A 53-year-old male patient, diagnosed in 1986 with stage V chronic renal failure of unknown etiology (probable lead poisoning), in hemodialysis program through arteriovenous fistula, who presented recurrent episodes of access pain.
Other relevant background.
- Nephrological history:
Kidney transplantation from cadaveric donor in March 1988, functioning until November 1997 with graft loss due to chronic rejection.
Second renal transplant from cadaveric donor in August 2002 with chronic graft dysfunction returning to hemodialysis program in 2006.
Third renal transplant in June 2014 with renal infarction in July 2014, renal artery stenosis in August 2014 requiring angioplasty.
To study for probable thrombotic microangiopathy.
Nephrogenic anemia.
Secondary hyperparathyroidism.
- Digestive history:
Chronic liver disease secondary to HCV.
Cholestatic fibrosing hepatitis in January 2007.
A functioning liver transplant in June 2014 required angioplasty for stenosis of the hepatic artery.
Grade II reflux esophagitis.
Antral erosive gastritis
- Other history:
Radiocef Arteriovenous Fistula in the left upper limb functions
Old tuberculosis.
Recurrent gout episodes
Pain occurred after more than half of the session and was described as a stabbing and burning sensation with VAS intensity of 9/10, located in the puncture areas and irradiated throughout the shoulder, with refractory analgesia.
No relationship was found with arterial hypotension, pump speed and venous pressure mismatch, cannulation problems or accidental needle movement.
On physical examination of the fistula, a vein of lax and tortuse characteristic was observed, with a tendency to collapse.
There were no signs of phlebitis or absence of murmur and thrill throughout the course.
I am well perfused, with radial and ulnar pulses present.
The blood flow of the fistula, measured using the thermodilution technique, was 1200ml/min, with a 3% clearance.
After multiple ineffective manipulations to guide the needle, the hemodialysis session was completed and, for the next hemodialysis sessions, a pre-puncture ultrasound assessment was proposed to choose the points.
However, due to the continuity of pain episodes, she was referred to vascular surgery for fistulographic examination due to possible stenosis of the access.
The study showed adequate permeability without observing stenosis in the path of the cefa and basilic vein from the elbow, as well as the axillary and subclavian veins.
In addition, multiple zones of dilation of the ceftazidime to the elbow were observed.
No alterations in radiocefá anastomosis were reported.
Finally, ultrasound monitoring of the access during the pain episode was chosen.
It was evidenced that the distal part of the arterial needle was inserted pressing the vessel wall (Imagen 1), possibly due to a movement of the fistula arm.
1.
Image 1.
Position Income
1.
Ultrasound guided needle placement was performed in order to place it in the vein lumen.
With a 35o inclination (Imagen 2) it was observed that the needle tip was still pulling the wall.
1.
Image 2.
Redirection 35o
1.
He required fixation and fixation of 45o to observe the needle in the lumen of the vein (Imagen 3), when the pain ceases instantaneously (Eva 0/10).
1.
Image 3.
Redirection 45o
