Back to ePosters

OBJECTIVES:
One of the most challenging patient populations in dialysis access are the ones with superior vena cava occlusion due to previous catheters and/or central venous interventions. Fortunately, patients can frequently collateralize adequately to prevent the need for intervention. Occasionally, such as in these 2 patients, collateralization is not enough.
METHODS:
The first patient is a 33-year old female with renal failure attributed to mixed connective tissue disorder. She had multiple failed bilateral upper extremity access attempts along with 2 failed kidney transplants. She was currently receiving dialysis via a left brachial-axillary AVG, whose patency was maintained through the azygos system. She presented October 2013 with a catastrophic upper GI bleed. Her endoscopic findings were consistent with downhill esophageal varices.
The second patient is a 53-year old male with renal failure attributed to hypertension. He had bilateral lower extremity DVTs, multiple failed bilateral upper extremity access attempts, 2 failed kidney transplants, and 2 failed attempts at peritoneal dialysis. He was receiving dialysis via a left radial-cephalic AVF when there was a sudden deterioration in volume flows. On fistulogram, he was found to have acute thrombosis of his superior vena cava. Subsequent angiojet thrombectomy was complicated by chest pains and desaturation.
RESULTS:
The first patient underwent an echocardiogram, followed by left axillary vein to atrial appendage bypass. She recovered well, with dramatic resolution of the varices on subsequent endoscopy. She is now 11 months out of surgery with a widely patent bypass.
The second patient underwent percutaneous recanalization of the right iliac vein to allow thrombectomy with angioplasty and stenting of the SVC under AngioVAC protection. He is now six months out of surgery being dialyzed through the fistula.
CONCLUSIONS:
Intrathoracic pathology in dialysis access can be challenging even for the most seasoned vascular surgeon. Both percutaneous and open approaches have limited longevity and pose unique hazards. Based on this, the best approach is sometimes non-operative. In the included 2 patients, however, intervention was necessary. One was treated by an infrequently described atrial appendage. The other was treated by the first described use of AngioVAC in an AV fistula in the literature.