Abstract
Dear Editor,
Vascular access is vital in patients with end-stage renal disease (ESRD) undergoing long-term hemodialysis. Several unlucky patients with thrombophilia often require multiple operations, and options for other access procedures become increasingly limited. Basilic vein transposition (BVT) offers vascular access in such difficult cases and is increasingly preferred over prosthetic grafts and central vein cannulation for decreasing the morbidity and costs of dialysis patients as highlighted in the KDIGO guidelines (1-3).
A 62-year-old woman was admitted with a diagnosis of chronic renal failure secondary to membranous glomerulonephritis. Her medical history was characterized by hypertension and right breast cancer treated by mastectomy without sign of recurrence on follow-up. She progressed to ESRD and regular thrice-weekly hemodialysis was started in July 2009 through a tunneled central venous catheter (CVC) in the right internal jugular vein. Two months later, a radiocephalic arteriovenous fistula over the left arm was created but suddenly thrombosed. Subsequently three attempts of arteriovenous fistula failed again. Then thrombophilia secondary to factor V Leiden mutation was discovered, and warfarin therapy was started. A polytetrafluoroethylene vascular graft was therefore inserted between the basilic vein and brachial artery on the left forearm, under strict surveillance to reduce the incidence of other complications; however, the graft thrombosed after 2 years (Tab. I summarizes vascular access operations). A tunneled CVC was then implanted in the left jugular vein. Three months later she was admitted to the hospital for severe catheter-related bloodstream infection due to Staphylococcus aureus treated with vancomycin and catheter removal. When blood culture became sterile, a temporary CVC was placed in the left femoral vein. A venography was performed without signs of critical stenosis, then using the patient's own vessel a BVT was tailored on the left arm as rescue procedure (discontinuing warfarin and starting on unfractionated heparin 2 days prior to the intervention). After the beginning of hemodialysis treatment an ischemic steal syndrome developed especially during dialysis session, manifested by cold hand, numbness, pain and swelling, then the use of BVT paused. The patient was scheduled for banding with partial improvement in the symptoms. The hand swelling with pain persisted and, suspecting a central venous stenosis, a new phlebography was performed showing steno-occlusion of the left truncus anonymous; collateral veins were also visible on clinical examination and patency of BVT (Fig. 1). One month later BVT was successfully used for hemodialysis.
On physical exam prominent collateral veins are along the anterior chest wall and axilla (A). The same finding detected by angiography (B).
Patient vascular access history
CVC = central venous catheter; PTFE = polytetrafluoroethylene; CRBSI = Catheter-related bloodstream infection.
An adequate pre-operative evaluation with physical examination, duplex ultrasonography and angiography are the keystones to avoid complications in the difficult access patients. Although angiographic study performed before surgery showed no critical central vein stenosis, in our patient thrombosis of ipsilateral left truncus anonymous was completely unexpected. However, the development of collateral circuits visible on physical and angiographic examinations has led us to a successful salvage of BVT. This latter has been used in the presence of a slight hand swelling.
Our case demonstrates that in thrombophilic patients, previous central venous cannulations and systemic inflammatory status especially in the infectious setting may additionally increase the risk of thrombosis despite the patient undergoing anticoagulant therapy. This awareness may improve patency rates and may decrease the incidence of central vein thrombosis in difficult vascular access patients.
Footnotes
Financial support: None.
Conflict of interest: None.