|Year : 2021 | Volume
| Issue : 5 | Page : 90-92
Running out of vascular access in chronic kidney disease patients - A case report on translumbar dialysis catheter
Nishant Agrawal1, Yadav Waghaji Munde2, Jignesh Navinchandra Shah1, Prajakta Sunil Lanjewar1, Sunil Jawale3
1 Department of Critical Care Medicine, Bharati Vidyapeeth (DTU) Medical College and Hospital, Pune, Maharashtra, India
2 Department of Interventional Radiology, Bharati Vidyapeeth (DTU) Medical College and Hospital, Pune, Maharashtra, India
3 Department of Nephrology, Bharati Vidyapeeth (DTU) Medical College and Hospital, Pune, Maharashtra, India
|Date of Submission||29-Dec-2020|
|Date of Decision||03-May-2021|
|Date of Acceptance||04-May-2021|
|Date of Web Publication||30-Aug-2021|
Yadav Waghaji Munde
Department of Radiology, Bharati Vidyapeeth (DTU) Medical College and Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Vascular access is the key in patients with end-stage renal disease requiring hemodialysis. After some years, failure of conventional access is a major cause of morbidity and mortality in patients on chronic hemodialysis. Translumbar tunneled dialysis catheter may be a salvage option in such cases for long-term hemodialysis, thereby improving survival and acting as a bridge for renal transplantation.
Keywords: End-stage renal disease, hemodialysis, renal transplantation, translumbar dialysis catheter, vascular access
|How to cite this article:|
Agrawal N, Munde YW, Shah JN, Lanjewar PS, Jawale S. Running out of vascular access in chronic kidney disease patients - A case report on translumbar dialysis catheter. Indian J Vasc Endovasc Surg 2021;8, Suppl S1:90-2
|How to cite this URL:|
Agrawal N, Munde YW, Shah JN, Lanjewar PS, Jawale S. Running out of vascular access in chronic kidney disease patients - A case report on translumbar dialysis catheter. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Dec 1];8, Suppl S1:90-2. Available from: https://www.indjvascsurg.org/text.asp?2021/8/5/90/324942
| Introduction|| |
Translumbar dialysis catheter (TLDC) was first described by Lund et al. in 1995. It offers a much safe and effective access for dialysis in both adults and children and is considered as a potential choice for those patients with lack of conventional venous routes., Maintenance of vascular access is very challenging in patients undergoing dialysis who have worn out their traditional vascular access such as arteriovenous (A-V) fistula, A-V graft, and central venous catheter (CVC) or have had contraindications for peritoneal dialysis. Extensive surgeries of CVC such as interposition of prosthetic graft material to bypass the occlusions are associated with significant morbidity.,
Herein, we report one such interesting case which had exhausted all the conventional vascular access, thereby necessitating the use of alternative access such as TLDC insertion.
| Case Report|| |
A 38-year-old female was admitted in the hospital with a history of breathlessness and bilateral pitting pedal edema for the past 1 week.
She was a known hypertensive for the past 4 years on regular treatment with oral antihypertensives. She was also a known case of chronic kidney disease on maintenance hemodialysis twice weekly. She initially used to get dialyzed with hemodialysis catheter that was inserted in the left internal jugular vein (IJV) and was later changed to right IJV due to inadequate blood flow. Six months back, an A-V fistula was created on the left arm. She had fixed flexion deformity of the right elbow due to trauma to her right elbow joint 5 years back. Hence, A-V fistula was not attempted in the right upper limb.
She was recently admitted in the outside hospital in view of left upper limb cellulitis, and hence, dialysis was carried out by the catheter that was newly inserted in the right femoral vein during her period of admission.
Following discharge, she did not get herself dialyzed and presented to us with signs of volume overload. She also had fever with chills and rigors during her last dialysis.
On arrival to intensive care unit, she was conscious and obeying, hemodynamically stable, and not requiring any vasopressor support. She was febrile, tachycardic, and had a respiratory rate of 20 cycles per minute and maintaining oxygen saturation of 96% with 5 L of oxygen per minute via face mask. Left upper limb swelling was noted, and she had right femoral dialysis catheter in situ. Right femoral vein was already cannulated when she presented to us and left was not cannulated as she complained of severe pain at the injection site, probably due to multiple attempts made outside to cannulate it. Arterial blood gas analysis done was suggestive of high anion gap metabolic acidosis; chest X-ray revealed bilateral diffuse shadows suggestive of pulmonary edema. Baseline electrocardiogram revealed low voltage complexes with poor R wave progression. Ultrasound thorax screening showed bilateral multiple B lines, and screening echocardiography showed hypokinesia of distal septum with ejection fraction of 45%, no right atrial and right ventricular dilation, and no pericardial effusion.
All routine laboratories including blood culture and sensitivity were sent, and she was started on injection meropenem. Right femoral dialysis catheter was removed. Nephrology consultation was taken, and she was advised urgent dialysis, and hence, temporary right IJV hemodialysis catheter was inserted for the same.
Plastic surgery reference was also taken for left upper limb cellulitis and was advised wound debridement and A-V fistula closure at later date. Meanwhile, vacuum dressing was applied daily. Right external jugular vein dialysis catheter was secured due to inadequate flow from prior catheter which in turn got blocked. A check venogram was done which showed occlusion of bilateral proximal IJVs, but this was not recorded.
A TLDC was hence inserted finally and dialysis was continued. Peritoneal dialysis was not a feasible alternative in this case due to multiple underlying issues and poor social background and thereby limiting options to hemodialysis with catheter in inferior vena cava (IVC). Follow-up could not be done in this case as the patient succumbed due to septic shock and multiorgan dysfunction syndrome, but she had few sessions of uneventful dialysis before her death.
TLDC insertion was done under fluoroscopic guidance in an angiographic suite under local anesthesia. Coagulation profile and platelet count were checked before carrying out this procedure. Written informed consent was taken for the same and baseline vitals were noted. This procedure was carried out by an interventional radiologist. The patient was put in prone position; the skin was prepared and draped.
IVC is punctured using ultrasonography and fluoroscopic guidance together. IVC was punctured 10 cm above iliac crest and 10 cm right of midline. Aiming for L2/L3 level, 18G × 15 cm DTN (diamond tip needle) was advanced 45° cephaloid and medial toward IVC under fluoroscopy. Blood was aspirated to confirm entry into IVC. Contrast was injected to confirm IVC entry, and then 0.035” stiff terumo ( Terumo Corporation, Japan) wire was passed through needle into IVC as shown in [Figure 1]). Then, the Terumo wire was exchanged with 0.035” Amplatz Ultra Stiff wire (Cook Medical, USA). The tract was then dilated with serial dilators. Long subcutaneous tunnel was made with exit on the lateral side, and Meditech maxima chronic dual lumen catheter of size 14.5 F × 36 cm was put via peel-away sheath with its tip in right atrium. Heplock of 2500 IU was given on both venous and arterial side of dialysis catheter.
|Figure 1: (a) Lumbar inferior vena cava punctured by 18 G × 20 cm diamond tip needle (Cook Medical Incorporation, USA) and 0.035” stiff Terumo wire through it (Terumo Corporation, Japan). (b) Tip of catheter (Meditech maxima chronic dual lumen catheter 14.5 F × 36 cm, India) in right atrium. (c) Shaft of catheter via inferior vena cava. (d) Extravascular part of catheter in intramuscular (for 5–6 cm from inferior vena cava entry) and subcutaneous plane|
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Catheter was then sutured with 2-0 ethilon and on achieving hemostasis by manual compression; adhesive dressings were applied. There was good flow noted via both ports of catheter. The procedure was well tolerated by patient with no perioperative complications.
| Discussion|| |
Translumbar catheter is an acceptable alternative for those patients who have been on dialysis for a long period in whom conventional vascular access to make an A-V fistula or to implant a catheter might fail, especially those patients with peripheral vascular disease, multiple comorbidities, and multiple previous attempts.
Few studies discourage the use of TLDC because of its low patency. Catheter patency at 3, 6, and 12 months as per Liu et al. was observed to be 43%, 25%, and 7% whereas as per Moura et al. was 91%, 75%, and 45%, and possible reason for better results by Moura et al. was apt catheter positioning during the procedure and scrupulous discernment and correction of kinks and misplacements. The reported translumbar catheter patency at 12 months ranges from 17% to 73.2%.
TLDC is anticipated to have much towering complications, exchanges, including the removals. The most familiar reported complication of TLDC was catheter-related infection and thrombosis., Lund et al. defined translumbar catheter failure as blood flow rate less than 200 ml/min. Low-dose (1 mg/ml) one-time alteplase was effectual in restoring catheter function in 72%–82.1% of nonfunctional catheters.
Another most common complication in a patient undergoing hemodialysis is 5–10 folds increased risk of bacteremia because of long-term indwelling catheter. However, TLDC exchange or removal is performed only in case of serious infection or recurrence of infection which is unresponsive to antimicrobial therapy as it is the last resort of vascular access unlike CVC which are removed if the patient has fever for more than 48 h despite antibiotic therapy.
Another leading cause of catheter failure in case of translumbar catheter is catheter dislodgment because of excess adipose tissue being concentrated at the tunnel area.
All these data cumulatively suggest that translumbar catheter can be used as a bridge to a new permanent or much effective vascular access in those patients with exhausted access sites for dialysis.
| Conclusion|| |
The percutaneous placement of subcutaneous tunneled double-lumen hemodialysis catheter directly into IVC is considered to be relative safe and most practical last choice for vascular access and should be used as a bridge to renal transplantation, especially for those patients who are not on the transplant list due to poor sociocultural condition.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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