Hello all,

This is a case that I think comes up often in ESRD patients due to peripheral vascular disease that can be seen in the dialysis patient population:

65 y/o AAF with ESRD, IDDM, and chronic hypotension presents to ER at outside hospital with septic shock and is transferred to admitting facility for ICU admission. Prior to her presentation to the ER, she had missed HD treatment x2 since she was not feeling well and thought she had a viral infection. She became confused and was taken to ER by family.  She had BP 69/50, HR 110, T 100.3F, RR 26, sO290% on 100% non-rebreather FM. She is noted to have discharge from the exit site of a tunneled dialysis catheter in the right femoral area. Tunneled catheter was removed in ER, not sure by who since notes from outside facility are unclear. She is given Vancomycin, Zosyn, and started on Levophed for BP support. She currently has a working AVG in the left thigh. History on the working left thigh AVG is that it was placed in May 2016, complicated infection with abscess requiring I&D about 1 week later. She was seen by vascular surgery on 10/5/2016 and AVG was healed and cleared for use. She has had multiple previous AVG with multiple procedures for maintenance and has suspected bilateral central venous stenosis due to presence of lower extremity dialysis access. Patient admitted to ICU, central line placement attempts by MICU team failed and LUE IO line is placed for use of pressors. Nephrology consulted for dialysis support due to severe lactic acidosis and ESRD so patient receives treatment via left thigh AVG with SLED on the night of admission.

Patient is without adequate IV access and only has LUE IO (on night of admission TLC was attempted at bedside by MICU resident but they were unable to thread guidewire and after several attempts procedure aborted. Surgery consulted to obtain subclavian central line but failed as well). The following day, a TLC was then placed by Interventional Nephrologist in Right groin in the afternoon. TLC appeared to be placed ok, however upon testing only the brown port was functioning. MICU team was weary of the line so it was removed and Interventional Radiology was consulted and patient taken to IR suite for line placement that night. Per IR procedure note, they were identified the right common femoral vein. A well-organized echogenic thrombus was seen in it. A Tortuous right inferior epigastric venous collateral was also visualized. Multiple attempts to pass a micropuncture wire after cannulation of the RCF vein with 20g needle was unsuccessful due to the thrombus. Right inferior epigastric collateral was also accessed under US guidance and contrast injected which confirmed occlusion of the right pelvic veins and due to the marked tortuosity of the inferior epigastric collateral, a line could not be placed and patient was returned to MICU with LUE IO in place. Repeat attempt by Interventional Nephrology was done the following morning. A 0.035 Glidewire was passed through the old tunnel of right femoral vein tunneled catheter that was recently removed. It was confirmed on fluoroscopy to advance to IVC. A Hickman catheter was then passed into the IVC and it was tested and flushed easily after tip was confirmed with fluoroscopy. Patient was then returned to ICU with a working Hickman line for pressors, however due to patient having a poor prognosis her family decided to withdraw care and she subsequently expired.

Questions:

1.       Does the presence of a tunneled catheter and possible fibrin sheath make her infection more resistant to treatment with antibiotics.

2.       It was suggested by other services that a central line be placed through the AVG for use since multiple attempts at central line placement failed. Are you for or against this idea and what are the major concerns that factor in the decision of placing a line though the dialysis access?

3.       Glidewire was able to pass successfully into the IVC via the old venotomy and tunnel. Do you feel passing the guidewire though an infected tunnel to obtain the central line should be avoided considering her infection issues?

I have attached pictures of IR angiogram that was done via inferior epigastric vein collateral. Picture of Hickman catheter in IVC, and a picture of the IVC angiogram done via Hickman catheter (unfortunately the last 2 images for some reason did not have great contrast when copied).

Have a great one!

Peter Van, MD

AC is an ambulatory, well appearing 53yom with a history of HTN, CAD, CHF w EF < 10%, left subclavian pacemaker, T2DM, and ESRD on HD referred to the access center for a clotted left upper arm graft.  Pt access was placed 2 months prior.  Pt had a history of multiple failed accesses and has had numerous IJ permcaths in the past.  The thrombectomy was successful with return of a good bruit and thrill to the access on physical examination following the procedure.  2mg of TPA and 5000 units of heparin were administered during the procedure.  However, post imaging revealed the presence of residual clot on the left subclavian pacer leads.  The clot was not present on initial imaging of the central veins.  The clot remained despite attempts to remove it with a fogarty and with balloon maceration.  The patient was not on anticoagulation at the time of the procedure.  The patient denied any history of recent GI bleeding.  Although, more extensive review of his medical history done later revealed the presence of a LGIB in the remote past (2010-2012).  The LGIB had been managed conservatively due to his numerous other co-morbid conditions.  The patient was treated with eliquis with plans to bing him back in two weeks for an angiogram to assess whether the clot had resolved, reduced in size, or was unchanged.

Questions:

1.  Should this patient be managed in an outpatient setting given his numerous co-morbidities?

2.  Should he be challenged with anticoagulants given his prior history of GIB in the past?

3.  What precautions, if any can be taken to prevent or treat residual clot formation in patients with low flow states?

4.  A stent graft was not considered because of the pacer leads, but should it be, is there a role?

Images:

Image 1: Scout film

Images 2 & 3:  Post thrombectomy images

First Outflow Failure, Patient History

Second Outflow Failure

Questions: 

Would like to invite all to participate in an online survey to Assess Physical Restrictions in Adult ESRD Patients on Hemodialysis. The survey is being conducted by Dr. Deepa Chand and myself.

https://www.surveymonkey.com/r/DAQA 

I suspect most of us try to avoid placing stents in the central venous system ,  but unfortunately sometimes those situations do arise. Factors such as covered vs bare metal (horrible instent restenosis but at least permit flow from neighboring veins), capacity of radial force to help hold a lesion open, stents that lengthen/forshorten, etc.

Tthoughts on our current available products/technologies to tackle these tough cases?

https://sites.google.com/site/abigailsarticles/october-2016-articles

Enjoy the articles for this month !!!!

Abigail

Dear Colleagues,

I want to run this interesting case by all the experts to get their insights:

A 62 year old male using a right IJ tunneled catheter for dialysis presented for a dysfunctional catheter. A preoperative examination showed good flow from both ports. However, considering the long duration of the catheter, a cathetergram was done after retracting the tip high in the neck. It showed a fibrin sheath, as expected. It was angioplastied and free flow of contrast was demonstrated. Catheter was replaced but had a 'catch' to suction of either port. Repeat cathetergram (Figure 1) suggested either a remnant of fibrin sheath or brachiocephalic vein stenosis which was angioplastied (Figure 2). The catch persisted but was intermittent. Patient left without dialysis.

At this point, I have the following questions:

Q1. What does the figure 1 show- left over sheath vs. brachiocephalic stenosis?

Q2. Does anyone have a different technique to ensure that the sheath is completely disrupted?

Q3. In either case, the tip of  the catheter was in lower right atrium. Why was there resistance to suction?

The patient returned 4 days later as the catheter was again found to be 'positional' in dialysis. Repeat cathetergram (figure 3) showed a well formed sheath again (in 4 days!). This was angioplastied and catheter was replaced, but the 'catch' was again evident. The patient was convinced to get an AVG placed the next week and was sent to dialysis where it was able to be done, with only occasional alarm.

Q4. What else can be done to diagnose the issue?

Q5. Is the time to reformation of sheath proportional to the dwelling time of catheter?

Q6. Would use of antiplatelet of anticoagulant help reduce growth of sheath at all?

A week later, the patient returned for similar issues. A new IJ catheter was placed on the left side. Patient is scheduled to get an AVG placed.