This document describes the medical history of a patient with difficult vascular access for dialysis over many years. The patient underwent multiple failed attempts to create arteriovenous fistulas and grafts in both arms for dialysis access. Eventually a subclavian arterio-arterial graft was placed, but the patient later developed Budd-Chiari syndrome and passed away.

1. Difficult vascular access
By
Salwa Mahmoud Elwasif, MD

2. • A 6-year old boy.
• 8th Sept., 1990
• Right lumbar renal allotransplantation
• Donor : father

3. 13th Oct. , 1998
• Graft failure 2ry to CAN
• Peritoneal dialysis

4. PERITONITIS
Exit-site infection

5. One year later,
• Temporary internal jugular venous catheter
• Creation of AV fistula
– Left brachiocephalic AV fistula ( closed before usage)
– Right brachiocephalic AV fistula. (1999 -2004)
– right AV synthetic graft (2004-2005)
– Left femoral A-V fistula (2005-2007)

6. Thrombophilia screen ( repeated)
Protein C
Protein S
Homocysteine
Factor V Leiden
Antiphospholipid Ab.
Anticardiolipin Ab.
Normal
Intradialytic
Hypotension

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

10. Feb. 2007
• Right subclavian arterio-arterial synthetic graft

11. Oct. 2008
• kt/v= 0.9
• Hyperkalemia
• Suction during session even with low pump
rate

12. October 2008

13. IVC catheter

16. 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

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