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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION </span></p><p class="elsevierStylePara">In patients with chronic kidney disease &#40;CKD&#41; on haemodialysis therapy&#44; vascular access for the procedure is one of the major problems faced by nephrologists on a daily basis&#46; Arteriovenous &#40;A-V&#41; fistulas with native vessels or grafts are ideal forms of access due to their long life and low rate of complications during use&#46; For patients in whom an A-V fistula cannot be used&#44; central venous catheters must be used&#44; although they frequently cause thrombosis of the vessels where they are placed and they exhaust the classic vessels &#40;internal jugular&#44; subclavian&#41; and non-classic vessels &#40;axillary and innominate&#41; in the upper hemithorax&#46;</p><p class="elsevierStylePara">Before using infradiaphragmatic vessels or&#44; for those patients where the use of those vessels is not possible&#44; there are two final alternatives for placing central lines&#58; intracardiac access &#40;right atrium&#41; and direct puncture of the superior vena cava&#46; In this report we present the placement of 4 catheters for haemodialysis in the superior vena cava using parasternal access&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORTS</span></p><p class="elsevierStylePara">Four patients who had previously had catheters placed in various supradiaphragmatic veins with ultrasound-documented thrombosis of the internal jugular&#44; subclavian&#44; axillary&#44; and innominate veins&#44; who were either not candidates for or refused peritoneal dialysis&#44; were selected for placement of a catheter in the superior vena cava&#46; All patients gave written consent for the procedure&#46; Exclusion criteria were age below 18&#44; coagulation test &#40;PTT and PT&#41; abnormalities&#44; thrombocytopoenia &#40;platelet count less than 50&#44;000 platelets&#41; and refusal to participate&#46; Patient characteristics and outcomes are shown in table 1&#46;</p><p class="elsevierStylePara">The surgical technique employed was as follows&#58; 1&#41; conventional preparation for surgery under general anaesthesia&#44; 2&#41; right anterior mediastinotomy&#44; with incision through the third intercostal space &#40;horizontally&#41; until resection of the chondrosternal junction&#44; 3&#41; ligation of the mammary vessels&#44; 4&#41; extrapleural approach to the superior vena cava&#44; 5&#41; creation of the subcutaneous tunnel and tunnelling of the catheter in the anterior thoracic wall with the catheter exit site at the midclavicular line of the fifth intercostal space&#44; 6&#41; under direct vision and after purse-string suture with 3-0 prolene&#44; the superior vena cava is punctured and the haemodialysis catheter &#40;indwelling type&#41; is placed&#44; directing the tip of the catheter downward and closing the purse-string suture&#44; 7&#41; the catheters are checked for patency and heparinised&#44; and 8&#41; mediastinotomy is closed in layers&#46;</p><p class="elsevierStylePara">This procedure was carried out successfully in 4 patients&#44; and the following complications were attributable to it&#58; three haemothorax episodes&#44; one of which was massive&#44; for which a thoracotomy was performed on each patient and a chest tube was placed for an average of 5 days&#59; the patient with massive haemothorax required transfusion of 5 units of red blood cells&#44; mediastinostomy&#44; ligation of the bleeding vessels&#44; and thoracotomy with chest tube for 7 days &#40;figures 1 and 2&#41;&#46;</p><p class="elsevierStylePara">Subsequently&#44; the patients were taken for chronic haemodialysis and progressed satisfactorily&#44; without complications attributable to the procedure&#46; Their last average Kt&#47;V was 1&#46;45 and one patient completed 36 months of using the catheter &#40;figure 3&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">As the population of CKD patients on haemodialysis therapy ages&#44; it becomes increasingly difficult to obtain satisfactory access through which to provide their therapy&#46; A-V fistulas have the tremendous advantage of permitting multiple punctures over a long period of time&#44; but in a group of patients&#44; mainly diabetics&#44; it becomes impossible to place them&#46; The same is true with A-V prosthesis placement&#46; In this group of patients&#44; the use of either temporary or indwelling central venous catheters&#44; inserted through various sites&#44; becomes necessary&#46;</p><p class="elsevierStylePara">The internal jugular vein approach is the most commonly used due to its easy puncture and the low rate of complications&#46;<span class="elsevierStyleSup">1</span> The subclavian route is not recommended&#44; since it results in high stenosis and thrombosis rates&#44; which subsequently prevent the use of the upper extremity for the creation of A-V fistulas&#46;<span class="elsevierStyleSup">2</span> The axillary and innominate veins can also be used for the placement of central catheters&#44; but they require medical personnel familiar with those puncture procedures in order to be utilized&#46;<span class="elsevierStyleSup">3&#44;4</span> The infradiaphragmatic approach offers several routes&#58; the femoral&#44; with easy access but with the disadvantage of a high thrombosis and infection rates&#59;<span class="elsevierStyleSup">5</span> on the other hand&#44; the transhepatic and translumbar routes<span class="elsevierStyleSup">6&#44;7</span> are technically more difficult&#46; At the supradiaphragmatic level&#44; two final approaches allow for catheter implantation&#58; the intracardiac and the right parasternal routes&#44; each of which requires the use of general anaesthesia and anterior thoracotomy to access the puncture site&#46; In the intracardiac access the right atrium is punctured&#44; with later placement and tunneling of the indwelling catheter&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara">Right parasternal access was first described in the year 2002 by Archundia et al&#44;<span class="elsevierStyleSup">9</span>&#160;who performed it on a patient who had exhausted all supra- and infradiaphragmatic vascular access points&#46; In this technical report&#44; 3 more patients are being reported&#44; without establishing its long-term outcomes&#46;</p><p class="elsevierStylePara">The lack of literature indicating the use of this route after its initial introduction is particularly curious&#46;</p><p class="elsevierStylePara">In our area&#44; about 25&#37; of patients on haemodialysis therapy require the use of indwelling catheters for haemodialysis&#44; which has forced us to employ the vast majority of known routes for both supra- and infradiaphragmatic catheter&#44; including femoral&#44; iliac&#44; and translumbar catheters&#46; Nephrologists perform the aforementioned percutaneous procedures&#44; the majority with ultrasound guidance&#44; while fluoroscopy or computed axial tomography is used only for translumbar placement&#46; When it comes to catheters such as those presented in this case&#44; vascular or thoracic surgeons must be involved&#46; Otherwise&#44; such placement would be impossible&#44; since this medical group possesses the requisite skills and knowledge of intrathoracic anatomy&#46;</p><p class="elsevierStylePara">Based on our experience&#44; it has been possible to achieve satisfactory placement of 4 catheters in the superior vena cava for 36 months&#46; It is important to note that surgical complications are common&#44; despite the experience of the surgical team with thoracic surgeries&#46; Our recommendation is to always rely on experienced surgeons and to be alert to the occurrence of complications in order to resolve them quickly and avoid fatal consequences&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10452&#95;108&#95;7891&#95;en&#95;10452&#95;t1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10452_108_7891_en_10452_t1.jpg" alt="Patient characteristics and outcomes"></img></a></p><p class="elsevierStylePara">Table 1&#46; Patient characteristics and outcomes</p><p class="elsevierStylePara"><a href="grande&#47;10452&#95;108&#95;7892&#95;en&#95;10452&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10452_108_7892_en_10452_f1.jpg" alt="Patient D on second post-operative day&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Patient D on second post-operative day&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10452&#95;108&#95;7893&#95;en&#95;10452&#95;f2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10452_108_7893_en_10452_f2.jpg" alt="PA chest x-ray of patient D&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; PA chest x-ray of patient D&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10452&#95;108&#95;7894&#95;en&#95;10452&#95;f3&#46;jpg" class="elsevierStyleCrossRefs"><img src="10452_108_7894_en_10452_f3.jpg" alt="Patient 36 months after catheter placement&#46;"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Patient 36 months after catheter placement&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">Se presentan 4 pacientes con enfermedad renal cr&#243;nica en terapia hemodial&#237;tica en quienes se hab&#237;an agotado los accesos venosos cl&#225;sicos &#40;yugular interno&#44; subclavio&#41; y no cl&#225;sicos &#40;axilar e innominado&#41; en el hemit&#243;rax superior para hemodi&#225;lisis&#44; debido principalmente a trombosis de los mismos por cateterismos anteriores&#44; y que no eran candidatos a di&#225;lisis peritoneal&#46; En ellos&#44; con la t&#233;cnica recomendada por Archundia et al&#46;&#44; se implantaron 4 cat&#233;teres permanentes directamente en la vena cava superior&#44; con posterior tunelizaci&#243;n subcut&#225;nea&#46; Los cat&#233;teres funcionaron adecuadamente y est&#225;n permeables actualmente despu&#233;s de un per&#237;odo de utilizaci&#243;n promedio de 19 meses&#46;</p>"
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