What Does Early Mean? Remarks on Immediate Prosthetic Vascular Access Cannulation for Urgent Hemodialysis

Management of complicated vascular access. A step-by-step description of a case of hyperkalemia and vascular access failure in a patient receiving maintenance hemodialysis treated for numerous previous stenosis and thrombosis of the native vascular access. The discussion revolves around the following key questions: 1. Basilic vein thrombosis and re-stenosis, what do you think it should be done after this complication? 2. Venous back bleeding was satisfactory; do you think thrombectomy was effective? 3. We thought that central vein stenosis stenting was needed, wasn't it? 4. What do you think about basilic stenosis? The patient had undergone multiple recent basilic angioplasties. Consequently, a surgical intervention could have been definitive. Various surgical options were possible. But first of all, we had to solve a dilemma: The patient had received multiple previous central vascular catheters; our aim was to avoid a new central vascular access placement. At the same time, we required a vascular access for prompt cannulation. Do you think that was a real problem? Do you agree with us, or in the present circumstance, would you have preferred a central venous device? 5. Finally, we decided in favor of creation of a prosthetic vascular access. We chose a graftspecifically designed for early cannulation. Do you agree with us? Do you think early cannulation could cause a worse vascular access outcome? 6. Patient underwent last hemodialysis (HD) 24 hours before surgery. Consequently we trusted that the next HD could be delayed for at least 24 hours. Unfortunately, intraoperative arterial blood gas analysis documented hyperkalemia and acidosis. Our nephrologist suggested HD. In your opinion what does “early” mean?.