A 26-year-old woman with CRE secondary to extracapilary proliferative glomerulonephritis type I. Active smoker, hypertensive although not currently requiring pharmacological treatment.
You have skin Darier's disease.
He received 14 sessions of plasmapheresis after his diagnosis in 2006.
She subsequently abandoned the follow-up visits and finally came to the emergency room 3 years later in a situation of terminal uremia starting dialysis.
The patient gave express consent for the presentation of the case.
History of vascular access
• Several unsuccessful attempts at arteriovenous fistula (AVF), all of them: left atrial fibrillation (LVEF) in 01 01, right hemi-cefá radio-09fá-11, left atrial fibrillation - 03,
A vascular map was made in which no veins suitable in the upper limbs were evidenced.
• Permanent right jugular venous catheter implanted on January 14, 2009 and removed on November 5, 2009 due to tricuspid endocarditis secondary to MARS.
• Several temporary catheters in both femoral veins removed due to thrombosis or dysfunction.
• Permanent left jugular catheter placed on 11/16/09 and removed on 06/21/10 due to thrombosis of the left jugular vein.
• Permanent right femoral catheter placed on 06/21/10 and removed 4 days later due to persistent dysfunction.
• After this, an endovascular study was performed showing complete occlusion of the left iliac vein and inferior vena cava, which prevented the femoral access.
With regard to the upper trunks, the situation is no better because there is occlusion of subclavian veins, right jugular vein, left brachiocephalic trunk and superior vena cava.
A permanent catheter was placed through a transhepatic approach through the right suprahepatic vein, with end in the right atrium9.
It was changed on 03/07/2012 due to dysfunction.
Since then, she has suffered from continuous infections that have required antibiotic treatment almost continuously.
• Spontaneous extrusion occurred in 12/2012 using a provisional left femoral catheter.
• A new study of venous trunks occlusion of the iliac vein with flow deviation from the hypogastric branch to the common iliac artery was performed, so it is not subsidiary to a permanent dialysis catheter for this access.
The right common femoral vein was found permeable but no Doppler flow was detected in the iliac vein, probably due to thrombosis.
Phlebography of both arms was performed, showing flow through intercostal collaterals up to bilateral azygos-hemiacigos due to occlusion of the subclavian veins.
Placement of a catheter by subclavian was ruled out.
Doppler ultrasound of both jugular veins was performed visualizing the left jugular vein permeable although it is very likely central stenosis of the left brachiocephalic trunk due to visible phlebography of this limb and the chronic venous occlusion.
• On January 17, 2013, a new transhepatic catheter was implanted and replaced on March 20, 2013 due to dysfunction.
This is their current and probably the only possible access.
In addition to all these problems, the enormous amount of nursing support received in their survival is due to the marked change in the patients health, as it does not hinder family support and is totally discouraged, and most times leads to rejection
It should be noted that the patient refuses to start any type of anticoagulant treatment (it has been proposed to take sintrom® on many occasions).
On the other hand, their inclusion in the transplant list was ruled out, as they did not attend the repeated appointments, self-exclusion by nurses and doctors as well as peritoneal dialysis proposals, given their refusal to comply with the guidelines
Figures 1 and 2 show the patient's current access: the transhepatic catheter.
1.
Nursing care
In each session, patients are informed about the care they should have to take to maximum care of their VA, with special emphasis on the importance of maintaining the dressing dryness and heat, and especially on reporting fever to the nursing staff about any incidence.
The entire nursing team meets the healing protocols of the catheter exit orifice, connection and disconnection according to the criteria accepted in our dialysis unit:
• The cure of the catheter exit orifice (OSC) is performed aseptically with 20% sodium chloride, 2% alcohol chlorhexidine and sterile gauze, observing the erythematous deposit, etc. early detection of the wound.
• The seal of the catheter branches is performed with Taurolock® and luer lock caps.
Since the last change of the transheptic catheter in the first weekly dialysis session, 50,000 IU/IU of Urokinase was sealed as intra-class fibrinolytic therapy according to the protocol of our unit.
The proper functioning of the catheter in each hemodialysis session is evaluated achieving adequate blood flows above 300 ml/min and Kt above 45 L.
Figure 3 shows the data obtained from dialysis sessions since January 2013.
