Case presentation dr. ahmad ewedah dr. zaghloul gouda

1. By
Dr./ Ahmad Ewedah
Dr./ Zaghloul Gouda
Nephrology Department
Damanhour Medical National Institute
Case Presentation

2. 25 year old female patient, on MHD since 12 years
Vascular access history:
Insertion of one RT and one Lt temporaryIJC the start
of HD
Performing Lt AVF and maintenance HD for 5 years
Insertion of Lt Brachiocephalic AVG since 7 years
Case 1

3. Problem:
Progressive Lt upper limb oedema
High machine venous pressure during HD
session
Patient sought her vascular surgeon
>>> He suggested closing AVG
We referred patient to radiologist for suspected
central vein obstruction

4. Left Brachiocephalic AVG Antegrade Venous Puncture :
• Appearance and congestion of the Hemiazygos vein and venous
collaterals.
• Retrograde reflux of the dye in the Lt IJV.
• Tight stenosis at the confluence of the brachioCephalic vein.

5. Central venous angioplasty
Balloon angioplasty using 14 mm high pressure balloon

6. Very good result:
• Disappearance of the Hemiazygos vein and venous collaterals.
• Disappearance of the retrograde reflux of the dye in the Lt IJV.
Post central venous angioplasty

7. 63 years old male on long standing MHD with no vascular access
referred to us obligatory for CAPD with no HD for 10 days due to
no access.
Patient presented by DLC, severe metabolic acidosis and
impending pulmonary edema.
Exam:
- Failed multiple AVFs
- USS Doppler of central venous system:
Obstruction of both IJVs & both Ext Iliac veins.
Case 2

8. Plan
Lt retrograde femoral vein temporary
catheter
+
2 SLED sessions until referral to
interventional radiology.

12. 30 ml/min
Inform
1- You have reduced kidney
function and you may need
kidney replacement therapy
(KRT) to save your life.
2- Describe modalities of
KRT.
3- Spare forearm and upper
arm veins from injections.
Dorsum of hands is the
preferred site for injections
and cannulation. This will
save these veins for creation
of AVF.
20 ml/min …….
Create
This is the optimal time for creation of
AVF/
preparation for preemptive kidney
transplantation
Stage 4 Stage 3
(a,b)
Stage 5
Stage 1&2