Even in patients with chronic renal failure and chronic intermittent hemodialysis, continuous venovenous hemofiltration (CVVH) is the most often practiced renal replacement technique in the intensive care unit. Although patients show less hemodynamic instability during CVVH than during hemodialysis, it requires a blood flow exceeding 200 ml/min in the extracorporeal circuit necessitating the use of large bore catheters. Vascular access in critically ill septic and edematous patients is sometimes difficult, or even impossible

A Davenport

A Innes

AA Alarabi

B Charra

C Ronco

GJ Murphy

Guus Crooijmans

Johannes H Rommes

Jos NM Barendregt

JV Dicarlo

MI Matsagas

Peter E Spronk

R Bambauer

TS Huber

W Weyde

Yolande M Vermeeren

Journal of Medical Case Reports

English

PubMed

Crossref

Brachio-cephalic ('Gracz') fistula use for continuous hemofiltration in a hemodynamically unstable hemodialysis patient without venous vascular access: a case report

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BioMed CentralJournal of Medical Case Reports
ssOpen AcceCase report
Brachio-cephalic ('Gracz') fistula use for continuous hemofiltration 
in a hemodynamically unstable hemodialysis patient without venous 
vascular access: a case report
Peter E Spronk*1,2,4, Jos NM Barendregt3, Guus Crooijmans3, 
Yolande M Vermeeren3 and Johannes H Rommes1
Address: 1Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands, 2Department of Intensive Care Medicine, 
Academic Medical Center, Amsterdam, The Netherlands, 3Department of Internal Medicine, Gelre Hospitals, Apeldoorn, The Netherlands and 
4Hermes critical care group, Amsterdam, The Netherlands
Email: Peter E Spronk* - p.spronk@gelre.nl; Jos NM Barendregt - j.barendregt@gelre.nl; Guus Crooijmans - g.crooijmans@gelre.nl; 
Yolande M Vermeeren - y.vermeeren@gelre.nl; Johannes H Rommes - h.rommes@gelre.nl
* Corresponding author    
Abstract
Even in patients with chronic renal failure and chronic intermittent hemodialysis, continuous
venovenous hemofiltration (CVVH) is the most often practiced renal replacement technique in the
intensive care unit. Although patients show less hemodynamic instability during CVVH than during
hemodialysis, it requires a blood flow exceeding 200 ml/min in the extracorporeal circuit
necessitating the use of large bore catheters. Vascular access in critically ill septic and edematous
patients is sometimes difficult, or even impossible.
We describe a technique of using a brachio-cephalic arterio-venous fistula in a hemodialysis patient
for continuous hemofiltration (HF) resulting in improved hemodynamic stability.
Background
Even in patients with chronic renal failure and chronic
intermittent hemodialysis (CIHD), continuous veno-
venous hemofiltration (CVVH) is the most often practiced
renal replacement technique in the intensive care unit
(ICU) with a filtration rate of at least 2 liters/hour [1].
Patients show less hemodynamic instability during CVVH
than during hemodialysis (HD) [2]. However, CVVH
requires a blood flow exceeding 200 ml/min in the extra-
corporeal circuit implicating the use of large bore cathe-
ters. Obtaining or maintaining vascular access in critically
ill septic and edematous patients is sometimes difficult, or
even impossible.
We describe a technique of using a brachio-cephalic (BC)
arterio-venous fistula in a hemodialysis patient for contin-
uous hemofiltration resulting in improved hemodynamic
stability.
Case presentation
A 58 year old caucasian male with renal insufficiency due
to nephrosclerosis was admitted to the ICU with septic
shock following bowel perforation. Previous renal
replacement therapies had consisted of, in chronological
order, continuous ambulatory peritoneal dialysis (CAPD)
for 5 years ending with catheter removal due to bacterial
peritonitis. Intermittent HD was then performed on cen-
tral venous hemodialysis catheters, complicated by bilat-
eral jugular thrombosis. Due to vessel usability, a classical
Published: 30 June 2007
Journal of Medical Case Reports 2007, 1:39 doi:10.1186/1752-1947-1-39
Received: 3 April 2007
Accepted: 30 June 2007
This article is available from: http://www.jmedicalcasereports.com/content/1/1/39
© 2007 Spronk et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Journal of Medical Case Reports 2007, 1:39 http://www.jmedicalcasereports.com/content/1/1/39Cimino fistula could not be constructed in the lower arm.
Hence, a left-sided BC-fistula was constructed in the upper
arm and successfully used for 1 year after which CAPD
was resumed for 1 year. No signs of steel syndrome with
hand ischemia occurred during the HD period [3]. The
catheter was again removed when treatment was compli-
cated by ultrafiltration (UF) failure and bacterial peritoni-
tis. A history of massive vomiting, an abdominal CT-scan
and pathological examination of a peritoneal biopsy
taken upon removal of the catheter led to a diagnosis of
encapsulating peritoneal fibrosis. Treatment for this disor-
der had been started with prednisolone and tamoxifen
while intermittent HD was resumed on the well devel-
oped BC-fistula. Abdominal symptoms had practically
been absent in the preceding two years.
Due to septic shock and hemodynamic instability, central
venous access was needed for CVVH and vasopressor sup-
port besides other intravenous administrations. Because
the left arm and subclavian vein were left untouched to
spare the AV-fistula for future hemodialysis, CVVH was
initiated on the left femoral vein while vasoactive medica-
tion was given on a right sided subclavian catheter. In
spite of prophylactic administration of subcutaneous
nadroparine 2850 IU daily, the patient developed a deep
vein thrombosis of the left leg 1 week after admission,
probably related to the large bore catheter for CVVH.
Ultrasound examination confirmed the presence of a
thrombus in the left common iliac vein. Further, intermit-
tent fever and a purulent exit-site made the diagnosis of
suspected catheter sepsis, after which the left femoral cath-
eter was removed.
Frequent hemodialysis was performed but was compli-
cated by hypotension in spite of the use of vasopressor
support and this therapy failed to reverse the severe ede-
matous state. In view of this clinical dilemma, we decided
to try hemofiltration by vascular access to the existing bra-
chio-cephalic fistula.
Hemofiltration
His shunt had been used for 3 years three times a week for
intermittant HD without problems. Two large bore teflon
canulas (15 Gz, Clampcath, Togo Medikit CO, Japan)
were used to access the shunt for connection to the hemo-
filtration machine (Multifiltrate, Fresenius Medical Care,
Germany). The clinical setting is depicted in figure 1 and
2. Subsequently, the normal CVVH protocol was used.
Blood flow was started at 200 ml/min without volume
extraction, substitution rate was set at 3000 ml/hour.
Anticoagulation was done systemically with unfraction-
ated heparin aiming at an activated partial partial pro-
thrombin time between 70–90 seconds in view of the
thrombosis. Since hemodynamic parameters remained
stable, blood flow was increased to 350 ml/min, substitu-
tion rate to 4500 ml/hour, while fluid extraction was
started as well. In the subsequent hours, UF rate could be
increased to 500 ml/hour without changes in hemody-
namic measurements. After 12 hours of continuous
hemofiltration, the canulas were removed to spare the AV
fistula. In the following 14 days, the patient underwent
daily continuous HF with an average volume extraction of
4.5 liters/day. In the mean time, his hemodynamic state
had improved in such a way that we successfully switched
to intermittent HD.
Discussion
We describe the use of a brachio-cephalic fistula for HF-
treatment in a hemodynamically unstable patient with
inaccessibility to the central venous compartment. In crit-
ically ill patients, the clinical application of continuous
techniques like arteriovenous hemofiltration (CAVH) and
intermittent HF have changed treatment modalities of
renal failure which used to include only HD. To perform
such treatments a reliable vascular access is of vital impor-
tance. Unfortunately, multiple vascular access problems
are frequently seen among chronic HD or HF patients
despite the reliability of the conventional arteriovenous
fistula [4]. Since the introduction of large-bore catheters
for acute HD, many problems with handling, material,
and contamination of these catheters have been
described. Nevertheless, catheterization of the femoral
and jugular veins with a large-bore catheter has proved to
be suitable as a rapid connection process for hemodialy-
sis, hemofiltration, hemoperfusion, and plasmapheresis.
In our patient, the femoral catheter had only been in place
for 5 days, but thrombosis developed despite thrombosis
prophylaxis. Prolonged femoral vein catheterization is a
known risk factor of both the femoral and iliac veins
large bore venflon catheters introduced into the arteriov-enous fistulaFi re 1
large bore venflon catheters introduced into the arteriov-
enous fistula.Page 2 of 4
(page number not for citation purposes)
Journal of Medical Case Reports 2007, 1:39 http://www.jmedicalcasereports.com/content/1/1/39thrombosis and stenosis [5]. Although a rising number of
ICUs will use extra corporal citrate anticoagulation in
unstable patients at risk for bleeding, many dialysis cent-
ers still use unfractionated heparine in those cases. The
controle of heparinization (usually 2 × normal value of
aPTT) and reversibility of heparine overdose (protamine
sulfate) are important potential advantages. Moreover,
heparine given by the dialysis line may produce a higher
local (femoral vein) heparine concentration with concur-
rent improved prevention of femoral/iliac vein thrombo-
sis when compared to subcutaneous application of low
molecular weight heparin analogues. Besides side-effects
related to central venous catheters [6], obtaining or main-
taining vascular access for continuous hemofiltration can
sometimes be problematic, especially in the child or adult
in multiple organ failure with edema and/or coagulopa-
thy [7]. Ultrasound guidance for cannulation of the inter-
nal jugular and subclavian veins may be used.
Nevertheless, common access problems include obstruc-
tion of the femoral, subclavian, or jugular veins due to
previous thrombosis, insertion difficulties, safety con-
cerns when cannulating the subclavian vein in coagulop-
athy, and catheter and circuit occlusion due to
disseminated intravascular coagulation.
Alarabi et al. describe a needleless prosthetic vascular
access device (Hemasite) as an alternative solution in
patients with high incidence of previous access failures,
i.e. 1–8 failures per patient [8]. The 1 year cumulative sur-
vival rate of the device was 55%, failure being caused pre-
dominantly by thrombosis. However, due to the clinical
setting of our patient, this was not an option. One possi-
ble alternative to the chosen access strategy in this patient
might have been the lumbar insertion of a vena cava cath-
eter [9]. In our centre we have no practice with inserting
and using these catheters and the use of such a catheter
just proximal to an established venous thrombosis did
not seem safe.
There are several risks in using the hemodialysis access for
continuous renal replacement. Sparing the access site for
future hemodialysis is a well recognized adagium in these
patients. Severe bleeding from the access site can occur
after needle displacement. Meticulous fixation of the nee-
dles and blood-lines was applied to prevent this compli-
cation. In spite of these measures we refrained from
continuing treatment during nightly hours. However, this
approach could have reduced the risk of damaging the
access by frequent puncturing. Damaging by frequent
puncturing would especially be a problem in a synthetic
graft shunt. Infection of the access site however would still
be a major concern in any prolonged treatment. Neverthe-
less, fistula needle insertion for 12 hours seems to be safe.
The Tassin experience showed that long term hemodialy-
sis sessions up to 10 hours with fistula cannulation did
not produce additional problems with fistulas [10,11].
Conclusion
While, for obvious reasons, we do not recommend the
routine use of existing hemodialysis access for continuous
treatment, it is important to realize that when no alterna-
tives are feasible, like in our patient, the hemodialysis
access can be used for delivering continuous or semi-con-
tinuous hemofiltration therapy in the intensive care unit.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
All authors contributed substantially to the manuscript.
PES was involved in the primary care of the patient, con-
ceived of the study, contributed to the interpretation and
analysis of the data, and drafted the manuscript. JNMB
revised the manuscript for intellectual content. GC was
involved in the primary care of the patient and contrib-
uted to the interpretation of the data. YMV revised the
patient connected to hemofiltration machineFigure 2
patient connected to hemofiltration machine.Page 3 of 4
(page number not for citation purposes)
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manuscript for intellectual content. JHR conceived of the
study, contributed to its design and the interpretation of
the data, and revised the manuscript for important intel-
lectual content. All authors approved the final version
submitted for publication.
Acknowledgements
The patient consented to the publication of these findings to help improve 
patient care
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Brachio-cephalic ('Gracz') fistula use for continuous hemofiltration in a hemodynamically unstable hemodialysis patient without venous vascular access: a case report

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