#2923 Intracardiac vascular access as a last resort for hemodialysis in patients with exhausted traditional vascular access: a case report
Authors: Mejía Carlos Narváez , Fernández Florentino Villanego , Singh Arshdeep , Lopez Juan Manuel Cazorla , Martínez Tomas Daroca , Mozo Marta Alonso , Amaro José Manuel , Blanca María Auxiliadora Mazuecos 
Published: May 2024

Abstract

Introduction
The dysfunction of vascular access (VA) constitutes one of the main problems faced by nephrologists and patients in chronic hemodialysis (HD). This challenge becomes particularly worrying in patients who have depleted their upper extremity venous resources and have no longer arteriovenous fistula available, requiring the placement of a central venous catheters. It leads to an increase in morbidity and mortality and a higher of infections, thrombosis and exhaustion of access points. In such cases, alternatives to conventional VA are limited, with intracardiac access being an emerging option, albeit with very limited documented experience.

Case Report
We describe the case of a 68-year-old male with a history of hypertension, nasopharyngeal carcinoma in 2012 treated with chemotherapy and radiotherapy. In 2018 he was diagnosed with low-grade urothelial bladder carcinoma (PT1G1) that infiltrated the subepithelial corion while sparing the muscular layer. He also had severe hydronephrosis with impaired renal function, requiring radical cystoprostatectomy with Bricker bladder reconstruction and subsequent bilateral nephrostomy due to persistent dilatation and progressive deterioration of renal function. He began chronic HD in June 2020 through a left femoral catheter due to the inability to access the upper thoracic vascular tree due to stenosing fibrosis from previous radiotherapy.
He was placed on the waiting list for a kidney transplant (KT) in the right iliac fossa but experienced multiple catheter dysfunction episodes, requiring the placement of a right femoral venous catheter to continue with his HD sessions. Additionally, peritoneal dialysis was not considered due to previous urological surgery.
Considering the limitation of VA and the possibility of KT as its best alternative, we opted for the insertion of a tunnelled intracardiac catheter at the right atrium. This procedure was conducted by the Cardiac Surgery Department on 03/12/2021 through a median sternotomy in the 4th intercostal space. A permanent hemodialysis catheter was inserted in the right atrium through the 3rd intercostal space and fixed with a purse-string suture. It was then tunnelled under the breast to the 2nd intercostal space through a counter-incision. The cuff was appropriately placed in the subcutaneous tissue (Figs 1 and 2). The intervention proceeded without any complication and the catheter exhibited normal functionality. After that, the patient received anticoagulation with enoxaparin the days between dialysis sessions. Consequently, the right femoral catheter was safely removed.
Two weeks later, the patient successfully received a KT from a deceased donor. He was discharged on the day 11st post-KT with any complication and maintains a good renal function after 2 years of follow-up with a serum creatinine 1.7 mg/dL (eGFR: 39 ml/min). The intracardiac catheter was removed one month later through a mini-thoracotomy.

Conclusions
Intracardiac VA is an unusual and high-risk resource that seems an alternative in patients with exhausted VA with no alternative emergency renal replacement therapy, so it should be considered as the last resort. In the case of our patient, the implantation of this catheter allowed for the continuation of dialysis and access to KT.