This hospital in Shanghai repairs the "lifeline" of dialysis for her. For uremic patients, years of dialysis have caused vascular stenosis and thrombosis. Dialysis | catheterization | blood vessels
Pain is a real problem that maintenance hemodialysis patients fear to face, but cannot avoid, especially during the maintenance process of the dialysis pathway. Therefore, how to truly benefit this special group of patients with comfortable medical care is an important clinical issue that every kidney disease doctor is considering.
Recently, the Department of Nephrology at the Fourth People's Hospital of Shanghai, affiliated with Tongji University, successfully treated a maintenance hemodialysis patient with "narrow dialysis vascular access accompanied by thrombosis". Through interdisciplinary cooperation with the Department of Anesthesiology and Perioperative Medicine, the patient truly felt the good medical experience brought by "comfortable" medical treatment.
It is understood that Aunt Liu, 56 years old from Chuzhou, Anhui, underwent a semi permanent right jugular vein hemodialysis catheter insertion surgery 6 years ago due to end-stage renal disease, and began regular hemodialysis. Four years ago, she underwent an autologous arteriovenous fistula in her left upper arm and used the fistula for hemodialysis treatment. The dialysis catheter was not removed and kept as a backup pathway. Later, due to stenosis of the brachiocephalic vein in her left upper limb, she developed severe tumor like dilation and thrombosis. She underwent multiple vascular incisions and thrombectomy, as well as artificial vascular bypass surgery.
Since June this year, the pressure of Aunt Liu's internal fistula has significantly increased. After each dialysis, it is necessary to compress and stop bleeding for more than 1 hour, and the puncture site has been in severe pain for a long time. In order to reduce pain and discomfort, and reduce the number of punctures, Aunt Liu requested the use of a left upper arm fistula for arterial end blood drainage, and the use of a catheter venous end as a blood circuit, resulting in a "four different" dialysis process.
After admission, Chen Shunjie, the director of the Department of Nephrology at Shanghai Fourth Hospital, carefully evaluated Aunt Liu's condition and, with the cooperation of the imaging team, completed a three-dimensional CTV reconstruction examination of the left upper limb vein. Chen Shunjie proposed that Aunt Liu's vascular lesions are relatively complex, and the surgical treatment can be divided into two stages. The first stage surgery involves vascular restriction remodeling and thrombus clearance, while the second stage surgery involves digital subtraction angiography with balloon dilation of the left upper limb head vein and removal of a semi permanent dialysis catheter. After the surgery, an internal fistula can be used regularly for maintenance hemodialysis.
Having experienced multiple painful surgeries, Aunt Liu is very sensitive and fearful of pain. Yang Ming deduced various surgical plans before the surgery and conducted in-depth discussions and research with the Department of Anesthesiology and Perioperative Medicine. Finally, with the full cooperation of the anesthesia team led by Professor Xiong Lize, the Dean of Shanghai Fourth Hospital, a first phase surgery was performed for the patient. The surgery took about 2 hours and was successfully completed. On the second day after surgery, Aunt Liu underwent routine hemodialysis using an arteriovenous fistula. After getting off the machine, she underwent routine compression hemostasis without the need to extend the compression time, and the puncture pain was significantly improved.
The second phase surgery was successfully completed by Yang Ming with the full cooperation of the medical technology team in the DSA room. By using balloons of different diameters, Aunt Liu's narrowed blood vessels were dilated, and the failed semi permanent dialysis catheter was removed, allowing Aunt Liu to return to a "normal" dialysis life.
Chen Shunjie introduced that hemodialysis is currently the main renal replacement therapy for dialysis patients, and the prerequisite for hemodialysis is to have a dialysis pathway, which is called the "lifeline" of dialysis patients. Long term hemodialysis pathways mainly include autologous arteriovenous fistulas, semi permanent dialysis catheters, and artificial blood vessels. At present, autologous arteriovenous fistula has become the preferred blood dialysis pathway in clinical practice due to its advantages of easy care, no foreign body implantation, relatively simple surgery, and low cost.
"Establishing an autologous arteriovenous fistula is not a one-time solution and requires regular maintenance," Chen Shunjie said. Factors such as repeated vascular puncture, inappropriate fistula care, repeated hypotension, and thrombosis can all lead to complications such as stenosis and occlusion of the fistula blood vessels, tumor like dilation, pseudoaneurysm formation, and fistula infection, which can affect the effectiveness of dialysis treatment.
Chen Shunjie said that with the development of endovascular technology, minimally invasive intervention therapy provides a new technical guarantee and support for the maintenance of dialysis access. However, due to the risk of recurrent vascular stenosis or thrombosis in patients after endovascular intervention treatment for narrowed blood vessels, it is recommended that patients undergo an evaluation of the fistula vessel every 3-6 months, and if necessary, perform balloon dilation surgery for the narrowed vessel again.
