We usually use an AVF (arteriovenous fistula) or AVG (arteriovenous graft) for VA (vascular access) for hemodialysis. However, if we cannot use an AVF or AVG, a vascular catheter is used. However, vascular catheter use is associated with many complications, such as obstruction and infection. Therefore, it is difficult to use vascular catheters safely in the long term. Our hospital invented a new VA method, named SVBP (saphenous vein buttonhole puncture). We created SVH (saphenous vein buttonholes) in 20 patients and performed 2,687 hemodialysis sessions in these patients. SVH can be used from the day after they are created. In addition, after 1 year of continuous use none of the SVH had become blocked. Regarding VAI (vascular access‒related infections), the frequency of such infections was about one‒half of that associated with TCC (tunneled cuffed catheters) and about one‒twelfth of that associated with NCC (non‒tunneled cuffed catheters). SVH is a new surgical technique; therefore, there are many problems to be solved, such as preventing thrombosis and thromboemboli. However, SVBP has many advantages over vascular catheter use, and hence, may be a useful third VA method for use in cases in which AVF and AVG cannot be employed.

The patient was a 9‒year and 1‒month‒old girl. She was started on peritoneal dialysis for end‒stage renal disease due to focal segmental glomerular sclerosis (FSGS). After 5 years, she underwent a renal transplantation. However, because of graft failure associated with the recurrence of FSGS shortly after transplantation, catheter‒based hemodialysis was initiated. To help the patient return to a more normal home and school life and experience adequate growth and development, she was referred to our clinic so that home hemodialysis (HHD) could be initiated. We explained about HHD to the patient and her parents and obtained written informed consent. HHD training was conducted twice a day, and we trained the patient’s mother and father for 6 and 5 days, respectively. As HHD safety mechanisms, we focused on setting appropriate water removal parameters using the blood volume system, instructions for catheter use, and the use of a videophone as a backup tool. The initial dialysis conditions were 5 times a week for 3 hours. About 2 months after HHD was initiated, the doses of antihypertensive agents were decreased, and the patient’s height and weight had improved. HHD was performed safely and allowed the patient a more normal life.

In Japan, the number of patients that are started on dialysis and the number of patients receiving chronic dialysis have increased. As the dialysis patient population is aging, the number of dialysis patients who have dementia has also increased. Safely providing renal replacement therapy for such patients is a challenge. Here, we report two cases of shunt occlusion in chronic hemodialysis patients with severe dementia. As they did not understand their dialysis treatment, they frequently moved their arms or bodies during dialysis and occasionally pulled the needles out. We inserted tunneled cuffed catheters with upper shoulder blade exit sites for safety reasons. The patients were able to continue receiving dialysis through the catheters without any major complications. Although there are some issues with this technique, which involves an unconventional exit site, that need to be examined in future, such as the risk of long‒term complications, the complications of catheter insertion are comparable to those of the conventional method. This method may be useful for achieving vascular access for safe dialysis in patients that are considered to be at high risk of needle‒removal incidents.