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| Journal of Vascular Access 2005; 6: 1 - 2 |
| Vasculorama |
G. Dunea1
1Cook County Hospital, Chicago, Illinois, USA
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 G. Dunea
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ABSTRACT
None
Excellent access survival with daily dialysis
Two recent studies suggest that the more frequent needle punctures of daily dialysis do not result in premature vascular access failure. During a period of six years of nightly home dialysis in Virginia, survival time was 190 months for fistulae and 20 months for grafts. Mean dialysis catheter life was 8.5 months and some catheters remained functional for 66.7 months. In Turin, Italy, the probability of daily dialysis patients remaining free from access related adverse effects was 80% at six months and 89% at twelve months, with overall results better in men than women. The Italian authors stressed the importance of having skilled operators, and also pointed out that vascular access surgery is done by nephrologists in Italy and to some extent in France, but by vascular surgeons in North America. (Hemodial Internat 8: 349; Nephrol Dial Transplant 19: 2084).
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Neurological complications from wrist fistulae
Following difficult venous cannulations during several dialysis sessions, two patients presented with motor and sensory signs of median nerve injury. Both patients had swellings over patent brachial arteriovenous fistulae caused by hematoma and pseudoaneurysm formation. They had partial neurological recovery following evacuation of the hematomas and ligation of the fistulae (Nephrol Dial Transplant 19: 1923).
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Digital ischemia from wrist fistula
A renal transplant recipient suddenly had a painful left index finger that on examination was cold and livid and had several splinter hemorrhages. Investigation by arteriography showed an aneurysm of the left radial artery at the anastamosis site of a non-functional arteriovenous fistula; and it appears that he had suffered a shower of emboli from this aneurysm. (Nephrol Dial Transplant 19: 1656).
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Femoral vein cannulation as cause of pulmonary thromboembolism
One day after femoral vein cannulation for emergency dialysis, an elderly Chinese patient suddenly developed acute swelling and tenderness of her right calf, followed a day later by an asthma-like episode due to several pulmonary emboli. Further investigations showed that the patient had underlying hemostatic abnormalities consisting of deficiencies of antithrombin III, proteins C and S, as well as a circulating lupus anticoagulant. It appears that these changes, in combination with immobilization by restraints, were responsible for a complication that occurs but rarely within such a short time after cannulation (Clin Nephrol 62: 162).
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Femoral vein stenosis after prolonged femoral vein catheter insertion
Another complication of femoral vein cannulation is stenosis of the femoral and iliac veins, according to a study at the University of Wroclaw, Poland. The stenoses, found by magnetic resonance imaging, occurred only in patients in whom no other vascular access sites were available and who had been dialyzed through indwelling femoral catheters for over four weeks (Nephrol Dial Transplant 19: 1618).
Occult stenosis at the insertion of internal jugular dialysis catheters
A high incidence of venous stenosis (42%) was found in an English study in which venography was done in consecutive 69 patients undergoing percutaneous placement of tunneled right internal jugular vein catheters for emergency dialysis. These stenosis, clearly attributable to vascular trauma, were more frequent in patients who had undergone previous cannulations. Though asymptomatic at the time of the study, they clearly set the stage for future complications such as central vein occlusion, thus emphasizing the need for early fistula placement and avoidance of catheter dialysis (Nephrol Dial Transplant 19: 1542).
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Catheter related Lemierre syndrome
Septic thrombophlebitis as a rare complication of venous catheterization may affect the internal jugular vein, causing fever, pain in the throat and neck; sometimes a neck mass, dysphagia, or Horner’s syndrome, even carotid rupture or pulmonary emboli. The clinical features resemble those described in 1936 by Dr Andre Lemierre in patients with septic thrombophlebitis complicating oropharyngeal infections. Often caused by Fusobacterium necrophorum, an organism difficult to grow in culture, this is a potentially fatal complication that requires prompt diagnosis and treatment (Hemodial Internat 8: 400).
Infection from surgical implants
Compared to dialysis catheter-related infections, infections of surgical implants are even more difficult to treat, hence the eventual abandonment of most dialysis devices such a buttons for access to the circulation or to the peritoneal cavity. Infections of prosthetic heart valves, aortic grafts, orthopedic devices, ventricular shunts, and also mammary and penile implants, have considerable clinical and economic consequences. They generally follow the formation on the surface of the implant of a biofilm composed of fibrinogen, fibronectin, and collagen. Antibiotic treatment is often ineffective and the infected device usually needs to be removed. Detailed guidelines for individual devices, including recommendations for appropriate antibiotic and surgical management, can be found in an excellent review published earlier last year (N Engl J Med 350: 1423).
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Principles of antibiotic therapy
The above-mentioned review includes recommendations to avoid using vancomycin for methicillin-susceptible staphylococci; provide empirical coverage against such organisms pending the identification of the microbiologic cause; include rifampin in regimens for staphylococcal infection (rifampin helps penetrate biofilms); and use appropriate coverage during implant replacement or when an implant needs to be placed in an infected area (ibid).
George Dunea, MD FRCP, FACP
Associate Editor
Address for correspondence:
Cook County Hospital
1825 West Harrion Street
Chicago, Illinois 60612 - USA
geodunea@aol.com
REFERENCES
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