Temporary vascular access via the external iliac vein as a salvage procedure: A report of two cases
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《血管的通路杂志》
1.Department of Urology, Ankara Cankaya Hospital, Ankara - Turkey
2.Transplantation Unit, Faculty of Medicine, Gazi University Ankara - Turkey
ABSTRACT
Central venous catheters (CVCs) provide easy, immediate and rapid vascular access (VA) for he-modialysis (HD) in patients with acute renal failure (ARF), and in an increasing number of patients with end-stage renal disease (ESRD) as well. For this purpose, the vessels mainly used are the cephalic, jugular, subclavian and femoral veins. In some patients, vascular catheter insertion via these routes can become impossible. We report two hopeless cases, in which the external iliac veins (EIVs) were used as a temporary VA insertion site as a last resort.
Key Words: Vascular access, External iliac vein, Hemodialysis
INTRODUCTION
Dialysis catheters provide a short-term bridge to permanent vascular access (VA). They play a pivotal role in the immediate management of the uremic patient. However, they substantially increase the risk of bacteremia, stenosis and thrombosis of the central veins. Catheter related complications, like fibrin sheathing, extrusion and kinking, also are common, impairing the correct
delivery of dialysis treatment (1).
Central venous catheters (CVCs) can be placed by a surgical cutdown on the cephalic vein, or percutaneously via the subclavian, femoral or the jugular veins (2-4). In some cases, the insertion of temporary CVCs via these routes can be impossible because of thrombosis in axillary, subclavian veins or superior vena cava, unsuccessful subclavian venipuncture, central line sepsis, bilateral femoral vein thrombosis or stenosis (5). We report two hopeless cases, in which no access to large blood vessels for hemodialysis (HD) was
possible, due to bilateral subclavian and femoral vein stenosis.
Case 1
A 48-year-old female patient with end-stage renal disease (ESRD), who had been on HD for 10 yrs, was referred to our department for permanent VA.
On admission, we observed that the vessels of both upper extremities of the patient had been exhausted for multiple arteriovenous (AV) HD fistula interventions. She also had bilateral subclavian and brachio-cephalic vein obstruction due to several central catheterization procedures. We created an
AV fistula between the femoral artery and the saphenous vein, but the fistula failed following a hypotensive episode during an HD session. Unfortunately,
her left leg veins were also thrombosed.
Therefore, we decided to use the external iliac vein (EIV) as an emergency VA site for HD. For the percutaneous approach, our radiology department was
not experienced enough; therefore, we decided to perform an open surgical procedure. With the patient in a supine position, under general anesthesia,
a right flank skin incision 8 cm in length was made in the lower abdomen. A retroperitoneal plane was then developed exposing the right EIV and inferior vena cava. The iliac vein was gently freed from the surrounding tissues by blunt dissection and a catheter (Splitcath-II Carbothane vascular catheter, 16F, 55 cm, Medcomp, USA) was inserted in the EIV and sent all the way through the inferior vena cava to the right atrium. An abdominal X-ray taken post-operatively confirmed the correct position of the catheter (Fig. 1) and the patient was treated effectively with HD.
Two months later, after the placement of a permanent peritoneal dialysis catheter, the vascular catheter was removed with an open surgical procedure.
Case 2
A 53-year-old male patient was referred to our department for permanent VA. He had been treated with HD for about 4 yrs. As in our first case, we observed
that the vessels of both upper extremities had been exhausted for multiple AV HD fistula interventions. Similarly, he had bilateral subclavian and brachio-cephalic vein obstruction due to several central catheterization procedures. We placed a prosthetic vascular graft between the femoral artery and the saphenous vein. The graft worked well until the patient experienced graft infection and septicemia. We had to remove the graft. Unfortunately, the femoral veins on both legs were sclerotic. Therefore, we decided to insert a CVC via the EIV. Under general anesthesia, we placed the catheter (Splitcath-II Carbothane vascular catheter) in the right EIV of the patient with a similar surgical approach to our first case. From the same skin incision, we also placed a peritoneal dialysis catheter in the peritoneal cavity. On chest X-ray taken post-operatively, the catheter tip was seen in the right atrium.
The patient underwent a successful HD session on the first post-operative day. Two months later, the vascular catheter was removed with an open surgical procedure after the patient had been adequately trained for peritoneal dialysis.
DISCUSSION
Central venous catheterization in ESRD patients who have thrombosis or stenosis of the subclavian, superior vena cava or femoral vein remains a major problem. Catheters are often used for temporary VA in HD patients, as they provide rapid and easy extracorporeal blood flow until the creation of an
AV fistula or peritoneal catheter placement. However, they also frequently determine vein thrombosis. The National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines recommend temporary catheters to remain in place no longer than 5 days in the femoral vein, and 3 weeks in the
internal jugular vein based on the cumulative risk of bacteremia (6). Therefore, in problematic cases, inferior vena cava catheterization can be life saving. Catheters can be placed in the inferior vena cava via EIV either by an open or percutaneous approach. Mathur et al inserted 53 long-term venous access catheters percutaneously and observed that 51% of cases remained free of any complication after the procedure (5). They even reported one patient who had the catheter still working after 5 yrs.
In using a direct surgical venous puncture in an open surgical approach, the vein wall microtrauma and the damage caused by the needle insertion attempts during percutaneous punctures would be eliminated. In addition, catheter placement in this high flow vein would reduce the risk of thrombogenesis near the insertion site. In addition, this procedure keeps the opposite iliac vein catheter free as a salvage access site in the future. In conclusion, as a last resort, in patients whose central veins are occluded or impossible to use for any reason, EIV seems a useful, life saving route for
chronic HD patients.
REFERENCES
1. Kairaitis LK, Gottlieb. Outcome and complications of temporary hemodialysis catheters. Nephrol Dial Transplant 1999; 14: 1710-4.
2. Hughes CJ, Ramsey-Stewart G, Storey DW. Percutaneous infraclavicular insertion of long term central venous Hickman catheters. Aust N Z J Surg 1989; 59: 889-93.
3. Annest LS, Ryan JA. Use of a split-sheath vein introducer for subclavian venipuncture in the placement of silicone catheters for chronic venous access. Am J Surg 1982; 144: 367-9.
4. Slater H, Goldfarb IW, Jacob HE, Hill JB, Srodes CH. Experience with long-term outpatient venous access utilizing percutaneously placed silicone elastomer catheters. Cancer 1985; 56: 2074-7.
5. Mathur MN, Storey DW, White GH, Ramsey-Stewart G. Percutaneous insertion of long-term venous access catheters via the external iliac vein. Aust N Z J Surg 1993; 63: 858-63.
6. NKF-DOQI clinical practice guidelines for vascular access. National Kidney Foundation-Dialysis Outcomes Quality Initiative. Am J Kidney Dis 1997; 30 (suppl 3): S150-91.(H. Tokgoz, M. Onaran, C. )
2.Transplantation Unit, Faculty of Medicine, Gazi University Ankara - Turkey
ABSTRACT
Central venous catheters (CVCs) provide easy, immediate and rapid vascular access (VA) for he-modialysis (HD) in patients with acute renal failure (ARF), and in an increasing number of patients with end-stage renal disease (ESRD) as well. For this purpose, the vessels mainly used are the cephalic, jugular, subclavian and femoral veins. In some patients, vascular catheter insertion via these routes can become impossible. We report two hopeless cases, in which the external iliac veins (EIVs) were used as a temporary VA insertion site as a last resort.
Key Words: Vascular access, External iliac vein, Hemodialysis
INTRODUCTION
Dialysis catheters provide a short-term bridge to permanent vascular access (VA). They play a pivotal role in the immediate management of the uremic patient. However, they substantially increase the risk of bacteremia, stenosis and thrombosis of the central veins. Catheter related complications, like fibrin sheathing, extrusion and kinking, also are common, impairing the correct
delivery of dialysis treatment (1).
Central venous catheters (CVCs) can be placed by a surgical cutdown on the cephalic vein, or percutaneously via the subclavian, femoral or the jugular veins (2-4). In some cases, the insertion of temporary CVCs via these routes can be impossible because of thrombosis in axillary, subclavian veins or superior vena cava, unsuccessful subclavian venipuncture, central line sepsis, bilateral femoral vein thrombosis or stenosis (5). We report two hopeless cases, in which no access to large blood vessels for hemodialysis (HD) was
possible, due to bilateral subclavian and femoral vein stenosis.
Case 1
A 48-year-old female patient with end-stage renal disease (ESRD), who had been on HD for 10 yrs, was referred to our department for permanent VA.
On admission, we observed that the vessels of both upper extremities of the patient had been exhausted for multiple arteriovenous (AV) HD fistula interventions. She also had bilateral subclavian and brachio-cephalic vein obstruction due to several central catheterization procedures. We created an
AV fistula between the femoral artery and the saphenous vein, but the fistula failed following a hypotensive episode during an HD session. Unfortunately,
her left leg veins were also thrombosed.
Therefore, we decided to use the external iliac vein (EIV) as an emergency VA site for HD. For the percutaneous approach, our radiology department was
not experienced enough; therefore, we decided to perform an open surgical procedure. With the patient in a supine position, under general anesthesia,
a right flank skin incision 8 cm in length was made in the lower abdomen. A retroperitoneal plane was then developed exposing the right EIV and inferior vena cava. The iliac vein was gently freed from the surrounding tissues by blunt dissection and a catheter (Splitcath-II Carbothane vascular catheter, 16F, 55 cm, Medcomp, USA) was inserted in the EIV and sent all the way through the inferior vena cava to the right atrium. An abdominal X-ray taken post-operatively confirmed the correct position of the catheter (Fig. 1) and the patient was treated effectively with HD.
Two months later, after the placement of a permanent peritoneal dialysis catheter, the vascular catheter was removed with an open surgical procedure.
Case 2
A 53-year-old male patient was referred to our department for permanent VA. He had been treated with HD for about 4 yrs. As in our first case, we observed
that the vessels of both upper extremities had been exhausted for multiple AV HD fistula interventions. Similarly, he had bilateral subclavian and brachio-cephalic vein obstruction due to several central catheterization procedures. We placed a prosthetic vascular graft between the femoral artery and the saphenous vein. The graft worked well until the patient experienced graft infection and septicemia. We had to remove the graft. Unfortunately, the femoral veins on both legs were sclerotic. Therefore, we decided to insert a CVC via the EIV. Under general anesthesia, we placed the catheter (Splitcath-II Carbothane vascular catheter) in the right EIV of the patient with a similar surgical approach to our first case. From the same skin incision, we also placed a peritoneal dialysis catheter in the peritoneal cavity. On chest X-ray taken post-operatively, the catheter tip was seen in the right atrium.
The patient underwent a successful HD session on the first post-operative day. Two months later, the vascular catheter was removed with an open surgical procedure after the patient had been adequately trained for peritoneal dialysis.
DISCUSSION
Central venous catheterization in ESRD patients who have thrombosis or stenosis of the subclavian, superior vena cava or femoral vein remains a major problem. Catheters are often used for temporary VA in HD patients, as they provide rapid and easy extracorporeal blood flow until the creation of an
AV fistula or peritoneal catheter placement. However, they also frequently determine vein thrombosis. The National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines recommend temporary catheters to remain in place no longer than 5 days in the femoral vein, and 3 weeks in the
internal jugular vein based on the cumulative risk of bacteremia (6). Therefore, in problematic cases, inferior vena cava catheterization can be life saving. Catheters can be placed in the inferior vena cava via EIV either by an open or percutaneous approach. Mathur et al inserted 53 long-term venous access catheters percutaneously and observed that 51% of cases remained free of any complication after the procedure (5). They even reported one patient who had the catheter still working after 5 yrs.
In using a direct surgical venous puncture in an open surgical approach, the vein wall microtrauma and the damage caused by the needle insertion attempts during percutaneous punctures would be eliminated. In addition, catheter placement in this high flow vein would reduce the risk of thrombogenesis near the insertion site. In addition, this procedure keeps the opposite iliac vein catheter free as a salvage access site in the future. In conclusion, as a last resort, in patients whose central veins are occluded or impossible to use for any reason, EIV seems a useful, life saving route for
chronic HD patients.
REFERENCES
1. Kairaitis LK, Gottlieb. Outcome and complications of temporary hemodialysis catheters. Nephrol Dial Transplant 1999; 14: 1710-4.
2. Hughes CJ, Ramsey-Stewart G, Storey DW. Percutaneous infraclavicular insertion of long term central venous Hickman catheters. Aust N Z J Surg 1989; 59: 889-93.
3. Annest LS, Ryan JA. Use of a split-sheath vein introducer for subclavian venipuncture in the placement of silicone catheters for chronic venous access. Am J Surg 1982; 144: 367-9.
4. Slater H, Goldfarb IW, Jacob HE, Hill JB, Srodes CH. Experience with long-term outpatient venous access utilizing percutaneously placed silicone elastomer catheters. Cancer 1985; 56: 2074-7.
5. Mathur MN, Storey DW, White GH, Ramsey-Stewart G. Percutaneous insertion of long-term venous access catheters via the external iliac vein. Aust N Z J Surg 1993; 63: 858-63.
6. NKF-DOQI clinical practice guidelines for vascular access. National Kidney Foundation-Dialysis Outcomes Quality Initiative. Am J Kidney Dis 1997; 30 (suppl 3): S150-91.(H. Tokgoz, M. Onaran, C. )