Tunneled HD Catheters Dr. Zaghloul Gouda

Egyptian Society of Nephrology and Transplantation4th Interventional Nephrology Workshop

Mansoura International Hospital

Tunneled HD Catheters

Zaghloul GoudaNephrology Department,

Damanhour Medical National Institute

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

• My Participant colleagues• All members of Mansoura International Hospital• Nephrology Department• Committee of ESNT interventional Group


Anatomy of venous system


Venous system of the neck


Venous system of LLs


Insertion of Tunneled Dialysis CatheterInsertion 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.


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 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:

A - Central IJV approach

B - Subclavicular subclavianvein approach


B

AC

DE F

C – Posterior IJV vein approach

D - Supraclavicular subclavianvein approach

E – Low IJV approach

F – Innominate vein approach


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 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 providedduring the practical part of the

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

Complications ofTunneled Dialysis Catheter Insertion


Complications ofTunneled Dialysis Catheter Insertion


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

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

Acute Complications of Tunneled Dialysis Catheter InsertionAcute Complications of Tunneled Dialysis Catheter Insertion

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

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 toarrest the bleeding.

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

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 toarrest the bleeding.

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


C. Hemothorax:In the event of a hemothorax, surgicalintervention is often necessary to stop thebleeding and evacuate the blood.

B. Pneumothorax:In the event of apneumothorax, chesttube insertion is oftennecessary to evacuatethe air leak

C. Hemothorax:In the event of a hemothorax, surgicalintervention is often necessary to stop thebleeding and evacuate the blood.


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:

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.


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 triggeringarrhythmias during the procedure,always pass the guide wire tip into theIVC during the procedure.

F. Vessel Injury During Dilatation of the Venotomy Tract:• The guide wire might kink or buckle during dilatation of the venotomy tract.• Always pull back the wire slightly before pushing the dilators into the vessels.


Subacute Complications of Tunneled Dialysis CatheterSubacute Complications of Tunneled Dialysis Catheter

FibrinSheath

Clots

Mal-Position

Suboptimal Flow

FibrinSheath


Mal-position/kink:If the tunneled catheter has poor flow within a week of placement, it is often due tosuboptimal 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 anykinks in the catheter (Next Fig)

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

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


Suboptimal Flow:

Mal-position/kink:If the tunneled catheter has poor flow within a week of placement, it is often due tosuboptimal 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 anykinks in the catheter (Next Fig)

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

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


ba c


Suboptimal Flow:

Mal-position/kink:

c

( 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


Mal-position/kink:


Suboptimal Flow:


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

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

B. Remove the caps of the catheter ports and aspirate 5 ml of blood from each lumento 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:

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

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

B. Remove the caps of the catheter ports and aspirate 5 ml of blood from each lumento 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.


Fibrin Sheath:If the catheter develops poor flow more than a month after placement, it is probablysecondary 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 aguide 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 arterialport to visualize the fibrin sheath.

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


Suboptimal Flow:

Fibrin Sheath:If the catheter develops poor flow more than a month after placement, it is probablysecondary 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 aguide 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 arterialport to visualize the fibrin sheath.

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


F. Exchange a new-tunneled dialysis catheter over the guide wire and place the tipwithin the proximal SVC. Inject 10–15 ml of contrast via the arterial port to check forresidual fibrin sheath. If fibrin sheath is still present, repeat the angioplasty. If there isno residual fibrin sheath, advance the catheter tip to the desired position in the midatrium.


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


Exit Site Infection:1. Exit site infection is usually superficial and involves tissues distal to the catheter cuff,

however, if it is left untreated, it may progress to become a tunnel tract infection withloss of catheter access.

2. Depending on the severity of the infection, oral or systemic antibiotics may be used.3. If the infection does not improve or progresses despite antibiotic therapy, exchange of

the catheter with creation of new tunnel tract and exit site may be attempted.

Removal of Tunneled Dialysis CatheterRemoval of Tunneled Dialysis Catheter


TroubleshootingProblem

Make a small incision over the cuff and doblunt dissection through the incision to freeup the cuff

Cuff is placed too far from the exit site.Unable to reach cuff with hemostat

Palpate for the cuff in the subcutaneoustunnel.Make a small incision over the cuff. Using ahemostat and a forceps, remove the cuffusing blunt dissection techniques

Cuff became separated from the catheterand was left behind in the subcutaneoustunnel after removal of the catheter

Potential Problems and Troubleshooting

Removal of Tunneled Dialysis CatheterRemoval of Tunneled Dialysis Catheter

Palpate for the cuff in the subcutaneoustunnel.Make a small incision over the cuff. Using ahemostat and a forceps, remove the cuffusing blunt dissection techniques

Cuff became separated from the catheterand was left behind in the subcutaneoustunnel after removal of the catheter


Stage 1&2

Stage3a,b

Stage 5

Stage 4

30 ml/minInform

1- You have reduced kidneyfunction and you may needkidney replacement therapy(KRT) to save your life.

2- Describe modalities of KRT.

3- Spare forearm and upperarm veins from injections.Dorsum of hands is thepreferred site for injections andcannulation. This will savethese veins for creation of AVF.

٣١

Stage 1&2Stage 5

30 ml/minInform

1- You have reduced kidneyfunction and you may needkidney replacement therapy(KRT) to save your life.

2- Describe modalities of KRT.

3- Spare forearm and upperarm veins from injections.Dorsum of hands is thepreferred site for injections andcannulation. This will savethese veins for creation of AVF.

20 ml/min ……. CreateThis is the optimal time for creation of AVF/

preparation for preemptive kidneytransplantation


''Fistula First, Catheter Last''''Fistula First, Catheter Last''


''Fistula First, Catheter Last''''Fistula First, Catheter Last''

My Access, My Life

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Tunneled HD Catheters Dr. Zaghloul Gouda

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