**1. Introduction**

The depletion of vascular accesses for haemodialysis is seen in some patients who reach this situation due to multiple causes [1, 2] such as procoagulant factors, lack of good management of their accesses, lack of resources, etc.

In these cases, the skills of the surgical team to respond must be technically sharpened.

When a patient is without vascular access and cannot dialyze, it is an extreme situation.

It is understood that a patient does not have vascular access when not even a catheter can be implanted to be able to dialyze.

That is, there is occlusion or inability to progress a catheter through the following veins:


#### **1.1 Options for implanting a catheter in these conditions**

Where do wrong decisions bring bad results? The following options are the most common ones for implanting a permanent catheter. In some cases, this catheter can be connected to a prosthesis to make a fistula.

There are not many options to do this; some of the possible options are listed below:

a.Translumbarpuncture of the inferior vena cava [3, 4]

b.Direct puncture of the superior vena cava [5]

c.Transliver puncture [6],

d.Sternotomy or thoracotomy for direct access to the right atrium.

All of these options are not the subject of this chapter.
