CASE REPORT
Using r e ca n a lize d e x t e r n a l ilia c ve in for t u n n e le d h e m odia lysis ca t h e t e r
in se r t ion
Rica r do W a gne r da Cost a M or e ir aI; Le ona r do Ca r le t t o Bor ge sI I; Ke lle n M iche lle Alve s Cost aI I I; Ra que l M a r t ins e QuininoI I I; Yvis Ga de lha Se r r aI V; Luís Ca r los de Olive ir aV IVascular surgeon, Vascular and I nt ervent ionist Radiology, Clínica I nt egrada, Nat al, RN, Brazil. I IVascular surgeon, Clínica Cordis, Nat al, RN, Brazil.
I I INephrologist , Hospit al do Coração de Nat al, Nat al, RN, Brazil. I VVascular surgeon, Hospit al Divina Providência, Russas, RN, Brazil. VAnest hesiologist , Clínica de Anest esiologia ( CLI ARN) , Nat al, RN, Brazil.
Correspondence
J Vasc Bras. 2008; 7( 2) : 171- 173.
ABSTRACT
The frequent insert ion of cervical venous cat het ers for hem odialysis is closely relat ed t o venous st enosis or occlusion. As an alt ernat ive, fem oral cat het er insert ions are helpful but are also associat ed w it h fem oral vein occlusion and an even higher infect ion rat e. Alt ernat ive venous accesses have been increasingly used when t he aforem ent ioned accesses are not feasible. We report a case in which a recanalized ext ernal iliac vein was used for hem odialysis t unneled cat het er insert ion. The t echnique approach is discussed, focusing on it s advant ages and disadvant ages.
Ke yw or ds: Cat het erizat ion, cent ral venous, hem odialysis, iliac vein, radiology, int ervent ional.
RESUM O
O uso de cat et eres venosos cervicais para hem odiálise leva freqüent em ent e à oclusão dessas veias. Com o alt ernat iva, os acessos venosos fem orais são válidos, porém o seu uso t am bém est á associado à oclusão dessas veias e a um m aior índice de infecção. Vias alt ernat ivas são cada vez m ais ut ilizadas na im possibilidade dos acessos previam ent e m encionados. Descrevem os nest e relat o de caso um a alt ernat iva para o im plant e de cat et er de longa perm anência para hem odiálise usando a veia ilíaca ext erna recanalizada. Com ent am os os det alhes da t écnica ut ilizada, suas vant agens e desvant agens.
I n t r odu ct ion
Venous cat het ers as vascular access for dialyt ic t reat m ent are applied in pat ient s who need hem odialysis but do not have an art eriovenous fist ula as definit ive access.1 - 3
I n case of an acut e renal failure, short- t erm cat het ers can be used, since t here is possibilit y of a fast reest ablishm ent of renal funct ion.1 - 3 I n case t here is no expect at ion of renal funct ion
im provem ent , t unneled cat het ers are im plant ed. Short- t erm cat het ers can also be used in pat ient s wit h chronic renal failure, in which t he creat ion of an art eriovenous fist ula is not possible, or when it is necessary t o wait unt il t he fist ula is developed.1
The int ernal j ugular or subclavian veins are com m only used. Fem oral veins can also be used, but t heir use is associat ed w it h t he possibilit y of lower lim b venous t hrom bosis, higher m orbidit y and m ort alit y rat es in relat ion t o t he upper lim b, and also t o a higher incidence of infect ion.4 - 6
Translum bar inferior vena cava and t ranshepat ic access are usually except ion accesses.4 - 6
Ca se de scr ipt ion
A 53- year- old m ale pat ient , diabet ic, hypert ensive and wit h chronic renal failure in hem odialysis was adm it t ed at t he em ergency room com plaining of abdom inal discom fort , vom it ing, nausea and st at e of m ent al confusion. The pat ient had previous hist ory of venous cat het ers in t he cervical region and fem oral veins. There was an art eriovenous fist ula wit h palpable t hrill and large edem a in t he right upper lim b. The fist ula was always punct ured successfully, but t here was never effect ive flow in t he hem odialysis m achine. Doppler ult rasound showed bilat eral occlusion of t he int ernal j ugular vein, subclavian vein and fem oral vein. At adm it t ance, he had a short- t erm cat het er in t he right com m on fem oral vein, but it was not funct ioning. He had been wit hout hem odialysis for 6 days.
I nit ially, t he cat het er posit ion observed in radioscopy suggest ed t hat it had perforat ed t he ext ernal iliac vein. I nj ect ion of cont rast confirm ed suspicion, showing cont rast ext ravasat ion int o t he
ret roperit oneum .
Due t o t he urgent need of perform ing hem odialysis, choice was for a t unneled cat het er insert ion, and t hen st udy t he right subclavian vein occlusion for possible angioplast y.
The short - t erm cat het er was rem oved over t he guide wire and an 8F sheat h was insert ed in it s place. Then, a select ive cat het erizat ion of t he left com m on iliac vein was perform ed, using
D iscu ssion
The initial conduct in this case (before the radioscopic examination) would be to recanalize the occluded iliac vein using recombinant tissue plasminogen (rt-PA) and then implant the tunneled catheter. However, presence of venous perforation contraindicated thrombolysis. Another
important fact was the urgent need of hemodialysis. The patient could not wait 12 hours or more, which is usually the time required for thrombolysis. For that reason, use of the external iliac vein was a good option, since translumbar puncture of the inferior vena cava would not be necessary, a procedure that was the second option for this case.
Although puncture of the external iliac vein is a higher puncture and has a higher risk of bleeding
for the retroperitoneum, presence of calcifications in the external iliac artery and use of roadm ap
made the procedure easier, obtaining success in the first attempt. A more lateral exteriorization of the catheter through subcutaneous tunnels aimed at reducing the chances of infection usually associated with the inguinal region.
In our opinion, combined use of radioscopy and anatomical parameters allowed for a safe puncture of the external iliac vein. "Blind" puncture of this vein should not be encouraged, due to the
possibility of complications that are hard to solve, especially in an uremic patient. When the external iliac vein is chosen for puncture, catheter insertion should ideally be guided by Doppler
ultrasound.7
Re fe r e n ce s
1. NKF-K/DOQI clinical practice guidelines for vascularAccess: Update 2000. Am J Kidney Dis.
2001;37(Suppl 1):137-81.
3. Work J. Catheter insertion: techniques, cost and outcomes. In: Gray RJ, Sands JJ, editores. Dialysis Access a multidisciplinary approach. Philadelphia: Lippincot Williams & Wilkins; 2002. p. 261-9.
4. Zaleski GX, Funaki B, Lorenz JM, et al. Experience with tunneled femoral hemodialysis catheters. AJR Am J Roentgenol. 1999;172:493-6.
5. Lund GB, Trerotola SO, Scheel PJ Jr. Percutaneous translumbar inferior vena cava cannulation for hemodialysis. Am J Kidney Dis. 1995;25:732-7.
6. Weitzel W, Boyer C, El-Khatib M, Swartz R. Successful use of indwelling cuffed femoral vein catheters in ambulatory hemodialysis patients. Am J Kidney Dis. 1993;22:426-9.
7. Betz C, Kraus D, Muller C, Geiger H. Iliac cuffed tunnelled catheters for chronic haemodialysis vascular access. Nephrol Dial Transplant. 2006;21:2009-12.
Cor r e sponde nce :
Ricardo Wagner da Costa Moreira
Av. Rui Barbosa, 1110/103, Bloco C, Lagoa Nova CEP 59056-300 – Natal, RN, Brazil
Tel.: (84) 3206.9567
Email: [email protected]
No conflicts of interest declared concerning the publication of this case report.
