Case Report Abdominal Collateral Vein as an Unconventional Vascular Access for Hemodialysis in Patient with Central Vein Occlusion z_ ecki,* Mariusz Flisin ski,* Zbigniew Serafin,† Joanna Wiechecka-Korenkiewicz,* Paweł Stro and Jacek Manitius* *Department of Nephrology, Hypertension and Internal Medicine, The Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Dr. Antoni Jurasz University Hospital No.1, Bydgoszcz, Poland, and †Department of Radiology and Diagnostic Imaging, The Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Dr. Antoni Jurasz University Hospital No.1, Bydgoszcz, Poland
ABSTRACT A 65-year-old female patient with chronic kidney disease stage 5 and a history of spleen neoplasm with dissemination within peritoneum is presented. During 5 years of hemodialysis therapy, bilateral occlusion of brachiocephalic and iliac vein developed as a consequence of vein cathe-
terization. An attempt to cannulate inferior vena cava was unsuccessful. A cannulation of dilated collateral abdominal veins with dialysis needles allowed to perform several hemodialysis sessions in the patient.
Vascular access continues to be a leading cause for hospitalization and morbidity in patients with chronic kidney disease (CKD) stage 5 (1). Gradual exhausting of vascular access is potentially a lifethreatening condition in hemodialysed patients, particularly in catheter dependent patients (2). The number of venous access sites is limited. Progressive loss of access sites during long-term HD therapy requires interdisciplinary approach to maximize patient’s survival. In patients with no possibility of peritoneal dialysis or urgent kidney transplantation, unconventional vascular access such as: inferior vena cava, hepatic vein, or recanalized vein, should be considered (2,3). Collateral vein should be taken into account as alternate vascular access in patients with exhausted conventional access sites (2,3).
tory of the patient included neoplasm of the spleen (hemangiopericytoma), treated with splenectomy (2001), radiotherapy, and chemotherapy (2001– 2008). Despite therapy, in 2012, the dissemination of neoplasm within the peritoneum was observed. The patient’s vascular access history included right jugular vein temporary catheter (August–October 2008), left internal jugular vein tunneled cuffed catheter (TCC) (October 2008–October 2009), right femoral vein TCC (October 2009–February 2010), and femoro-femoral gore-tex arteriovenous graft (AVG) created in February 2010. In July 2009, the patient underwent catheter-related staphylococcal sepsis. At that time, left and right jugular vein thrombosis was diagnosed. Native arteriovenous fistula (AVF) was not created in the patient due to small arterial diameter and lack of appropriate vein in her upper limbs. In July 2013, the patient was admitted to hospital due to thrombosis of femorofemoral AVG. Due to lack of vascular access, an attempt to introduce dialysis catheter to right femoral vein was undertaken, but it was unsuccessful. Venography revealed right iliac vein occlusion with collateral circulation toward superficial epigastric vein (SEV). Then left femoral vein was catheterized using TCC. Several days after catheter placement, left inferior limb edema occurred and Doppler-duplex ultrasound showed femoral vein thrombosis. At the same time, signs of catheter dysfunction with inadequate pump flow rate appeared and the patient became uremic.
Case Presentation 65-year-old female patient with end-stage renal disease has been undergoing renal replacement therapy with hemodialysis since 2008. The medical his z_ ecki, MD, DepartAddress correspondence to: Paweł Stro ment of Nephrology, Hypertension and Internal Medicine, Ul. M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland, Tel.: +48 52 585 45 51, Fax: +48 52 585 40 30, or e-mail: [email protected]. Seminars in Dialysis—Vol 27, No 4 (July–August) 2014 pp. E48–E50 DOI: 10.1111/sdi.12244 © 2014 Wiley Periodicals, Inc. E48
UNCONVENTIONAL VASCULAR ACCESS FOR HD
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Computed tomography angiography (CTA) was performed to localize potential new vascular access. The examination demonstrated bilateral brachiocephalic vein occlusion and bilateral iliac vein occlusion. As a result of central vein occlusion, collateral circulation was observed with dilated azygos vein, internal thoracic vein (Fig. 1), and bilateral dilated superficial epigastric vein (Fig. 2). The tip of femoral TCC was localized in inferior vena cava (IVC), with thrombus on the tip of the catheter (Fig. 3).
Fig. 3. Abdominal CT—venous phase, coronal MIP reformation. Note the TCC in the inferior vena cava (arrow) and the thrombus on the tip of the catheter (arrowhead).
Fig. 1. Thoracic CT—MIP reconstruction of venous phase after contrast medium administration into the left antecubital vein. Occlusion of both brachiocephalic veins resulted in collateral flow from the head and upper limbs. Superior vena cava arises from the azygos vein (arrow) and the internal thoracic vein (arrowhead), both severely dilated.
Fig. 2. Thoracoabdominal CT—SSD reconstruction. Bilateral dilated superficial epigastric veins (arrows), which continue into thoracoepigastric veins.
An attempt to cannulate IVC was unsuccessful due to liver enlargement and difficult anatomical conditions. There was no possibility to convert the patient to peritoneal dialysis due to neoplasmatic dissemination in the peritoneal cavity. As physical examination showed collateral circulation on the abdominal wall, with dilated, winding SEV, and Doppler-duplex examination showed each SEV diameter of about 5 mm, with blood flow of about 300 ml/minute, it was decided to perform HD session using one SEV as an “arterial” part of vascular access and the other one as “venous” part. Both SEVs were cannulated with 16G dialysis needle (Fig. 4), and HD session was performed with blood pump flow of 220 ml/minute. After HD session, urea reduction ratio (URR) was 60%. Ureabased protocol for assessment of blood recirculation
Fig. 4. Superficial epigastric veins cannulated with dialysis needles.
z_ ecki et al. Stro
E50
showed no recirculation in vascular access. Several HD sessions using both SEV cannulation were performed. The patient defined collateral vein cannulation as painless. There were no technical problems with SEV cannulation. After several weeks, the patient died due to progression of neoplasmatic cachexia. Discussion Percutaneous vein catheters provide immediate vascular access, however these devices are plagued by their propensity for infection, thrombosis, inadequate blood flow, and damage to large central veins (4). Kidney Disease Outcomes Quality Initiative (KDOQI) and European Best Practice Guidelines (EBPG) recommendations allow catheters as target vascular access in patients with limited life expectancy, such as patients with congestive heart failure, severe peripheral vascular disease, and disseminated cancers (4,5). In the presented patient vascular catheters were used as target vascular access due to advanced neoplasm and lack of appropriate vessels to create AVF in upper limbs. Clinical course of the patient indicates that central vein occlusion was a consequence of thrombotic and infectious complications of previous vein catheterization. Only femorofemoral AVG provided 3-year complication-free period, however finally this vascular access was lost due to thrombotic complications. Exhausted options of vascular access forced the dialysis team to utilize an unconventional vascular access. As physical examination revealed dilated superficial epigastric veins, the idea developed to utilize abdominal collaterals as vascular access for hemodialysis. Extensive abdominal wall venous collaterals are important clinical finding, which indicates central inferior vena cava obstruction (6). The idea of epigastric vessels utilization as vascular access is not new. In 1976, Kauffman successfully placed a Teflon-silicone rubber A-V shunt in the inferior epigastric artery and vein in a hemodialysed patient (7). In children, inferior epigastric vein was used as a vascular access when central venous nutrition could not be delivered through the usual routes (8,9). However, to the authors’ knowledge, this was the first cannulation of abdominal wall collaterals performed as a direct vascular access for hemodialysis in patient with central vein occlusion.
As neoplasmatic disease was advanced, the discontinuation of hemodialysis therapy with palliative care was also considered. Discontinuation of dialysis therapy prior to death accounted for 24.6% of deaths among dialysis patient in The United States between 1995 and 2009 (10). However, in our country, discontinuation of dialysis therapy is very uncommon and was unacceptable for the patient’s family. The clinical history of vascular access in the presented patient suggests that even in patients with unfavorable prognosis, efforts should be undertaken to avoid long-term catheter use. In patients with limited life expectancy and central vein occlusion, abdominal collateral veins may be suitable as vascular access for hemodialysis. Acknowledgment The article (proofreading of the manuscript) was supported by Fundacja Nerkadar, Bydgoszcz, Poland.
Conflict of Interest The authors declare that they have no conflict of interest.
References 1. Centers for Medicare & Medicaid Services: 2004 Annual Report. EndStage Renal Disease Clinical Performance Measures Project. Baltimore, MD: Department of Health and Human Services, Centers for Medicare & Medicaid Services, Center for Beneficiary Choices, 2004 2. Lorenz J: Unconventional venous access techniques. Semin Intervent Radiol 23:279–286, 2006 3. Funaki B: Unconventional central access: catheter insertion in collateral or in recanalized veins. Semin Intervent Radiol 21:111–117, 2004 4. Vascular Access 2006 Work Group: Clinical practice guidelines for vascular access. Am J Kidney Dis 48 (Suppl 1):S176–S247, 2006 5. Tordoir J, Canaud B, Haage P, Konner K, Basci A, Fouque D, Kooman J, Martin-Malo A, Pedrini L, Pizzarelli F, Tattersall J, Vennegoor M, Wanner C, ter Wee P, Vanholder R: EBPG on Vascular Access. Nephrol Dial Transplant 22 (Suppl 2):ii88–ii117, 2007 6. Wittens C, Bukkems S, Toonder I: Abdominal wall venous collaterals. The latent clinical sign for central chronic venous obstruction. Circulation 122:2089–2090, 2010 7. Kauffman HM: Deep inferior epigastric arteriovenous shunt for hemodialysis. Surgery 78:675–676, 1975 8. Donahoe P, Kim S: The inferior epigastric vein as an alternate site for central venous hyperalimentation. J Pediatr Surg 15:737–738, 1980 9. Saleh H, Abdelaziz A, Hefnavy E, Mansour O: Alternate routes for children with difficult central venous access. Acta Chir Belg 08:563– 568, 2008 10. Gessert CE, Haller IV, Johnson BP: Regional variation in care at the end of life: discontinuation of dialysis. BMC Geriatr 13:39, 2013
ABSTRACT A 65-year-old female patient with chronic kidney disease stage 5 and a history of spleen neoplasm with dissemination within peritoneum is presented. During 5 years of hemodialysis therapy, bilateral occlusion of brachiocephalic and iliac vein developed as a consequence of vein cathe-
terization. An attempt to cannulate inferior vena cava was unsuccessful. A cannulation of dilated collateral abdominal veins with dialysis needles allowed to perform several hemodialysis sessions in the patient.
Vascular access continues to be a leading cause for hospitalization and morbidity in patients with chronic kidney disease (CKD) stage 5 (1). Gradual exhausting of vascular access is potentially a lifethreatening condition in hemodialysed patients, particularly in catheter dependent patients (2). The number of venous access sites is limited. Progressive loss of access sites during long-term HD therapy requires interdisciplinary approach to maximize patient’s survival. In patients with no possibility of peritoneal dialysis or urgent kidney transplantation, unconventional vascular access such as: inferior vena cava, hepatic vein, or recanalized vein, should be considered (2,3). Collateral vein should be taken into account as alternate vascular access in patients with exhausted conventional access sites (2,3).
tory of the patient included neoplasm of the spleen (hemangiopericytoma), treated with splenectomy (2001), radiotherapy, and chemotherapy (2001– 2008). Despite therapy, in 2012, the dissemination of neoplasm within the peritoneum was observed. The patient’s vascular access history included right jugular vein temporary catheter (August–October 2008), left internal jugular vein tunneled cuffed catheter (TCC) (October 2008–October 2009), right femoral vein TCC (October 2009–February 2010), and femoro-femoral gore-tex arteriovenous graft (AVG) created in February 2010. In July 2009, the patient underwent catheter-related staphylococcal sepsis. At that time, left and right jugular vein thrombosis was diagnosed. Native arteriovenous fistula (AVF) was not created in the patient due to small arterial diameter and lack of appropriate vein in her upper limbs. In July 2013, the patient was admitted to hospital due to thrombosis of femorofemoral AVG. Due to lack of vascular access, an attempt to introduce dialysis catheter to right femoral vein was undertaken, but it was unsuccessful. Venography revealed right iliac vein occlusion with collateral circulation toward superficial epigastric vein (SEV). Then left femoral vein was catheterized using TCC. Several days after catheter placement, left inferior limb edema occurred and Doppler-duplex ultrasound showed femoral vein thrombosis. At the same time, signs of catheter dysfunction with inadequate pump flow rate appeared and the patient became uremic.
Case Presentation 65-year-old female patient with end-stage renal disease has been undergoing renal replacement therapy with hemodialysis since 2008. The medical his z_ ecki, MD, DepartAddress correspondence to: Paweł Stro ment of Nephrology, Hypertension and Internal Medicine, Ul. M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland, Tel.: +48 52 585 45 51, Fax: +48 52 585 40 30, or e-mail: [email protected]. Seminars in Dialysis—Vol 27, No 4 (July–August) 2014 pp. E48–E50 DOI: 10.1111/sdi.12244 © 2014 Wiley Periodicals, Inc. E48
UNCONVENTIONAL VASCULAR ACCESS FOR HD
E49
Computed tomography angiography (CTA) was performed to localize potential new vascular access. The examination demonstrated bilateral brachiocephalic vein occlusion and bilateral iliac vein occlusion. As a result of central vein occlusion, collateral circulation was observed with dilated azygos vein, internal thoracic vein (Fig. 1), and bilateral dilated superficial epigastric vein (Fig. 2). The tip of femoral TCC was localized in inferior vena cava (IVC), with thrombus on the tip of the catheter (Fig. 3).
Fig. 3. Abdominal CT—venous phase, coronal MIP reformation. Note the TCC in the inferior vena cava (arrow) and the thrombus on the tip of the catheter (arrowhead).
Fig. 1. Thoracic CT—MIP reconstruction of venous phase after contrast medium administration into the left antecubital vein. Occlusion of both brachiocephalic veins resulted in collateral flow from the head and upper limbs. Superior vena cava arises from the azygos vein (arrow) and the internal thoracic vein (arrowhead), both severely dilated.
Fig. 2. Thoracoabdominal CT—SSD reconstruction. Bilateral dilated superficial epigastric veins (arrows), which continue into thoracoepigastric veins.
An attempt to cannulate IVC was unsuccessful due to liver enlargement and difficult anatomical conditions. There was no possibility to convert the patient to peritoneal dialysis due to neoplasmatic dissemination in the peritoneal cavity. As physical examination showed collateral circulation on the abdominal wall, with dilated, winding SEV, and Doppler-duplex examination showed each SEV diameter of about 5 mm, with blood flow of about 300 ml/minute, it was decided to perform HD session using one SEV as an “arterial” part of vascular access and the other one as “venous” part. Both SEVs were cannulated with 16G dialysis needle (Fig. 4), and HD session was performed with blood pump flow of 220 ml/minute. After HD session, urea reduction ratio (URR) was 60%. Ureabased protocol for assessment of blood recirculation
Fig. 4. Superficial epigastric veins cannulated with dialysis needles.
z_ ecki et al. Stro
E50
showed no recirculation in vascular access. Several HD sessions using both SEV cannulation were performed. The patient defined collateral vein cannulation as painless. There were no technical problems with SEV cannulation. After several weeks, the patient died due to progression of neoplasmatic cachexia. Discussion Percutaneous vein catheters provide immediate vascular access, however these devices are plagued by their propensity for infection, thrombosis, inadequate blood flow, and damage to large central veins (4). Kidney Disease Outcomes Quality Initiative (KDOQI) and European Best Practice Guidelines (EBPG) recommendations allow catheters as target vascular access in patients with limited life expectancy, such as patients with congestive heart failure, severe peripheral vascular disease, and disseminated cancers (4,5). In the presented patient vascular catheters were used as target vascular access due to advanced neoplasm and lack of appropriate vessels to create AVF in upper limbs. Clinical course of the patient indicates that central vein occlusion was a consequence of thrombotic and infectious complications of previous vein catheterization. Only femorofemoral AVG provided 3-year complication-free period, however finally this vascular access was lost due to thrombotic complications. Exhausted options of vascular access forced the dialysis team to utilize an unconventional vascular access. As physical examination revealed dilated superficial epigastric veins, the idea developed to utilize abdominal collaterals as vascular access for hemodialysis. Extensive abdominal wall venous collaterals are important clinical finding, which indicates central inferior vena cava obstruction (6). The idea of epigastric vessels utilization as vascular access is not new. In 1976, Kauffman successfully placed a Teflon-silicone rubber A-V shunt in the inferior epigastric artery and vein in a hemodialysed patient (7). In children, inferior epigastric vein was used as a vascular access when central venous nutrition could not be delivered through the usual routes (8,9). However, to the authors’ knowledge, this was the first cannulation of abdominal wall collaterals performed as a direct vascular access for hemodialysis in patient with central vein occlusion.
As neoplasmatic disease was advanced, the discontinuation of hemodialysis therapy with palliative care was also considered. Discontinuation of dialysis therapy prior to death accounted for 24.6% of deaths among dialysis patient in The United States between 1995 and 2009 (10). However, in our country, discontinuation of dialysis therapy is very uncommon and was unacceptable for the patient’s family. The clinical history of vascular access in the presented patient suggests that even in patients with unfavorable prognosis, efforts should be undertaken to avoid long-term catheter use. In patients with limited life expectancy and central vein occlusion, abdominal collateral veins may be suitable as vascular access for hemodialysis. Acknowledgment The article (proofreading of the manuscript) was supported by Fundacja Nerkadar, Bydgoszcz, Poland.
Conflict of Interest The authors declare that they have no conflict of interest.
References 1. Centers for Medicare & Medicaid Services: 2004 Annual Report. EndStage Renal Disease Clinical Performance Measures Project. Baltimore, MD: Department of Health and Human Services, Centers for Medicare & Medicaid Services, Center for Beneficiary Choices, 2004 2. Lorenz J: Unconventional venous access techniques. Semin Intervent Radiol 23:279–286, 2006 3. Funaki B: Unconventional central access: catheter insertion in collateral or in recanalized veins. Semin Intervent Radiol 21:111–117, 2004 4. Vascular Access 2006 Work Group: Clinical practice guidelines for vascular access. Am J Kidney Dis 48 (Suppl 1):S176–S247, 2006 5. Tordoir J, Canaud B, Haage P, Konner K, Basci A, Fouque D, Kooman J, Martin-Malo A, Pedrini L, Pizzarelli F, Tattersall J, Vennegoor M, Wanner C, ter Wee P, Vanholder R: EBPG on Vascular Access. Nephrol Dial Transplant 22 (Suppl 2):ii88–ii117, 2007 6. Wittens C, Bukkems S, Toonder I: Abdominal wall venous collaterals. The latent clinical sign for central chronic venous obstruction. Circulation 122:2089–2090, 2010 7. Kauffman HM: Deep inferior epigastric arteriovenous shunt for hemodialysis. Surgery 78:675–676, 1975 8. Donahoe P, Kim S: The inferior epigastric vein as an alternate site for central venous hyperalimentation. J Pediatr Surg 15:737–738, 1980 9. Saleh H, Abdelaziz A, Hefnavy E, Mansour O: Alternate routes for children with difficult central venous access. Acta Chir Belg 08:563– 568, 2008 10. Gessert CE, Haller IV, Johnson BP: Regional variation in care at the end of life: discontinuation of dialysis. BMC Geriatr 13:39, 2013
