RUNNING OUT OF ACCESS

Resident(s): Joseph Giampa

Attending(s): Waseem Bhatti

Program/Dept(s): Atlantic Health System - Overlook Medical Center

CHIEF COMPLAINT & HPI

Reason for Consultation: Acute renal failure currently in need of dialysis access.

HPI: 35 year old man with spina bifida and end stage renal disease secondary to a neurogenic bladder. The patient has had failure of a multitude of dialysis access sites. Peritoneal dialysis is not an option due to the patient having diverting colostomy (for recurrent stool contaminated decubitus ulcers), ileostomy (for neurogenic bladder and recurrent UTI), and VP shunt.

RELEVANT HISTORY

Past Medical History: Spina bifida with lower extremity paralysis, ESRD, hypertension, anemia, hyperparathyroidism, pulmonary embolism, decubitus ulcers.

Past Surgical History: Multiple hip and leg orthopedic procedures, VP shunt, colostomy, ileal conduit,

parathyroidectomy left and right AV fistula, right axillo-axillary loop graft, right brachial to subclavian

arteriovenous graft. All dialysis access sites have failed: SVC, IVC, subclavian, jugular, and femoral veins are occluded.

Family and Social History: Wheelchair bound. Lives at home. Does not drink alcohol or smoke cigarettes.

Allergies: Anaphylaxis to latex

Medications: Fosrenol, Warfarin, calcium, vitamin D, midodrine

Family History: Non-contributory

INTERVENTION

A CT guided transthoracic azygos vein permacather was placed for hemodialysis access.

A 10 cm 20 gauge Chiba needle was used to access the enlarged azygous vein through a right paravertebral approach. Hydrodissection was performed using approximately 15 ml of sterile water.

INTERVENTION

A second incision was made in the lateral posterior chest through which a dual lumen permacatherwas advanced for tunneling purposes. The permacather was brought out of the more medial incision site and advanced through the peel away sheath into the azygous vein.

INTERVENTION

The following day a fluoroscopically guided venogram was performed to document catheter positioning and flow.

Excellent flow within the azygousvein was demonstrated.

CLINICAL FOLLOW UP

The patient was able to resume effective hemodialysis utilizing the recently placed azygous catheter.

SUMMARY AND DISCUSSION

Traditional sites for dialysis catheter access include jugular, subclavian, and femoral veins, with last resort being transhepatic access to the IVC. In this case we present an innovative method of venous hemodialysis catheter access in a patient where peritoneal dialysis is not an option. Utilizing a tunneled permacatheter the azygous vein was accessed through a paravertebral approach. This may be preferred over a transhepatic approach due to its known complications including intraperitoneal bleeding, hemorrhagic pleural effusion, and Budd Chiari syndrome.

QUESTION

What is the most common cause of a dysfunctional dialysis access graft?

a. Obstruction of venous outflow at the graft-to-vein anastomosis due to intimal fibromuscular hyperplasia and perivenous fibrosis related to shear stress and turbulent flow.

b. Obstruction of arterial inflow at the graft-to-arterial anastomosis secondary to intimal fibromuscular hyperplasia and perivenous fibrosis related to elevated arterial velocity.

c. Short stenosis within the needling segment of the access vein related to fibrotic reactions from repeated cannulations.

d. Mid-graft stenosis related to excessive in growth of fibrous tissue related to multiple puncture holes.

CORRECT!

What is the most common cause of a dysfunctional dialysis access graft?

a. Obstruction of venous outflow at the graft-to-vein anastomosis due to intimal fibromuscular hyperplasia and perivenous fibrosis related to shear stress and turbulent flow.

b. Obstruction of arterial inflow at the graft-to-arterial anastomosis secondary to intimal fibromuscular hyperplasia and perivenous fibrosis related to elevated arterial velocity.

c. Short stenosis within the needling segment of the access vein related to fibrotic reactions from repeated cannulations.

d. Mid-graft stenosis related to excessive in growth of fibrous tissue related to multiple puncture holes.

CONTINUE WITH CASE

SORRY, THATS INCORRECT.

What is the most common cause of a dysfunctional dialysis access graft?

a. Obstruction of venous outflow at the graft-to-vein anastomosis due to intimal fibromuscular hyperplasia and perivenous fibrosis related to shear stress and turbulent flow.

b. Obstruction of arterial inflow at the graft-to-arterial anastomosis secondary to intimal fibromuscular hyperplasia and perivenous fibrosis related to elevated arterial velocity.

c. Short stenosis within the needling segment of the access vein related to fibrotic reactions from repeated cannulations.

d. Mid-graft stenosis related to excessive in growth of fibrous tissue related to multiple puncture holes.

CONTINUE WITH CASE

REFERENCES

1. Lund GB, Trerotola SO, Scheel PJ (1995) Percutaneous translumbar inferior vena cava cannulation for hemodialysis. Am J Kidney Dis 25:732737. PubMedCrossRef

2. Biswal R, Nosher JL, Siegel RL et al. (2002) Translumbar placement of paired hemodialysis catheter (Tesio catheters) and follow-up in 10 patients. CardioVasc Interv Radiol 23:7578. CrossRef

3. Stavropoulos SW, Pan JJ, Clark TWI et al. (2003) Percutaneous transhepatic venous access for hemodialysis. J Vasc IntervRadiol 14:11871190. PubMed

4. Murthy R, Arbabzadeh M, Lund G (2002) Percutaneous transrenal hemodialysis catheter insertion. J Vasc Interv Radiol13:10431046. PubMedCrossRef

5. Punzi M, Ferro F, Petrosino F et al. (2003) Use of an intra-aortic Tesio catheter as vascular access for hemodialysis. NephrolDial Transplant 18:830832

6. Jaber MR, Thomson MJ, Smith DC. Azygos vein dialysis catheter placement using the translumbar approach in a patient with inferior vena cava occlusion. Cardiovasc Intervent Radiol. 2008;31 Suppl 2:S206-8.