Abstract: FR-PO647
Physical Examination of the Hemodialysis Vascular Access: An Unforgettable Tool
Session Information
- Trainee Case Reports - IV
October 26, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 704 Dialysis: Vascular Access
Authors
- Albert messiah dhas, Jessita singh natasha, Geisinger Medical Center, Danville, Pennsylvania, United States
- George, Jason Christopher, Geisinger Medical Center, Danville, Pennsylvania, United States
- Bonebrake, Steven R., Geisinger, Danville, Pennsylvania, United States
- Nadal, Luis L., Geisinger Health System, Danville, Pennsylvania, United States
- Bucaloiu, Ion D., Geisinger Medical Center, Danville, Pennsylvania, United States
Introduction
Hemodialysis (HD) access failure is an important cause of morbidity and mortality in HD patients. We present a case of false-negative fistulography in an end stage renal disease patient presenting with life-threatening hyperkalemia.
Case Description
A 66-year-old man on chronic HD for 5 years via right brachiocephalic fistula presented with one day of profound weakness. There were no missed HD sessions and no major dietary indiscretions by history. Initial labs showed serum potassium of 8.7 mmol/L (non-hemolyzed), serum bicarbonate 23 mmol/L, glucose 98 mg/dL. EKG showed widened QRS complex and he promptly received intravenous calcium gluconate and insulin. On physical exam his fistula was well-developed and had a harsh, pulsatile bruit. He underwent an emergent, 4-hour HD session with 2K dialysate, blood flow of 400 mL/minute, and dialysate flow of 800 mL/min. Labs 4 hours after HD showed serum potassium 6.1 mmol/L. Reflux fistulography showed no stenosis at the anastamotic segment. Given recurrent hyperkalemia despite an additional 3.5 hours of HD the following day, the case was reviewed with Interventional Radiology and variable contrast densities were noted along different fistula segments. Repeat fistulography via retrograde access was obtained, during which a wire and catheter were advanced across the anastomosis, placing the catheter retrograde in the brachial artery prior to infusing contrast. A hemodynamically significant anastomotic and juxta-anastomotic narrowing was identified and successfully treated with angioplasty. Back pressure generated by reflux angiography masked the stenoses that were apparent when retrograde approach was utilized. After another 4-hour HD session, the patient’s hyperkalemia resolved.
Discussion
Thorough assessment of the HD vascular access includes both physical and radiological data. Retrograde arterial catheterization and angiography in a dialysis access circuit provides better physiologic imaging when stenosis is suspected at the anastomosis and/or juxta-anastomotic segment. This case illustrates the importance of correlating clinical and physical examination data with subtle angiographic findings and raises awareness among nephrologists of potential pitfalls in the diagnosis and management of HD access failure with important patient safety implications.