Ringed Gore-Tex for haemodialysis access
Basil Agroyannis1,
Dimitrios Mourikis2,
Costas Fourtounas1,
Helen Tzanatos1,
Ioannis Kopelias1,
Achilles Chatzioannou2 and
Panagiotis Dimakakos3
1 Department of Nephrology
2 Interventional Radiology
3 Vascular Surgery
Aretaieon University Hospital, Athens,Greece
Sir,
In uraemic patients with ESRD, in whom peripheral veins have been exhausted or are inadequate for the creation of native A-V fistula, prosthetic grafts are used for arterio-venous anastomosis [13]. In this report we present a case with unusual central vein complications after recurrent catheterization, because two native and one with prosthetic graft fistula had been thrombosed. At present the patient is haemodialysed adequately from a left unilateral subclavian-jugular (A-V) anastomosis, by a ringed prosthetic graft.
Case: the patient is a 60-year-old woman with ESRD. She suffered from hypertension, atrial fibrillation and short bowel due to resection of a large part of the bowel after mesenteric embolism 1 year ago. A good radial cephalic fistula at the wrist was created in advance of need. This fistula was occluded after a small number of HD sessions. In the same side another native fistula was created, by the anastomosis of the median cubital vein and brachial artery. This fistula presented a serious haematoma and occlusion in the first 24 h. After these unsuccessful native fistula a prosthetic graft was placed in the same side between branchial artery and the proximal brachial vein in the axilla. This prosthetic graft was occluded after 1 month of adequate function. After evaluation of the vessels by colour Doppler ultrasound another prosthetic graft (ringed Gore-Tex) between the subclavian artery and jugular vein was placed in the left side (Figure 1
).
During 10 months, as problems with the AV fistula occurred in our patient, multiple catheterizations of central veins were required to continue HD. Recurrent cannulation was performed in the right jugular and subclavian vein and in both femoral veins, but not in the left subclavian and jugular which were preserved, anticipating the placement of a prosthetic graft. By the repeated cannulation of central veins, serious thrombosis and stenosis were developed. However, two events related to the catheterization procedure should be emphasized. First, a Permcath in the right jugular vein did not function well. The radiologists verified that the tip of the catheter had been entered in the inferior vena cava, resulting in catheter removal (Figure 2
). Secondly, we attempted to put a usual double-lumen catheter in the central veins, but this was impossible as the veins had developed stenosis and thrombosis. At this time we decided in cooperation with the radiologists to put two Super Arrow-Flex Sheath catheters in the stenotic left femoral vein (Figures 3 and 4
). By these catheters, HD was adequately performed for 50 days. During that time the above mentioned subclavian-jugular anastomosis was performed by a ringed prosthetic graft, the patient keeps on dialysing from for more than 10 months.

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Fig. 4. Two Super-Arrow Flex-Sheath catheters entered the inferior vena cava through the left femoral vein.
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Comment: central venous catheters are commonly placed in uraemic patients with ESRD who are either awaiting for creation or for maturation of the fistula [46]. The central vein catheter is associated with complications during the insertion procedure (pneumothorax, perforation of vessels wall etc.) and with later complications such as infection and stenosis, or thrombosis of the central vein [5]. It has also been reported that stenosis can be present after temporary access catheters have been removed.
Our patient showed two unusual events by the cannulation of central veins. First, the Permcath in the right jugular vein was advanced from the right atrium to the inferior vena cava. The blood flow was poor and the catheter was removed. This complication may be due the insertion of a full sized catheter, while the patient was rather small. Secondly, the patient developed unusual thrombosis and stenosis in the central veins and the usual double-lumen catheter could not be advanced into the veins. For this reason we decided, in cooperation with the radiologists, to insert in the stenotic left femoral vein two Super Arrow-Flex Sheath catheters, which are designed to successfully negotiate tortuous vessels. These catheters were advanced higher from the location of the stenosis and thrombus and HD was adequately performed for 50 days. This time period was sufficient for the creation and maturation of the subclavian-jugular (A-V) anastomosis by a ringed prosthetic graft in the left side by which the patient is haemodialysed over two months now.
The unusual and frequent thrombosis of central veins in our patient may be due to recurrent cannulation, to some infections and to short bowel syndrome which may cause apolipoprotein abnormalities. We decided that the last placed prosthetic graft between subclavian artery and jugular vein should be a ringed Gore-Tex, to avoid kinking and the risk of easy thrombosis. Our patient has been adequately haemodialysed by this prosthetic graft for more than 10 months without any disorders and bleeding by the puncture site.
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