I have been meaning to present this case for a while. This case taught me many different lessons. Firstly, never trust what anyone says (even yourself) about what can and cannot be done. Secondly, always have a plan B, and, hopefully, a plan C.

This was a patient that I had known for years. At the time he was 49 years old. He had had multiple attempts at a permanent dialysis access with each failing early after creation or within a few months to years. This was in spite of mapping and aggressive maturation procedures as well as active surveillance/monitoring. Part of the issue was non-compliance on his part, but, also, he seemed to stenose quickly and easily despite even stenting. He had accrued multiple medical conditions in his young life, including: coronary artery disease and peripheral vascular disease in addition to diabetes, obesity, and hypertension. He was poor surgical candidate for anything extremely invasive.

Interestingly, he had also developed SVC syndrome that was symptomatic (he had a swollen head). At the University, a CT of the chest showed the SVC occlusion. The local expert in central vein stenoses said "there was nothing to do".

I had seen him multiple times for access issues, but, for some reason, after his last graft had failed, he went to the local hospital where a surgeon placed the tesio catheters. Yes, there is a RIJ vein tesio with a cephalad venotomy site and a left SCV tesio. He was sent to me due to poor function of the tesios.

I was able to cut down to the RIJ vein tesio after an angiogram showed no blood flow to the right atrium. Using a 180-cm stiff straight Glidewire and guiding Berenstein catheter, I was able to pass the guidewire through the occlusion (after removing the internal portion of the tesio and cleaning the guidewire). Amazingly, the guidewire passed through the right heart and into the IVC. I, then, dilated the SVC with a 12mm Conquest catheter with 80-90% residual due to elasticity. So, I decided to stent the SVC. I deployed a 14mm by 4cm Luminexx stent, that although I allowed time for it to expand and with the occlusion in the middle of the stent, the stent traveled forward and dropped into the right atrium. Thankfully, the stent was still on the guidewire. Now, I was in a dilemma. I was in an outpatient center with a patient who would likely not survive open heart surgery. If the stent embolized, he would likely die as well. I could not grab the stent with anything. A 14mm by 4cm Atlas catheter passed right through the stent. Additionally, the IVC appeared to come off the right atrium somewhat anteriorly which kept the stent from passing out of the heart. The one image shows the stent in the right atrium, but it is somewhat faint. Finally (after trying multiple ideas), I was able to grab the stent with an 18mm by 4cm Atlas catheter and pass it through the right atrium and park it in the IVC. I performed an angiogram that showed successful placement in the IVC.

Now, I still had the occluded SVC. The blood flow was through the azygous system. Therefore, I deployed a second 14mm by 4cm Luminexx stent in basically the same fashion as the first one (but, making certain that it did not travel even the slightest). It was placed across the occlusion and seated with the 14mm by 4cm Atlas catheter. There was about 20% residual stenosis, but blood flowed into the right atrium.

To make matters worse, the surgeon had placed the RIJ vein tesio with a cephalad venotomy site as the RIJ vein was occluded at the clavicle. Therefore, I cannulated an 8mm by 4cm Vaccess catheter at the clavicle that been used to dilate the RIJ vein and right innominate veins using the 180-cm stiff straight Glidewire that was already in place. I used this new venotomy site to place a RIJ vein tunneled dialysis catheter. I collapsed the balloon around the micro-wire after inserting it into the balloon using the 21 gauge needle. I had cannulated the balloon with this needle using ultrasound guidance just cephalad to the clavicle. Remember, this patient was obese and had a short neck which made this cannulation difficult. The micro-wire and balloon were passed centrally giving me a venotomy site just cephalad to the clavicle to keep the catheter from kinking. With a nicely functioning RIJ vein tunneled dialysis catheter, I also removed the left SCV tesio.

Therefore, like I said. Never trust anyone, even yourself. Sometimes, we just need to try a case and find out if there is nothing left to do. And, always have a Plan B and a Plan C (if you can).