Use of an intra-aortic Tesio catheter as vascular access for haemodialysis

Massimo Punzi1,, Francesco Ferro1, Fernando Petrosino2, Paolo Masiello3, Vincenzo Villari4, Vincenzo Sica4 and Giuseppe Cavaliere1

1 Department of Nephrology and Dialysis, 2 Department of Vascular Surgery, 3 Department of Cardiac Surgery and 4 Department of Interventional Radiology, Azienda Ospedaliera S. Giovanni di Dio e Ruggi D'Aragona, Salerno, Italy

Keywords: haemodialysis; Tesio catheter; vascular access



   Introduction
 Top
 Introduction
 Case
 Discussion
 References
 
Haemodialysis (HD) access-related problems account for ~25% of nephrologic hospitalizations [1]. When vascular accesses are exhausted, peritoneal dialysis (CAPD) or permanent central venous catheters (pCVC) are valid alternatives. On the other hand, recurrent peritonitis can irreversibly complicate the use of peritoneum [2], and infections and venous thrombosis the use of pCVC [3,4].

We describe the case of a 59-year-old diabetic woman who started on intermittent HD in March 1998. Recurrent central venous catheterization led to an extensive thrombosis of the superior and inferior vena cava. After starting CAPD she suffered from frequent peritonitis episodes with multiple adherences resulting in an exhausted peritoneum. As a last life-saving option a 70 cm long Tesio catheter (MCTC 1070 K-A Medcomp.) was placed in the aorta through the right femoral artery. Seven months later the patient is still successfully treated as an outpatient without any complication.



   Case
 Top
 Introduction
 Case
 Discussion
 References
 
A 59-year-old diabetic female patient started intermittent HD treatment in March 1998 through femoral vein catheterization.

A distal right arteriovenous fistula (AVF) was first created but failed 15 days later. Due to a left subclavian artery stenosis, a right proximal AVF was constructed but clotted only 24 h later. After negative blood checking for coagulation problems (Aca, LAC, AT III, protein C, protein S) a right upper limb phlebography was performed, showing a right subclavian vein stenosis that was treated with a wall-stent placement.

Subsequently, a right transposed basilic vein-brachial artery AVF was created but failed to work. Again, a right cephalic vein-brachial artery AVF, bridged by a PTFE graft, remained unsuccessful.

A Tenckhoff catheter was then placed and temporary HD was allowed by a left internal jugular vein Tesio catheter. After 1 month (June 1998), CAPD was started and the Tesio catheter removed. The treatment was uncomplicated until November 1999 when the patient developed facial and neck swelling. A new phlebography showed extensive thrombosis of the superior vena cava circle (Figure 1Go).



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Fig. 1.  Superior vena cava phlebography showing extended thrombosis of the superior vena cava circle with multiple collateral veins in the thoracic region.

 
In January 2001, following a recurrent peritonitis due to Staphylococcus epidermidis, the Tenckhoff catheter was replaced and a low volume automated peritonal dialysis (APD) treatment started; despite antibiotic therapy the infection did not clear and the Tenckhoff catheter had to be definitively removed. A 70 cm long Tesio catheter was temporarily placed in the right femoral vein and, in the meantime, after wall stenting of the left iliac vein axis, a left thigh AVF with a ProCol® (mesenteric bovine vein) prosthesis was performed. The AVF graft thrombosed 20 days later and consequently the temporary Tesio catheter was replaced by a permanent 45 cm long double lumen cuffed Mahurkar (Quinton).

In August 2001, a reduction in blood flow during HD led to a phlebography that showed extensive thrombosis of the inferior vena cava (Figure 2Go). Attempts to place another Tenckhoff failed because of extensive peritoneal adherences. HD was than ensured by temporary puncture of the femoral and pedidia arteries but with difficult venous return because of an exhausted venous circulation. Consequently, HD performance was largely inadequate and the patient developed congestive cardiac failure, pleural and pericardial effusions, dyspnea, acidosis, atrial fibrillation and hypotension.



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Fig. 2.  Inferior vena cava phlebography showing extensive thrombosis of the inferior vena cava.

 
At the end of August 2001, because of the need of a life-saving procedure, a 70 cm long Tesio catheter was positioned under fluoroscopic examination in the abdominal aorta after surgical exposure of the right femoral artery, using the Seldinger technique. The Tesio catheter was then fixed in the femoral artery using a prolene 5/0 purse string suture and superficialized to the skin through a 15 cm long subcutaneous tunnel; continuous heparin solution infusion was administered through the catheter and no oral anticoagulation started.Go



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Fig. 3.  Angiography after 6 months through the aortic Tesio catheter: no thrombotic complications and no stenosis of aorta or right femoral-iliac artery axis were observed. A thrombosis of the external left iliac artery, caused by repeated arterial puncture to allow HD before Tesio catheter implantation, is visualized.

 
Ten days later the patient was able to resume her family life. She was subsequently treated three times a week with single needle, double pump HD (inflow and outflow through the same lumen). Angiography through the Tesio catheter was performed 2 and 6 months after catheter implantation and showed no abnormal features (Figure 3Go). Seven months after the positioning, the catheter is still working without major complications.



   Discussion
 Top
 Introduction
 Case
 Discussion
 References
 
The increased survival of HD patients may require alternative vascular accesses when the usual vascular options are exhausted. Giorgelli et al. [5] reported that in 0.4% (4/1037) of AVF operations it was impossible to obtain a vascular access in the upper limbs. A common alternative is peritoneal dialysis or pCVC, although a high incidence of infectious and thrombotic complications has been reported [6,7]. Alternative vascular accesses have been proposed for such critical situations. Lund et al. [8] reported a percutaneous translumbar approach for long-term HD catheter implantation, with a cumulative patency of 52% at 6 months and 17% at 12 months, and a high incidence of complications. Others proposed a right-atrial by-pass grafting with a large diameter PTFE tube in patients with central venous obstruction [9]. Some studies reported the placement of an intra-cardiac catheter (ICC) with different approaches, but not always with satisfactory results [10,11]. Chavanon et al. [12] described the repositioning of an ICC catheter for three times in the same patient due to infection, malfunctioning and rupture, whereas Archundia et al. [11] described a similar patient, who survived for 12 months without any complication. In our case, the patient's critical condition did not allow an ICC placement because of the high surgical risk. The treatment option we took was carried out under local anaesthesia and required a short operating time. There was no surgical complication except for a suboptimal blood flow rate, which spontaneously improved after three HD sessions. It was possible to use the Tesio catheter 24 h after the implantation. Oral anticoagulation (INR 2,5-3) prevented the catheter from clotting.

In conclusion, when usual vascular access possibilities are exhausted and no alternative dialysis method is feasible, the positioning of an intra-aortic catheter can be a low risk, life-saving procedure, particularly for patients who are waiting for a renal transplant.



   Notes
 
Correspondence and offprint requests to: Dr Massimo Punzi, Department of Nephrology and Dialysis, Azienda Ospedaliera San Giovanni di Dio e Ruggi D'Aragona, Via S. Leonardo, I-84131 Salerno, Italy. Email punzi.m{at}tiscalinet.it Back



   References
 Top
 Introduction
 Case
 Discussion
 References
 

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Received for publication: 19. 5.02
Accepted in revised form: 21.11.02





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