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| Journal of Vascular Access 2002; 3: 138 - 139 |
| Vasculorama |
G. Dunea1
1Cook County Hospital, Chicago, Illinois, USA
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ABSTRACT
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Hand amputation after vascular access placement
Symptoms of vascular steal or ischemia are common with upper extremity fistulae but only rarely progress to hand amputation. Yet this was the case in three patients, whose unfavorable outcome emphasizes the need for taking the utmost care. It is accordingly important to assess the circulation preoperatively with ultrasound, to minimize multiple surgeries on the same extremity, and to exercise caution when excising a graft. In some cases one may need to visualize the entire circulation by an aortic arch study in order to assess the level of the blockage. Surgeons should also remember that complications are more frequent in patients with generalized vascular disease, in diabetics, and in patients who develop symptoms soon after the fistula is created (Am J Nephrol 21: 498).
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Vascular access results worse in diabetics
The outcome of vascular access surgery in diabetics is much worse than in other patients. Their vessels are frequently arteriosclerotic and inadequate, making fistulae more difficult to establish. Infections are also more frequent, especially with tunneled catheters, being reported in one large French series in 33% of diabetics vs 16% of non-diabetics (Kidney Int 62: 329, Nephron 91: 399).
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Uncertain value of mupirocin ointment
Nasal carriage of staphylococci, a risk factor for bacteremia when tunneled catheters are used, can be eliminated in over 90% of patients by local treatment with mupirocin ointment. It is not clear, however, whether such treatment improves the long term outcome. Nor is it known whether applying the ointment promotes staphylococcal resistance to other antibiotics (Nephron 91: 399).
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Possible ototoxicity from catheter lock gentamicin
The instillation of concentrated citrate-antibiotic solution into the catheter lumen between dialyses may help prevent infections and prolong catheter life. Gentamicin, however, must be used with caution. Excessive blood levels and transient dizziness and vertigo have been reported, and there is danger of serious ototoxicity, especially after repeated use. A reduced gentamicin dose or a different antibiotic may prove safer (J Am Soc Nephrol 13: 2133 and 2195).
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Retrieving the broken dialysis catheter
During a guide wire exchange of a clotted internal jugular catheter, the patient suddenly moved, causing the proximal section of the cut catheter to disappear from the surface and lodge itself into the right internal jugular vein. It was retrieved by means of two gooseneck snares inserted by the transcutaneous femoral route, allowing the catheter fragment to be pulled out through the superior and the interior vena cava, the right iliac and right femoral vein (Nephrol Dial Transplant 17: 1126).
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Questionable value of thrombolytic agents
When hemodialysis catheters allow only poor flow or no blood flow, it has become common practice to instill a thrombolytic agent such as alteplase in order to clear the catheter. But a recent Irish study throws doubt on the long term outcome and cost effectiveness of this procedure. Thrombolysis allowed only an average of 5-7 extra dialyses and an additional survival of only 10-18 days before another instillation became necessary or the catheter had to be changed (Am J Kidney Dis 39: 86).
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Percutaneous ligation of accessory fistula veins
When arteriovenous fistulae fail to develop it may be helpful to ligate the accessory veins present near the fistula. Such ligation can be done percutaneously, after a fistulogram, by identifying the vein at fluoroscopy and using a curved needle to place around it a non-absorbable propylene suture at a point marked on the skin (Am J Kidney Dis 39: 824).
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Desperate remedies for desperate situations
An ingenious life-saving approach to the patient with occluded central veins and an obliterated peritoneal cavity is to insert a double lumen catheter by a parasternal approach. This is done under general anesthesia by dissecting in the infraclavicular area, resecting part of the second rib cartilage, dissecting through the intercostals space, ligating the internal thoracic vessels, pushing aside the pleura, phrenic nerve, and ascending aorta, and inserting a catheter into the exposed superior vena cava. A subcutaneous tunnel for the catheter is made on the anterior thoracic wall (Nephrol Dial Transplant 17: 134).
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Surgeons please read this!
Access surgery is not a simple procedure that can be delegated to inexperienced surgical beginners. There is no place for compromise, and even minor errors should not be tolerated. Such errors include choosing the wrong vessels, making the wrong incision, failing to make a correct anastamosis, and handling the vein incorrectly. Grafts should be avoided whenever possible but inserted correctly if so needed, and the skin should be closed atraumatically (Nephrol Dial Transplant 17: 376).
George Dunea, M.D. FRCP, FACP
Associate Editor
Reprint requests to:
Cook County Hospital
1825 West Harrion Street
Chicago, Illinois 60612, USA
e-mail: geodunea@aol.com
REFERENCES
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G. Dunea
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