**8. References**


(Yap et al 2010). In exceptional lack of options, transrenal access into the renal vein with

Hemodialysis central venous catheters CVCs are commonly used in patients with renal failure requiring dialysis once other vascular options have been exhausted. Long-term catheters should be inserted using the Seldinger technique with a dilator and hemostasis valve under ultrasound guidance and fluoroscopic screening. Tunneled catheters with cuffs may be used both temporarily and permanently. The subcutaneous tunnel and cuff ensure stabilization of their position and limiting the migration of microorganisms on its external surface hence reducing the risk of infections. Finally, it must be emphasized that a well-functioning arteriovenous fistula is the best vascular access inducing the lowest number of complications.

Part of the work described in this paper was supported by the L & T Charitable Foundation

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Betjes M, Van Agteren M: Prevention of dialysis catheter-related sepsis with a citratetaurolidine-containing lock solution. *Nephrol Dial Transplant* 2004;19:1546-1551. Bleyer AJ, Mason L, Russell G, Raad II, Sherertz RJ: A randomized, controlled trial of a new

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Faintuch S, Salazar GM: Malfunction of dialysis catheter: management of fibrin sheath and

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Fuchs S, Pollack A, Gilon D: Central venous catheter mechanical irritation of the right atrial free wall: a cause of thrombus formation. *Cardiology* 1999; 91: 169-172. Goldberg JP, Contiguglia SR, Mishell JL, Klein MH: Intravenous streptokinase for thrombolysis of occluded arteriovenous access. *Arch Intern Med* 1985; 145: 1405-1408.

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consequent insertion of a tunneled catheter has been attempted (Murthy et al 2002).

**6. Conclusion** 

**7. Acknowledgement** 

& the House of INDOCAFE

**8. References** 


**8** 

*Japan* 

Masaki Fujioka

**Complex Wounds in Patients** 

*National Hospital Organization Nagasaki Medical Center* 

*Department of Plastic and Reconstructive Surgery, Clinical Research Center* 

Patients receiving hemodialysis (HD) often have complex chronic wounds, which are hard to heal because of complications of other diseases, including DM, calciphylaxis, collagen disease, arteriosclerosis obliterans, chronic anemia, and weakness of the skin (Figures 1-3)1-3). Subsequent infection of necrotic skin tissue is associated with the risk of sepsis, which may

Fig. 1. (A) A 54-year-old woman was referred from an emergency unit for complex necrotic ulcer of the right hand with high fever. She had systemic lupus erythematosus and had been treated with 20 mg/ day of prednisolone for 40 years. She had received hemodialysis because of lupus nephritis for 34 years through a blood access shunt in the right elbow, which also showed inflammation. Debridement of the right hand was immediately

**1. Introduction** 

performed.

be fatal if the blood access shunts become infected 4).

**Receiving Hemodialysis** 

