Management of patients with challenging vascular access needs.

The proportion of patients on dialysis with multiple access procedures, failed transplant(s), or no suitable sites for conventional arteriovenous (AV) fistula is increasing. We report on 4 patients at our institution requiring unusual measures to achieve vascular access for dialysis. All 4 patients had temporary femoral vein catheters for dialysis, but 3 had tunneled femoral catheters, with 1 patient using this modality of access for 28 months. One patient who had 13 vascular access procedures developed collateral circulation that was amenable to a new autogenous AV fistula. Two patients died of causes unrelated to vascular access, whereas 1 died from infection of an access device. In patients with challenging vascular access requirements, the use of simple procedures such as the insertion of a tunneled femoral catheter should be considered. A thorough assessment must be made before each new access procedure as collateral circulation may present new options.