Transhepatic venous access as a vessel-preserving salvage strategy for temporary hemodialysis in venous access exhaustion

Patients with end-stage renal failure may develop progressively limited venous access for hemodialysis, particularly after repeated catheterization, thrombosis, and central venous stenosis. This may be especially problematic when temporary dialysis access is required while a permanent arteriovenous fistula is still maturing. We report the use of transhepatic tunneled double-lumen hemodialysis catheter placement as a salvage, vessel-preserving strategy in a 51-year-old woman with complex venous occlusive disease, an immature right upper extremity arteriovenous fistula, and a recently reconstructed right subclavian vein. The transhepatic route was selected to maintain dialysis while preserving the reconstructed right-sided venous outflow and protecting fistula maturation, in keeping with the Kidney Disease Outcomes Quality Initiative (KDOQI) principle of vessel preservation. The catheter functioned for 7 weeks before dysfunction developed because of inferior migration of the tip to a subdiaphragmatic position. Catheter revision with superior repositioning and vertical configuration restored satisfactory flow and allowed continued hemodialysis until the fistula became usable. The catheter was removed 4 weeks later following fistula maturation, with recurrent inferior tip migration again demonstrated at removal. This case highlights the importance of individualized vascular access planning and supports the role of transhepatic venous access as a temporary option in selected patients with exhausted conventional venous access. It also demonstrates recurrent catheter-tip migration despite revision as an important procedural limitation requiring close surveillance.