Indirect Complication of AV Graft Thrombectomy-Thrombolysis Secondary to Previously Attempted Placement of a Temporary Hemodialysis Catheter.

Common interventional procedures on frequently encountered patients may wrongly place one on a track that deals with the task at hand while not assessing the global patient. Nowhere is this more problematic than in the dialysis population where in the course of achieving and maintaining vascular access, the interventionist becomes exceedingly familiar with each patient and his or her particular clinical history. Unfortunately, events that may have occurred in the past few hours may rarely be overlooked. We present a case of patient mortality as an indirect result of an upper extremity polytetrafluoroethylene graft thrombectomy-thrombolysis procedure that followed attempted nontunneled catheter placement via the groin.