Vascular access for hemodialysis

Hemodijaliza je postupak izvantjelesnog odstranjivanja tvari koje se nakupljaju u organizmu zbog privremenog ili trajnog gubitka ekskretorne funkcije bubrega. U pacijenata koji imaju indikaciju za započinjanje liječenja hemodijalizom, mogući krvožilni pristupi su: arteriovenska fistula, arteriovenski graft te trajni ili privremeni centralni venski kateter. Krvožilni bi pristup, idealno, za učinkovitu hemodijalizu trebao osigurati dostatan protok krvi za isporuku adekvatne doze hemodijalize te imati dug vijek korištenja uz nisku učestalost komplikacija. Unatoč relativno visokoj incidenciji primarnog izostanka funkcije, arteriovenska fistula predstavlja krvožilni pristup izbora jer je udružena s najduljim preživljenjem pristupa i bolesnika, nižim morbiditetom i mortalitetom bolesnika, najmanjom učestalosti komplikacija te najnižim troškovima liječenja. Arteriovenski graft predstavlja krvožilni pristup izbora u bolesnika kod kojih nije moguće kreirati arteriovensku fistulu. Centralni venski kateteri koriste se za brzu uspostavu adekvatnog krvožilnog pristupa kad je indicirana hitna hemodijaliza, za vrijeme sazrijevanja arteriovenske fistule i u pacijenata kojima su iscrpljeni svi ostali krvožilni pristupi. Najbolje preživljenje imaju bolesnici koji se dijaliziraju putem arteriovenske fistule. Osim krvožilnog pristupa, na preživljenje bolesnika utječu i brojna pridružena stanja i bolesti. Budući da su arteriovenski graft i trajni dijalizni kateter udruženi s višestruko većim rizikom od pobola i smrtnosti u odnosu na arteriovensku fistulu, nije sasvim jasno proizlazi li rizik za preživljenje bolesnika od samih krvožilnih pristupa ili od pridruženih stanja i bolesti.Hemodialysis is a method of extracorporeal removal of substances that accumulate in the body due to temporary or permanent loss of renal excretory function. In patients who have an indication for initiation of hemodialysis treatment, possible vascular accesses are: arteriovenous fistula, arteriovenous graft and non-tunnelled and tunelled dialysis catheters. For effective hemodialysis, vascular access should provide sufficient blood flow to deliver adequate dialysis dose and should have a long survival and low incidence of complications. Despite the relatively high incidence of the primary loss of function, arteriovenous fistula is the vascular access of choice because it is associated with the longest vascular access survival, the longest patient survival, lower morbidity and mortality of patients, the lowest complication rates and the lowest costs of treatment. Arteriovenous graft is the vascular access of choice in patients in whom arteriovenous fistula can not be created. Dialysis catheters are used for the rapid establishment of an adequate vascular access when an urgent hemodialysis is indicated, during the maturation of arteriovenous fistulas and in patients who have exhausted all other vascular accesses. The best survival is achieved by patients who are dialyzed using arteriovenous fistula. Since many comorbidities affect survival of dialysis patients, it is unclear whether the risk for the survival of patients arises from vascular access type or from associated conditions and diseases that are more often present in patients who are dialyzed through arteriovenous graft and catheter

Electrical storm and catheter ablation of ventricular tachycardia days after left ventricular assist device implantation

Ventricular arrhythmias are common complication associated with left ventricular assist devices (LVAD). We present a challenging case of a 57-year-old male LVAD recipient who developed ventricular tachycardia refractory to antiarrhythmic drugs and device therapy in the early postoperative period and was eventually successfully treated with radiofrequency catheter ablation. Ventricular arrhythmias were successfully mapped, eliminated with ablation, and remained non-inducible. This case demonstrates that ventricular arrhythmia catheter ablation can be feasible, effective, and safe in LVAD recipients with a scar-related electrical storm even days after LVAD implantation. Although optimal treatment strategy in this patient population still needs to be defined, catheter ablation should be considered in LVAD recipients with ventricular arrhythmias refractory to antiarrhythmic drugs and device therapy representing a treatment of last resort