72-year-old man on HD programme since December 2002, due to renal failure secondary to bilateral nephrectomy for renal neoplasia (1999 and 2002).

History of arterial hypertension, appendicectomy, cholecystectomy and right inguinal herniorrhaphy. Splenectomy for spleen injury during right nephrectomy (2002). Venous thrombosis in the right lower limb due to femoral cannulation (dialysis catheter). Ischaemic colitis, colon polyposis and lower gastrointestinal bleeding in 2007. In December 2008 a new episode of lower gastrointestinal haemorrhage due to angiodysplasia. Diagnosed in 2009 with moderate-severe aortic stenosis.

History of vascular access:

- Started treatment in December-02 via a right femoral catheter. It was withdrawn in February 2003 (venous thrombosis).

- A left humero-cephalic AVF was performed in January 2003. It was started at 4 weeks. It developed an aneurysmal dilatation, presenting partial thrombosis (December 2003), which allowed its use in unipuncture.

- In December 2003, a right humero-basilic AVF was performed, which did not work.

- In the same month a right humero-axillary PTFE graft was implanted, with thrombosis after 24 hours. It had to be removed due to infection in January 2004.

- Due to dysfunction of the left fistula, a tunneled catheter was implanted in the left internal jugular vein in January 2004. It was used as a VA until July 2004, and was removed due to infection refractory to antibiotic therapy.

- On 22-7-04 there was an unsuccessful attempt to cannulate the right internal jugular vein, and a catheter was placed in the right femoral vein: it was removed in Sep-04, as a functioning AVF was available.

- Again, on 23-7-04, unsuccessful attempts were made to cannulate both the right and left internal jugular veins.

- On 4-8-04 a PTFE prosthesis was implanted between the left femoral artery and vein. It was used from September until 22-10-04 (non-recoverable thrombosis).

- On the same day 22-10-04 a tunneled catheter was implanted in the right internal jugular vein:

- In October 2005 he presented an episode of bacteraemia due to E. coli, resolved with antibiotherapy.

- Subsequently, the catheter gave problems of insufficient flow, frequently requiring both local and systemic fibrinolytic treatment.

- For this reason, in November 2006, anticoagulation with acenocoumarol (Sintrom®) was indicated, with slight functional improvement.

- In February 2007 she suffered an episode of lower gastrointestinal haemorrhage, due to ischaemic colitis and colon polyps and conditioned by the anticoagulant treatment.

- After withdrawal of acenocoumarol the catheter stopped giving flow.

- On 22-2-07 an attempt was made to replace the catheter via the same venous line, but it was impossible to insert the new catheter due to complete thrombosis of the superior cava.

- On the same day, 22-2-07, a temporary catheter was placed in the left femoral vein. It was removed on 2-3-07 as a functioning central catheter was available.

- On 28-2-07 a Split-Cath tunneled catheter was placed directly in the right atrium, by means of a right anterior mini-thoracotomy.

- From the first dialysis session, there was minimal blood leakage through the junction of the catheter with the connection extensions. This did not prevent her from continuing to use the catheter.

- Hospitalisation in October 2007 due to catheter infection, resolved with antibiotic therapy.

- In November 2007 the blood leakage increased significantly and was resolved by sealing with sterile silicone and placing a PTFE sheath around the leakage point.

- In March 09, the blood leakage was again present, resolved with the same sealing procedure and PTFE sheath.

- On 30-11-09 it leaked again, and a new sealing attempt failed.

- On 22-3-09 he required the insertion of a temporary catheter in the right femoral artery for a few days.

- On 17-12-09 a new transthoracic replacement was performed by thoracotomy, and another Split-Cath catheter was inserted.

- As a complication, he developed post-surgery cardiogenic shock, and was diagnosed with moderate-severe aortic valve stenosis.

- The catheter gave inadequate flow, and it was shown that the distal ends were located in the suprahepatic vein.

- On 25-3-10 the catheter was repositioned in haemodynamics, the distal ends of the catheter being located in the inferior vena cava.

- On 24-9-10, again due to catheter dysfunction, the catheter was repositioned in haemodynamics, the distal ends remaining lodged in the right atrium.

- On 22-3-10 he required the insertion of a temporary catheter in the right femoral artery for a few days.

Since the last episode on 24-9-10 and until today (10-02-2012), the patient has been dialysed at his dialysis centre via the transthoracic catheter, with no incidents and with adequate catheter function.