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A 71-year-old woman in dialysis for 16 years due to hypertensive nephrosclerosis, initially undergoing peritoneal dialysis, had to been transitioned to hemodialysis in 2018 due to fungal peritonitis. Hospitalized in 2020 with COVID-19 at Hospital das Clínicas da UFMG, she lacked an arteriovenous fistula due to severe peripheral vasculopathy. A transhepatic catheter was implanted to sustain dialysis. Transferred to our hemodialysis service in 2021, she presented severe vascular access failure and was ineligible for renal transplant due to pelvic vessel thrombosis, maintaining the transhepatic catheter for dialysis. Over two years, the transhepatic catheter progressively malfunctioned with signs of venous obstruction, necessitating an increase in dialysis sessions to four times a week, even after catheter replacement. As a saving measure, "click clack" hemodialysis was performed. In collaboration with the vascular surgery team, considering the patient's worsening clinical condition, a decision was made to create an arterioarterial fistula using a polytetrafluoroethylene prosthesis in the right subclavian artery. To mature the fistula over two weeks, a short-term catheter was implanted in the left popliteal artery, using it for venous flow while maintaining the transhepatic catheter for arterial flow during dialysis sessions. Fistula puncture was performed without complications, preserving the access for hemodialysis and avoiding medication addministration through it to prevent complications from improper handling.
Chart analysis of a patient from the Hemodialysis Center at Hospital das Clínicas da UFMG in Minas Gerais.
The patient completed three months of using the fistula without complications, associated with clinical improvement and better control of urea level and hyperkalemia. One week after fistula use, the short-term catheter in the left popliteal artery was removed, while the transhepatic catheter was mantained for medication administration during dialysis sessions.
This case represents challenges in managing vascular complications associated with dialysis therapy and highlights the complexity of clinical decision-making in adverse conditions. The decision to create an arterioarterial fistula with a polytetrafluoroethylene prosthesis, after careful risk-benefit assessment, proved to be an effective approach to overcome vascular complications as a last choice therapy. This study emphasizes the importance of interdisciplinary collaboration among nephrologists, vascular surgeons, and nursing professionals in making complex decisions to optimize dialysis treatment in challenging clinical situations. While each case is unique, the approach taken in this specific situation provides valuable insights for addressing similar issues in patients with adverse vascular conditions.