Inferior epigastric artery injury after percutaneous imaging-guided peritoneal dialysis catheter placement.

Inferior epigastric artery (IEA) injury is a rare clinical entity that is usually associated with abdominal wall procedures and injuries though can also be spontaneous, particularly in individuals with coagulopathy. Of all described mechanisms of injury, percutaneous peritoneal dialysis (PD) catheter insertion is a rarely encountered, particularly in instances where insertion is performed under imaging guidance. While this injury is self-limited, it can be associated with hemodynamic instability and acute blood loss anemia, which can be fatal if left untreated. Computed tomographic (CT) angiography is the diagnostic method of choice. Transcatheter arterial embolization is an effective treatment modality with a high success rate. Here, we describe a 41-year-old female who underwent percutaneous PD catheter insertion that, despite intraprocedural imaging guidance, was complicated by large hemoperitoneum and clinical instability. Prompt identification of IEA injury followed by immediate intervention with coil embolization led to a successful outcome for this patient in the setting of a life-threatening uncommon complication of such procedure. The details of the diagnostic evaluation and management are outlined.

Loop arteriovenous graft of the chest wall as a viable option for dialysis.

The search for a reliable, complication-free vascular access is crucial among dialysis patients. The creation of a long-term access site for hemodialysis is dependent on several factors that mandate forming a life-plan for dialysis access, with upper extremity vascular access being the preferred route. However, complications including poor maturation, venous anastomosis lesions, and thrombosis are all associated with poor survival of these accesses. As a result, numerous patients within the dialysis population have exhausted access sites in the upper and lower extremities, requiring the search for other access options including chest wall arteriovenous graft (AVG). However, limited data is available about the outcomes of these chest wall grafts. Here, we describe two 62-year-old female dialysis patients who exhausted other dialysis access sites and subsequently underwent arteriovenous loop graft of the chest wall that connected the axillary artery with the ipsilateral axillary vein. These AVGs remained functional during the follow up period. This report highlights the viability of chest wall AVG access in the unique subset of hemodialysis patients who exhausted all other access sites.

Delayed diagnosis of a retained guidewire after bedside femoral venous catheter insertion: A preventable complication.

Central venous catheter (CVC) insertion is a commonly performed procedure that is used for continuous invasive hemodynamic monitoring, fluid resuscitation, drug therapy, and hemodialysis. CVC placement can be associated with serious complications that are mostly preventable. One of these complications is the loss of the guidewire within the intravascular space, which carries a high morbidity and mortality. Here, we describe a 44-year old patient who presented with acute kidney injury and metabolic derangements that necessitated bedside right femoral dialysis catheter to initiate emergent renal replacement therapy. A day after the catheter insertion, the guidewire was noted on a routine chest X-ray extending into the base of the skull. The clinical course was complicated with cerebral infarction. Subsequently, the retained guidewire was removed a few days after the CVC insertion. In summary, the retained guidewire within the circulation is associated with potentially life-threatening and hazardous outcomes. Continuing education, vigilant supervision, and implementing certain protocols are likely to prevent such undesirable events.

Endovascular Management of Thrombosed Dialysis Vascular Circuits.

A functional hemodialysis vascular access is the lifeline for patients with end-stage kidney disease and is considered a major determinant of survival and quality of life in this patient population. Hemodialysis therapy can be performed via arteriovenous fistulas, arteriovenous grafts, and central venous catheters (CVCs). Following dialysis vascular access creation, the interplay between several pathologic mechanisms can lead to vascular luminal obstruction due to neointimal hyperplasia with subsequent stenosis, stasis, and eventually access thrombosis. Restoration of the blood flow in the vascular access circuit via thrombectomy is crucial to avoid the use of CVCs and to prolong the life span of the vascular access conduits. The fundamental principles of thrombectomy center around removing the thrombus from the thrombosed access and treating the underlying culprit vascular stenosis. Several endovascular devices have been utilized to perform mechanical thrombectomy and have shown comparable outcomes. Standard angioplasty balloons remain the cornerstone for the treatment of stenotic vascular lesions. The utility of drug-coated balloons in dialysis vascular access remains unsettled due to conflicting results from randomized clinical trials. Stent grafts are used to treat resistant and recurrent stenotic lesions and to control extravasation from a ruptured vessel that is not controlled by conservative measures. Overall, endovascular thrombectomy is the preferred modality of treatment for the thrombosed dialysis vascular conduits.

Peritoneal Dialysis Catheter Placement: Percutaneous and Peritoneoscopic Techniques.

Chronic peritoneal dialysis (PD) is an underutilized renal replacement therapy in treating end-stage renal disease that has several advantages over hemodialysis. The success of continuous ambulatory PD is largely dependent on a functional long-term access to the peritoneal cavity. Several methods have been developed to place the PD catheter using both surgical and percutaneous techniques. The purpose of this article is to describe the percutaneous techniques using fluoroscopy guidance and peritoneoscope method. While fluoroscopic method uses fluoroscopy guidance and a guidewire to place the PD catheter, the peritoneoscopic technique utilizes a needlescope to directly visualize the peritoneal space to avoid adhesions and omentum during catheter placement. These percutaneous approaches are minimally invasive procedures that can be performed on an outpatient basis without the need for general anesthesia.

Endovascular embolization for managing a massive shoulder arteriovenous malformation.

Arteriovenous malformations (AVMs) are congenital high flow pathologic linkages between arteries and veins of different sizes that may occur in any part of the body. The clinical presentation is largely dependent on the size and location of AVMs and can range from an asymptomatic birthmark to congestive heart failure in extreme cases. In this report, we describe a 20-year-old male who presented with a large AVM of the right shoulder that resulted in significant cosmetic and physical impairment and treated with several sessions of endovascular embolization with good clinical outcomes. This case highlights the complexity of diagnosing and managing these AVMs. Most of these anomalies require a multi-disciplinary approach that integrates both trans-catheter and surgical interventions with trans-arterial lesion embolization being the cornerstone of the treatment.

Transhepatic Tunneled Catheter Using Left Hepatic Vein: The Last Resort for Dialysis.

Vascular access is the Achilles tendon of hemodialysis and is considered the lifeline for patients with end stage renal disease. Arteriovenous fistulas and grafts are the preferred traditional access for performing dialysis therapy. However, some patients exhaust the traditional routes of dialysis vascular access for different reasons. In search for alternatives, other unusual vascular routes have been explored, such as transhepatic and translumbar approaches, as the last resort to preserve life in this unfortunate population. Here, we present the unusual case of a 66-year-old female who ran out of the traditional vascular access options and became catheter dependent via the right femoral vein. However, due to recurrent femoral catheter infections, extensive skin calciphylactic lesions and her body habitus, other routes were explored and the decision was to use the transhepatic approach. Traditionally, the right and middle hepatic veins are used to insert these catheters. However, the use of the left hepatic vein was not reported in the literature. Hence, in order to avoid the skin lesions seen in our patient, the dialysis catheter was inserted using the left hepatic vein. Overall, this case highlights the challenges of securing a reliable vascular access to perform dialysis therapy and brings attention to other vascular dialysis routes in certain clinical scenarios.