**1. Introduction**

314 Chronic Kidney Disease

Lee, W. J., U. Patel, et al. (1994). Emergency percutaneous nephrostomy: results and

Lewis, S. and U. Patel (2004). Major complications after percutaneous nephrostomy-lessons

M Tan, P. u., PS Jaywantraj, D Wong (2010). Colonic Perforation during Percutaneous Nephrolithotomy Treated Conservatively. *J HK Coll Radiol.* 12(3): 117-121. Mariappan, P., G. Smith, et al. (2006). One week of ciprofloxacin before percutaneous

McDermott, V. G., M. G. Schuster, et al. (1997). Antibiotic prophylaxis in vascular and

Moskowitz, G. W., W. J. Lee, et al. (1989). Diagnosis and management of complications of

Mostafa, S. A., S. Abbaszadeh, et al. (2008). Percutaneous nephrostomy for treatment of

Ozden, E., O. Yaman, et al. (2002). Sonography Guided Percutaneous Nephrostomy: Success

Ramchandani, P., J. F. Cardella, et al. (2003). Quality improvement guidelines for percutaneous nephrostomy. *J Vasc Interv Radiol* 14(9 Pt 2): S277-281. Stables, D. P. (1982). Percutaneous nephrostomy: techniques, indications, and results. *Urol* 

Stables, D. P., N. J. Ginsberg, et al. (1978). Percutaneous nephrostomy: a series and review of

Tuttle, D. N., B. M. Yeh, et al. (2005). Risk of injury to adjacent organs with lower-pole

Wah, T. M., M. J. Weston, et al. (2004). Percutaneous nephrostomy insertion: outcome data

and multiplanar reformatted CT. *J Vasc Interv Radiol* 16(11): 1489-1492. von der Recke, P., M. B. Nielsen, et al. (1994). Complications of ultrasound-guided

nephrostomy. A 5-year experience. *Acta Radiol* 35(5): 452-454.

fluoroscopically guided percutaneous nephrostomy: evaluation with prone, supine,

from a prospective multi-operator study at a UK training centre. *Clin Radiol* 59(3):

Rates According to the Grade of the Hydronephrosis. *Journal of Ankara Medical* 

nephrolithotomy significantly reduces upper tract infection and urosepsis: a

complications. *J Vasc Interv Radiol* 5(1): 135-139.

from a department audit. *Clin Radiol* 59(2): 171-179.

prospective controlled study. *BJU Int* 98(5): 1075-1079.

posttransplant ureteral obstructions. *Urol J* 5(2): 79-83.

the literature. *AJR Am J Roentgenol* 130(1): 75-82.

*School* 24(2): 69-72.

255-261.

*Clin North Am* 9(1): 15-29.

interventional radiology. *AJR Am J Roentgenol* 169(1): 31-38.

percutaneous nephrolithotomy. *Crit Rev Diagn Imaging* 29(1): 1-12.

For many years, the arteriovenous (AV) fistula has been demonstrated to be the best vascular access for patients requiring chronical hemodialysis therapy.

The morbidity and mortality statistics for patients with AV fistula is significantly lower compared to patients with central venous catheters (1). However, many patients are found in which performing an arteriovenous fistula or implanting an AV graft is not a possibility. For these patients the usual protocol is the use of an indwelling catheter for chronic hemodialysis therapy practice.

The appearance of patients incompatible with AV fistula is due to the repetitive venous punctures in classical blood vessels, performed in the intensive care unit or for patients with chronic renal failure. These patients develop venous fibrosis making subsequent cannulations impossible.

The use of central venous catheters for initial hemodialysis therapy is also a common practice, this situation is repeated in all countries so that in the United States 60% of incident patients and 17 to 30% of prevalent patients depend on it as the only vascular access catheter despite the recommendation of the K/DOQI guides (Kidney Disease Outcomes Quality Initiative). (2)

In the year 2010, 100% of incident hemodialysis patients in our renal unit were treated with a central venous catheter. This reflects a late referral of doctors to the nephrology clinic, preventing the early practice of AV fistula.

In the same year 259 central venous catheters were implanted in our Renal Unit, 34% of them were transient in acute renal failure patients, 56% transient in patients with chronic renal failure and 10% tunneled catheters. Additionally our statistics showed that at the end of the year 2010 tunneled catheters represented 25% of vascular accesses and that in 94% of the patients using these catheters, arteriovenous fistula or AV graft implant were impossible, thus constituting the catheter tunneled the only access for the practice of chronical hemodialysis.

Traditionally, the most used vascular access is the internal jugular venous, but it can fail due to permanent thrombosis or agenesis. In these situations the usage of even more unusual

Unusual Vascular Access for Hemodialysis Therapies 317

Fig. 2. Edema in left arm by subclavian vein stenosis and brachiocephalic fistula.

this case the superior vena cava (Figure 3).

Fig. 3. Cava superior syndrome.

the implantation of catheters in the **axillary vein**. (3)

complications due to the bacterial flora that lives in this area. (4)

Catheters in the internal jugular vein kept for prolonged periods can also cause stenosis, in

For patients in which the implantation of catheters in the internal jugular vein is not possible, and those in which puncturing this vein or the subclavian vein would not be convenient (for example patients with tracheostomy), an alternative not commonly used is

This vein extends from the clavicle to the axilla (figure 4). The segment in the axillary fossa has been used for decades by pediatric surgeons especially in children with extended burns in whom this is the only preserved area. Unfortunately there are severe infectious

routes is necessary. Routine practice of procedures through these routes can make them much more available; the purpose of this article is to familiarize physicians with these routes and the correct techniques for accomplishing safe alternative vascular accesses.
