Report On Long final version 22.4.10

Report On Long-Term Dialysis Via The PakuMed
Titan-Port D ® Dialysis Port System
Dr. med. Jens Benders and Prof. Dr. med. Markus Hollenbeck
Case report
We wish to report on a patient with
terminal renal failure caused by a vascular
nephropathy secondary to long-standing
arterial hypertension and generalized
arteriosclerosis. Dialysis dependence
began in March 2007 after several
hydropic decompensation episodes in the
form of a cardiorenal syndrome secondary
to a dilitative form of ischemic
cardiomyopathy. Apart from severe heart
failure and the high grade aortic, mitral,
and tricuspid valve insufficiency, atrial
fibrillation was present as well. The patient
was on oral phenprocoumon
anticoagulation since implantation of a
VVI-Pacemaker several years ago.
Moreover the patient had a colon
segmental resection for carcinoma with a
temporary diverting colostomy several
decades ago as well as a left
hemicolectomy for a carcinoma recurrence
in 2006. Severe intraabdominal adhesions
were present at that time.
At the time of her first dialysis the 84-yearold
patient was in satisfactory condition
with respect to her age.
Dialysis Port Systems Description
Dialysis port systems can be implanted for
performing hemodialysis when other
therapeutic options, such as surgically
constructed shunts, are considered risky or
contraindicated for anatomical or medical
reasons (cardiologic problems in
particular).
The port systems are fully implantable
subcutaneously. The port is made of
titanium and is biocompatible,
hypoallergenic, and does not interfere with
MRI studies.
Fig.1: shows a double-lumen port system
Due to preexisting intraabdominal
adhesions secondary to multiple bowel
surgeries, peritoneal dialysis was
considered contraindicated.
Due to the patient’s heart failure an avshunt
was also not considered as an option.
We decided to implant a dialysis port
system as the treatment of choice.
Fig. 2 shows a special dialysis port puncture needle

Implantation of port systems
Implantation of the port system via the
right subclavian vein would prove to be
technically difficult due to prior placement
of a cardiac pacemaker. Moreover the left
jugular vein was chronically occluded. The
catheter lines were passed easily via the
right internal jugular vein (fig. 3, 4, 5).
After implantation hemodialysis could
proceed and continue without problems
(fig. 6).
Fig. 3: Surgical field of right internal jugular vein
Fig. 6: Depiction of an implanted port system
Fig. 4: Operative field port system
After disinfection and sterile draping of the
puncture sites each port chamber is
accessed with the special port needles. The
dialysis nurse wears sterile gloves and a
mask. The portal lock solution is aspirated.
The system is then flushed with
physiologic saline. Upon termination of
dialysis 46% citrate solution is once again
injected. 3-point rotation of the membrane
is recommended to ensure even
distribution of puncture points to prevent
excessive wear of the membrane material.
Fig. 5: Post-op x-ray of port system
Conducting hemodialysis via port
system

Fig. 7: Rotation principle of puncture sites
Fig. 9: Implanted port system in use (2,5 years after
implantation, post pacemaker battery revision)
Dialysis blood flow rates of 300 ml / min
were achieved. Excellent dialysis
efficiency values measured as Kt/V (urea)
were observed averaging 1,4 .
Fig.8 illustrates the port system with in situ
dialysis needles at 5 months post
implantation
During this 2,5 year period there were no
thrombotic or infection complications.
Long-Term Course
After a three year course of hemodialysis
the patient was in very good clinical
condition. Heart failure had improved and
the patient was fully compensated.
Because her cardiac status had improved
we decided to proceed with a shunt
procedure on her left forearm and
performed the surgery along with a
pacemaker battery replacement. Upon
uneventful initiation of hemodialysis via
shunt the port system was later removed.
Fig. 8: Port system in use at 5 months
Risks and Problems
Due to a slowly progressive skin defect on
one of the puncture sites, a new puncture
site proved necessary. Fig. 9 illustrates the
anatomic situation 2,5 years after
beginning hemodialysis.
Knappschaftkrankenhaus Bottrop
Osterfelder Str. 157
46242 Bottrop
Klinik für Nephrologie und Rheumatologie
Prof. Dr. med. M. Hollenbeck (Ltd. Arzt)
Dr. med. J. Benders (Oberarzt)
E-mail: hollenbeck@kk-bottrop.de
jens.benders@kk-bottrop.de