Tunneled catheter insertion

Tunneled HD Catheters

Dr.Zaghloul GoudaNephrology Department,

Damanhour Medical National Institute

www.hd-cath.com www.telekidney.com

Dr.Mohamed Abd El GawadNephrology Specialist at New Mansoura

General Hospital

http://www.hd-cath.com/



http://www.telekidney.com/

Anatomy of venous system


4th Mansura Workshop2_2017.pptx





Venous system of the neck






Venous system of LLs







Insertion of Tunneled Dialysis Catheter






Introduction:

• Insertion of a central venous catheter for hemodialysis is an interventional procedure in

which many principles of endovascular techniques are applied.

• It involves obtaining vascular access under real time ultrasound guidance, wire

manipulations and sheath placements.







Sites of Insertion:The preferred site of insertion is the rightinternal jugular (IJ) vein as it is the shortestand most direct route to the right atrium.The alternative insertion sites, indescending order of preference:• Left IJ,• Right external jugular (EJ),• Left EJ,• Right femoral and left femoral vein.• Subclavian veins should not be used for

catheter placement as they areassociated with an unacceptably highincidence of stenosis, which wouldcompromise future upper limb AVaccess placement. The







Sites of CVC insertion:

B

AC

DE F

A - Central IJV approach

B - Subclavicular subclavian

vein approach

C – Posterior IJV vein approach

D - Supraclavicular subclavian

vein approach

E – Low IJV approach

F – Innominate vein approach



challenging slide.pptx





EquipmentWill be provided during the workshop







Length/French of Cuffed Catheters:

Length:

• Rt IJC: 24, 28 cm

• Lt IJC: 28, 32 cm

• Rt femoral/iliac CATH 36, 42 or 55 cm

• Lt femoral/iliac CATH 55 cm

There are many variations according to patient size and CATH availability

• Rt IJV CATH (24 cm), French 14 or more

• Other approaches at least 15 French

French:






Right Sided IJ Tunneled Catheter Insertion


Catheter insertion will be provided during the practical part of the

workshop www.hd-cath.com www.telekidney.com





Complications of Tunneled Dialysis Catheter Insertion







• Regardless of how “minor” or “simple” the procedure, never underestimate the complications that may arise during the procedure.

• Obeying the “rules” and developing good habits during training can go a long way to decrease procedure related complications.

Acute Complications of Tunneled Dialysis Catheter Insertion

The following are some of the complications that one may encounter during dialysis catheter placement, and the precautions and steps to treat them if they occur:






Prevention:1. Always access the vein under real time ultrasound guidance and pay attention to the

depth and ultrasound plane.2. Always use the micro puncture set to access the vein initially as cannulation created

using the micro puncture needle is small and bleeding can be stopped readily by compression.

3. Always verify the position of the micro puncture wire by fluoroscopy.

A. Arterial Puncture:

Treatment :It depends on which stage of the procedure the complication is discovered:1. If the complication is discovered before dilatation of the venotomy tract, the wires

and micro-puncture sheath can be safely removed and direct compression applied to arrest the bleeding.

2. If the complication is discovered after dilatation of the venotomy tract, leave the dilator in-situ to tamponade the vessel and call for help. The arterial puncture can be closed either by open surgical repair or using an arterial closure device.






C. Hemothorax:In the event of a hemothorax, surgical intervention is often necessary to stop the bleeding and evacuate the blood.

B. Pneumothorax:In the event of a pneumothorax, chest tube insertion is often necessary to evacuate the air leak






Preventive measures:1. Identify high risk patients. Patients who are dehydrated are at increased risk of air

embolism during line insertion. Their veins may be collapsed or show variation in sizewith the respiratory cycle on ultrasound. Give fluid boluses and perform the insertionwith the patient in the Trendelenburg position to minimize the risk of air embolism.

2. Always occlude the hub of the needle and close the hemostatic valve of the peel awaysheath during the procedure. As an added precaution, pinch the peal away sheathbetween your fingers after you have removed the inner dilator.

3. Instruct the patient to hold his/her breath during puncture of the IJ vein and insert thewire though the needle rapidly after successful puncture to avoid this complication.

4. The patient should be instructed to hold his/her breath during exchanges over thewire.

D. Air Embolism:






If there is significant air embolism1. Immediately place the patient in the left lateral decubitus and Trendelenburg position. If

cardiopulmonary resuscitation is needed, place the patient in a supine and head downposition.

2. Administer 100 % oxygen and do endotracheal intubation if necessary.3. Attempt removal of air from the circulation by aspirating from the central venous

catheter.4. Fluid resuscitate the patient and consider hyperbaric oxygen treatment.

D. Air Embolism:






E. Cardiac Arrhythmia:To prevent the wire from triggering arrhythmias during the procedure, always pass the guide wire tip into the IVC during the procedure.






Subacute Complications of Tunneled Dialysis Catheter

Suboptimal Flow

Fibrin Sheath

Clots

Mal-Position






Mal-position/kink:If the tunneled catheter has poor flow within a week of placement, it is often due to suboptimal positioning of the catheter tip, migration of catheter tip or kinking of catheter.

A. Check the position of the catheter tip on a chest x ray, in particular, look for any kinks in the catheter (Next Fig)

B. Withdraw the catheter if the tip of the catheter is distal to the mid atrium. If the tip of the catheter is proximal to the mid atrium, advancing the catheter carries the risk of contaminating the subcutaneous tunnel tract and infection.

In the latter situation, exchanging the catheter over a guide wire is preferred.


Suboptimal Flow:






( a ) Catheter is too short. Arrow shows that the of catheter is in the superior vena Cava.( b ) Tip of catheter is in an optimal position but the arrow shows that catheter is “kinked” by the purse string suture at the exit site. ( c ) Arrow shows that the catheter is “kinked” at the venotomy site

ba c


Suboptimal Flow:

Mal-position/kink:

c






Clots:If the catheter tip is in the correct position, a trial of a thrombolytic agent may be attempted.

A. The procedure should be carried out in a sterile manner. Clean and drape the patient.

B. Remove the caps of the catheter ports and aspirate 5 ml of blood from each lumen to remove the locking agent.

C. Instill 2 ml of TPA (1 mg/ml) into each lumen and allow it to dwell for half an hour.D. Aspirate both catheter ports and discard the initial 5 ml of blood.E. Test catheter flow with a 20 ml syringe. If the flow remains suboptimal, schedule

for catheter exchange over a guide wire.


Suboptimal Flow:






Fibrin Sheath:If the catheter develops poor flow more than a month after placement, it is probably secondary to obstruction from fibrin sheath formation around the tip of the catheter.

A trial of tPA may be attempted. If unsuccessful, exchanging the tunneled catheter over a guide wire with or without disruption of the fibrin sheath is the treatment of choice.

A. Check the position of the catheter tip on chest x ray.B. Aspirate both catheter ports and discard the initial 5 ml of blood which contains the

locking agentC. Insert a 0.035 in. angled stiff guide wire through the venous port of the catheter into

the inferior vena cava.D. Free the preexisting catheter cuff by blunt dissection and withdraw the catheter gently

by approximately 3 cm. Gently inject 10–15 ml of contrast material into the arterial port to visualize the fibrin sheath.

E. Remove the preexisting catheter and insert the 12–14 mm angioplasty balloon catheter over the wire via the subcutaneous tunnel tract, and inflate the balloon in the SVC to disrupt the fibrin sheath.


Suboptimal Flow:






F. Exchange a new-tunneled dialysis catheter over the guide wire and place the tip within the proximal SVC. Inject 10–15 ml of contrast via the arterial port to check for residual fibrin sheath. If fibrin sheath is still present, repeat the angioplasty. If there is no residual fibrin sheath, advance the catheter tip to the desired position in the mid atrium.


Suboptimal Flow:

Stripping of Fibrin SheathWill be provided during the workshop







Tunnel Tract Infection:1. Tunnel tract infection is defined as infection of the portion of the subcutaneous tunnel that

extends between the catheter cuff and the venotomy site.2. Broad spectrum antibiotics are required accompanied by removal of the tunneled dialysis

catheter.3. Temporary dialysis catheter is often required for dialysis access. A new tunneled catheter is

placed at a new site after the tunnel tract infection is treated






Removal of Tunneled Dialysis Catheter








''Fistula First, Catheter Last''

My Access, My Life





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Tunneled catheter insertion

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