CASE REPORT
Ca se r e por t : t r a n sh e pa t ic in se r t ion of lon g- t e r m dia lysis ca t h e t e r
Fe lipe N a sse rI; Rodr igo Br u n o Bia gion iI I; Robe r t a Cr ist in a Alm e ida Ca m posI I; Em a n u e lla Ga lvã o de Sa le s e Silv aI I; Or la n do Cost a Ba r r osI I I; M a r ce lo Ca lil Bu r ih a nI I I; José Ca r los I n gr u n dI I I; Adn a n N e se rI V
IResponsible physician, Sect or of I nt er vent ional Radiology and Endovascular Surgery, Hospit al
Sant a Mar celina, São Paulo, SP, Brazil.
I IResident , Endovascular Sur ger y and I nt er vent ional Radiology, Hospit al Sant a Mar celina, São
Paulo, SP, Br azil.
I I IAssist ant physician, Vascular Surgery, Hospit al Sant a Mar celina, São Paulo, SP, Brazil. I VHead, Vascular Sur ger y Ser vice, Hospit al Sant a Marcelina, São Paulo, SP, Brazil.
Correspondence
J Vasc Bras. 2007; 6( 4) : 391- 4.
ABSTRACT
Transhepat ic inser t ion of long- t erm dialysis cat het er is an except ion pr ocedur e used t o obt ain access in pat ient s w it h cent ral vein occlusion of low er and upper lim bs. We report on a case of a young pat ient w it h hist or y of dialysis for 15 year s, w ho w as subm it t ed t o an unsuccessful renal t ransplant at ion. This pat ient w as in dialyt ic em er gency and had confir m ed occlusion of upper lim b cent ral veins and iliac veins. Tr anshepat ic inser t ion of a long- t erm cat het er w as perform ed under general anest hesia. The cat het er t ip was placed at t he level of t he r ight at r ium . Dialysis w as sat isfact orily per for m ed on t he sam e day.
Ke yw or ds:Transhepat ic insert ion, hem odialysis, access.
RESUM O
O im plant e t r anshepát ico de cat et eres de diálise de longa per m anência é um procedim ent o de exceção, ut ilizado par a obt er um acesso em pacient es com oclusão de veias cent rais de m em br os superiores e infer ior es. O caso descrit o relat a um pacient e j ovem , com hist ória de 15 anos de diálise, que foi subm et ido no passado a um t ransplant e r enal sem sucesso. Esse pacient e encont rava- se em ur gência dialít ica e oclusão com pr ovada de veias cent rais de m em br os
t ranspariet ohepát ico sob anest esia ger al. A pont a do cat et er foi posicionada ao nível do át r io direit o. A diálise foi r ealizada sat isfat or iam ent e no m esm o dia.
Pa la vr a s- ch a ve : I m plant e t ranshepát ico, hem odiálise, acesso.
I n t r odu ct ion
The num ber of pat ient s in need of dialysis is increasing w or ldw ide and in Br azil.1 I t is believed t hat t here is a 6% gr ow t h in dialyt ic pat ient s per year .1 , 2 These pat ient s r em ain under dialysis for a
long period due t o t ransplant at ion im possibilit y and t o t he large num ber of pat ient s in t he w ailing list . Cent r al cat het er s are an access m odalit y for dialysis t hat should be consider ed an except ion procedure, since t hey cause st enosis and/ or cent r al vein occlusion in up t o 40% of cases.2 , 3 I t is r ecom m ended t hat only 10% of pat ient s should use cent ral long- t erm cat het ers for dialysis.3 I n pract ice, how ever , t hat num ber is m uch higher and has been increasing, w hich rest rict s cr eat ion of vascular access. This w as decisive in t he sear ch of new sit es for t he im plant at ion of long- t erm cat het ers.4 - 1 0
When t her e is cent ral vein occlusion of t he low er and upper lim bs, opt ional accesses are t ranslum bar,3 , 4 t ranshepat ic,4 - 6 , 8 t ransrenal7 and t r ansazygos.4
Transhepat ic access w as descr ibed in 1994 by Po et al.1 0 Since t hen, som e ser ies have been
published w it h sm all num ber of cases using t hat access. I ncidence of prim ary success and infect ion are equal t o t hose r epor t ed in ot her accesses.5 , 6 Com plicat ions regarding t hr om bosis and cat het er
m igrat ion have higher incidence w hen com par ed t o t r anslum bar and t ransj ugular accesses.5 , 6 Prim ary pat ency w as 50% in 120 days in one of t he largest published ser ies.6
Ca se r e por t
A 35- year - old m ale pat ient , hyper t ensive and for m er sm oker . He has had chr onic r enal
insufficiency due t o hyper t ension for 15 year s, on dialysis for 14 years and subm it t ed t o a r enal t ransplant at ion in t he left iliac fossa 3 years ago, w it h no success.
The pat ient w as on dialyt ic ur gency, w it h t he follow ing values in labor at or y t est s: hem oglobin 5.5, pot assium 7.1, creat inine 19.4, ur ea 319, sodium 142, phosphorus 6.3, calcium 6.3, leukocyt e count 12950 and plat elet 254000.
At t em pt s of lesion t r ansposit ion w er e per for m ed, but w it h no success.
Due t o t hat sit uat ion, t he t ranshepat ic access w as chosen. The pr ocedur e w as perform ed at t he Sect or of Endovascular Surgery, w it h t he pat ient in a supine posit ion, under gener al anest hesia. Punct ure was perform ed using a Chiba needle ( kit NPAS- 100, William Cook Eur opeCook®) on t he 10t h r ight int er cost al space in post erosuperior direct ion ( Figure 2) . Aft er ident ificat ion of t he r ight hepat ic vein by inj ect ing cont rast under fluoroscopy, a guide w ir e w as int roduced using t he r oad-m apping t echnique t ow ard t he r ight at rium , w it h furt her placem ent of t he int r oducer sheat h
( Figure 3) . Once t he posit ion of t he dist al ext rem it y of t he sheat h w as confir m ed at t he level of t he right at rium t hrough inj ect ion of iodinat ed cont r ast , t he suppor t guide w ire w as int r oduced w it h furt her dilat at ion of t he hepat ic parenchym a for sheat h and cat het er int r oduct ion ( Per m cat h®
D iscu ssion
Transhepat ic access is an except ion pr ocedur e. This access, as w ell as t he t ranslum bar, is only j ust ified w hen t he ot her accesses have been discarded. The pr ocedur e w as perform ed under general anest hesia, since t he pat ient present ed w it h hyper pot assem ia and high ur em ia.
Cat het erizat ion of t he hepat ic vein has som e difficult ies, and it is necessary t o have proper anat om ical, radiological and t echnical know ledge by t he int er vent ionist . Pr esence of adequat e m at erials for t he t ranshepat ic punct ur e and proper visualizat ion in r adioscopy are fact or s direct ly influencing pr ocedur e success.
placement of catheter tip. In addition to complications inherent to the procedure, catheter removal can cause formation of fistulas across its path, which requires its occlusion using embolization materials.
Dialysis performed on the following day occurred satisfactorily, with flow higher than 300
mL/minute. Some authors describe that the main complication in this type of implant is thrombosis or formation of fibrin around the catheter.3,4 For that reason, monitoring of machine flow is an
important factor, since it allows an early approach for catheter exchange. Catheter migration is another reported complication, which is probably related to respiratory movements and atrial contraction.4
We conclude that it is extremely important to know this access, which is an effective alternative in the treatment of dialytic urgency in cases such as that described in this report.
Re fe r e n ce s
1. Treatment modalities for ESRD patients. United States Renal Data System. Am J Kidney Dis. 1998;32(2 Suppl 1):S50-9.
2. Oderich GS, Treiman GS, Schneider P, Bhirangi K. Stent placement for treatment of central and peripheral venous obstruction: a long-term multi-institutional experience. J Vasc Surg.
2000;32:760-9.
3. NKF-DOQI clinical practice guidelines for vascular access. National Kidney Foundation – Dialysis Outcomes Quality Initiative. Am J Kidney Dis. 1997;30(4 Suppl 3):S150-91.
4. Wacker FK, Lipuma J, Blum A. [Alternate hemodialysis catheterization access in patients with occluded peripheral venous access sites]. Rofo. 2005;177:1146-50.
5. Smith TP, Ryan JM, Reddan DN. Transhepatic catheter access for hemodialysis. Radiology. 2004;232:246-51. Epub 2004 May 20.
6. Stavropoulos SW, Pan JJ, Clark TW, et al. Percutaneous transhepatic venous access for hemodialysis. J Vasc Interv Radiol. 2003;14(9 Pt 1):1187-90.
7. Murthy R, Arbabzadeh M, Lund G, Richard H 3rd, Levitin A, Stainken B. Percutaneous transrenal hemodialysis catheter insertion. J Vasc Interv Radiol. 2002;13:1043-6.
8. Apsner R, Sunder-Plassmann G, Muhm M, Druml W. Alternative puncture site for implantable permanent haemodialysis catheters. Nephrol Dial Transplant. 1996;11:2293-5.
9. Duncan KA, Karlin CA, Beezley M. Percutaneous transhepatic PermCath for hemodialysis vascular access. Am J Kidney Dis. 1995;25:973.
10. Po CL, Koolpe HA, Allen S, Alvez LD, Raja RM. Transhepatic PermCath for hemodialysis. Am J Kidney Dis. 1994;24:590-1.
Cor r e spon de n ce : Rodrigo Bruno Biagioni
Rua Apucarana, 382/104, Bloco A, Tatuap• CEP 03311-000 – S‚o Paulo, SP, Brazil
