transposition (n = 5), axillary artery to popliteal vein bypass (n = 5), or femoral artery to right atrium bypass (n = 1). All grafts implanted were 6 mm, internally reinforced prostheses made of expanded polytetrafluoroethylene (Gore-Tex Intering Vascular Graft). Postoperatively patients had bimonthly clinical examinations in which the thrill, bruit, skin, cannulation sites, and adequacy of dialysis were reviewed. A bimonthly ultrasound dilution assessment that included estimation of the graft inflow rate, recirculation rate, and cardiac output was also performed. There was one serious postoperative complication: rapid-onset severe steal syndrome that required immediate tie off of the fistula. During the median follow-up time of 22 months, three patients died of causes unrelated to their vascular access. Nineteen dilatations and 10 surgical revisions were done. Primary patency rates were 83%, 63.5%, and 63.5%, respectively, at 6 months, 1 year, and 2 years; secondary patency rates were 91%, 77%, and 77%. Complex vascular access procedures can provide patients some additional good-quality time on hemodialysis.