Difficult vascular access dr. salwa mahmoud elwasif

1. Difficult vascular access
By
Salwa Mahmoud Elwasif, MD
Fellow of internal medicine and nephrology
Mansoura urology and nephrology center

2. • A 6-year old boy.
• End-stage kidney disease.
• Right lumbar renal allotransplantation
• Donor : father
• Same blood group : O +ve

3. 8 years later,
• Graft failure 2ry to CAN
• Peritoneal dialysis

4. PERITONITIS
Exit-site infection

5. After 1 year of PD
• Temporary internal jugular venous catheter
• Creation of AV fistula
– Left brachiocephalic AV fistula ( closed before usage)
– Right brachiocephalic AV fistula. (For 5 years)
– right AV synthetic graft (for 1year)
– Left femoral A-V graft (for 2years)

6. So what?

7. Hereditary Thrombophilia Screen ( Repeated)
Protein C
Protein S
Homocysteine
Factor V Leiden
Antiphospholipid Ab.
Anticardiolipin Ab.
Normal
Intradialytic
Hypotension

8. Role of anticoagulations even with
normal thrombophelia screen?

10. Dialysis interventions
• Dialysate temperature modeling
• Isothermic dialysis
• Dialysate calcium modeling
• Dialysate sodium modeling
• Pharmacological interventions
– Midodrine
– Carnitine
– Sertraline

12. Our patient has an ESKD for RRT
• Transplantation?
• PD?
• HD. . . . . . Vascular access?

14. • Right subclavian arterio-arterial synthetic graft

15. 1 year more
Poorly functioning AV graft
• kt/v= ?
• Hyperkalemia
• Suction during session even with low pump rate

17. SO WHAT?
Any suggestions ?

19. IVC catheter

20. Budd-chiari syndrome
Enlarged liver with patchy perfusion of the right liver lobe.
Normal parenchymal enhancement of the left and caudate lobe
Patent Portal vein

22. Rest In Peace (R.I.P.)

23. What is missing?

24. The end
Thank you