Yong-Shu Diao ( Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China. )
Yan-Huan Feng ( Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China. )
Chun-Cheng Liu ( Department of Ultrasonography, West China Hospital of Sichuan University, Chengdu, China. )
Tian-Lei Cui ( Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China. )
Ping Fu ( Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China. )
The patency of vascular access is of vital importance to dialysis patients. Access dysfunction is largely caused by vessel stenosis and thrombosis. Nephrologists usually find themselves helpless when all treatments fail and the vascular access seems to have exhausted. Here we report a successful establishment of vascular access through superior vena cava for a critical patient with multiple central venous stenosis or occlusion. To our knowledge, it is the first case ever reported on the successful establishment of vascular access through superior vena cava under such a complicated condition of vascular exhaustion.
Keywords: Vascular access, Dialysis, Multiple central venous or occlusion.
What is central to patients\\\' receiving dialysis is the patency of vascular access, the dysfunction of which is largely caused by stenosis and thrombosis. While the latter can be solved by re-canalisation or establishing a new vascular access, these available treatments lack clear evidence to support, especially in multiple central venous stenosis or occlusive patients. Here we report a successful establishment of vascular access through direct superior vena cava for a critical patient with multiple central venous stenosis or occlusion.
A 75-year-old woman with end-stage renal disease (ESRD) due to diabetic nephropathy (DN) visited our medical centre for the occlusion of artificial graft for 2 days in July 2012. She had a history of diabetes mellitus (DM), hypertension (HT) and hyperlipidaemia under poor control. The patient had begun to receive peritoneal dialysis (PD) 5 years earlier, superseded afterward by haemodialysis (HD) because of obstruction of PD catheter. She had then received internal jugular vein and femoral vein catheterisation repeatedly for the low flow rate of arteriovenous fistulas. In the preceding one year the patient had received left upper limb\\\'s artificial graft replacement resulting from the occlusion of the right brachiocephalic vein and the left internal jugular vein.
Primary associated symptoms were oliguria (urine output was less than 100 mL/d) and lower extremity oedema. No fever, jaundice, superficial lymph nodes or consciousness disorders were reported. Assessment of vital signs on presentation revealed temperature of 36.6°C, pulse of 66 beats per minute, and blood pressure of 145/97 mmHg. The upper limb colour ultrasound illustrated the full-length artificial blood vessel thrombosis and the median cubital vein thrombosis. Computed tomography angiography (CTA) showed that the bilateral brachiocephalic veins and the right internal jugular vein were all occlusive with the development of collateral circulation, and the bilateral femoral veins were extremely narrow, which was confirmed by subsequent digital subtraction angiography (Figure).
Laboratory tests indicated normal haemoglobin levels (139g/L), normal platelet count (167×109g/L), high serum creatinine levels (925.3mmol/L), electrolyte disorders and normal coagulation function.
Because of the high calcium-phosphorus product, hyperphosphatemia and unstable haemodynamics, the patient received haemodialysis through direct puncture. However, dialyses for the patient 4 times per week could not correct electrolyte imbalances. We tried to insert deep veins of lower limb catheter and arteriovenous graft for haemodialysis was provided, but all treatment approaches took us nowhere.
The patient\\\'s condition got progressively worse, with her left arm swelling and signs of acute heart failure (New York Heart Association class II) appearing. We, therefore, performed re-canalisation and balloon dilation, and successfully inserted a long-term cuffed double-lumen catheter into the joint of external jugular vein and sub-clavian vein, with the far end of the catheter located to the distal end of superior vena cava. Despite tolerable soreness experienced during the operation, no obvious discomfort was reported. Haemodialysis through the cuff saw an improvement and the flow rate reached above 250ml/min.
Monthly follow-up showed that the patient was able to receive maintenance haemodialysis and the graft had been in a good condition. CTA done during the follow-up period of 2 years indicated no abnormal imaging results.
It\\\'s a big challenge managing the central venous occlusive disease (CVD) and maintaining patency of vascular access among patients on haemodialysis. Exhaustion of vascular access causes add to dialysis-related complications and mortality. Yet the effective treatment of CVD and maintaining patency of vascular access, the so-called lifeline, remain major problems to overcome.
It\\\'s common for CVD in haemodialysis patients and the incidence may up to 27% with a history of previous central catherisation.1
Our patient had a history of repeated temporary catheterisation and fistulas, which is a high-risk factor of thrombosis.2 A long history of DM, HT and hyperlipidaemia under poor control further suggested the possibility of multiple thrombosis or stenosis. We initially had the patient undergo vascular ultrasound and contrast angiography to attain a definitive diagnosis and to ascertain the accurate position of thrombosis and that of the narrow part of the blood vessel, if any. Results showed the patient had a very difficult problem of exhaustion of vascular access. To meet the requirement of haemodialysis, temporary catheterisation is still an option for keeping the life signs stable temporarily, provided the possibility still remains of re-canalisation of the blood vessels\\\' stenosis. Unfortunately, first two attempts failed owing to the poor vascular condition and the thinness of orifice.
The fluctuation of blood pressure was no longer within the stable range, and the hyperkalaemia became more frequent, all of which implied that haemodialysis through direct puncture was no longer adequate and that there was an urgent need to build new vascular access during the treatment. Our effort to rebuild the prosthetic graft was unsuccessful, which may be ascribed to the degeneration of the primary graft that increased the possibility of failure by having gradually injured the blood vessels and the vascular wall, and thus making anastomotic extremely vulnerable.2,3
When the CVD in HD patients occur, endovascular intervention includes percutaneous transluminal angioplasty (PTA), and placement of bar-mental stents (BMS) is the primary treatment. The technical success rate about PTA ranged from 70-90% and the primary patency rates at 6 months and 12 months ranged 23-55% and under 50% respectively.4-10 The BMS\\\'s technical success rate is also very high, but the primary patency rates are as low as 14% at 12 months.6-18 It also lacked enough data to determine the effectiveness, especially in multiple central venous stenosis or occlusive patients.
Data on patients with multiple central venous stenosis or occlusion is very rare. Matsuura J et al. reported 3 cases of patients with central venous stenosis or occlusion, to all of whom PTA had been employed to perform central venous catheterisation.19 Meanwhile, confronted with the same cases, Kapoor B et al. succeeded in application of stents.20 Zmani N et al. reported a case of a middle-aged female patient with exhausted upper extremity access sites, whose life was successfully saved by surgically creating an arteriovenous graft in from the left common iliac artery to the inferior vena cava.21 Taking a closer look at the reported cases, we found the follow-up care and prognosis unsatisfactory which could be maintained for no more than 4 months.
Our patient was in a critical condition and because of the failure of the temporary catheterisation and rebuilding the prosthetic graft, we performed re-canalisation and balloon dilation and successfully inserted a long-term cuffed double-lumen catheter into the joint of external jugular vein and sub-clavian vein, with the far end of the catheter located to the distal end of superior vena cava. And after the complete monitoring mechanism for our patient, over a follow-up period of 2 years, the patient remained in a stable condition, outperforming cases reported in literature.19-21
Exhaustion of vascular access in HD patient is rare yet fatal, and will become increasingly common as the population of HD patients continues to climb. To our knowledge, it is the first case ever reported on the successful establishment of vascular access through superior vena cava under such a complicated condition of vascular exhaustion. The case reveals that what is central to successful treatment is whether or not it is able to overcome the problems of stenosis and thrombosis and to establish new vascular access.
The work was part of the National Key Technology R&D Programme and the Sichuan Province Health Department Scientific Research Programme.
Disclosure of grants or other Funding: This work was part of the Program on the National Key Technology R&D Program (No. 2011BAI10B08) and the Program on the Sichuan Province Health Department Scientific Research Program (No.140063).
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