Tunneled transhepatic hemodialysis catheter via the right hepatic vein in multilevel central venous occlusion with a permanent pacemaker.

Exhaustion of central venous access sites in hemodialysis patients represents a complex therapeutic challenge. We report the case of a 68-year-old woman with end-stage renal disease, a permanent pacemaker, and loss of peritoneal dialysis access who developed uremic encephalopathy secondary to dysfunction of her last available vascular access. Computed tomography demonstrated multilevel central venous occlusion involving the right subclavian vein and bilateral common iliac veins. In the absence of conventional alternatives, a tunneled transhepatic hemodialysis catheter was placed via the right hepatic vein under ultrasound and fluoroscopic guidance. The catheter tip was positioned in the suprahepatic inferior vena cava, immediately proximal to the cavoatrial junction. Immediate catheter function was achieved, followed by neurological improvement after the first dialysis session; catheter patency was maintained for more than 6 months. The transhepatic approach represents an effective salvage option in cases of advanced vascular access exhaustion when conventional routes are no longer feasible.