Tunneled HD Catheters Dr. Zaghloul Gouda

Egyptian Society of Nephrology and Transplantation
4th Interventional Nephrology Workshop
Mansoura International Hospital
Tunneled HD Catheters
Zaghloul Gouda
Nephrology 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 right
internal jugular (IJ) vein as it is the shortest
and most direct route to the right atrium.
The alternative insertion sites, in
descending 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 are
associated with an unacceptably high
incidence of stenosis, which would
compromise future upper limb AV
access placement. The
Sites of Insertion:
The preferred site of insertion is the right
internal jugular (IJ) vein as it is the shortest
and most direct route to the right atrium.
The alternative insertion sites, in
descending 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 are
associated with an unacceptably high
incidence of stenosis, which would
compromise future upper limb AV
access placement. The

Sites of CVC insertion:
A - Central IJV approach
B - Subclavicular subclavian
vein approach
B
A
C
D
E F
C – Posterior IJV vein approach
D - Supraclavicular subclavian
vein approach
E – Low IJV approach
F – Innominate vein approach

Equipment
Will 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 provided
during the practical part of the
workshopwww.hd-cath.com www.telekidney.com

Complications of
Tunneled Dialysis Catheter Insertion
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 InsertionAcute 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:
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.
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
C. Hemothorax:
In the event of a hemothorax, surgical
intervention is often necessary to stop the
bleeding 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 size
with the respiratory cycle on ultrasound. Give fluid boluses and perform the insertion
with 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 away
sheath during the procedure. As an added precaution, pinch the peal away sheath
between 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 the
wire 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 the
wire.
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 size
with the respiratory cycle on ultrasound. Give fluid boluses and perform the insertion
with 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 away
sheath during the procedure. As an added precaution, pinch the peal away sheath
between 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 the
wire 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 the
wire.

If there is significant air embolism
1. 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 down
position.
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.
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
Fibrin
Sheath
Clots
Mal-
Position
Suboptimal Flow
Fibrin
Sheath

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:
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.

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 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:
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.

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 agent
C. 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:
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 agent
C. 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.

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 Sheath
Will 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 with
loss 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 do
blunt dissection through the incision to free
up the cuff
Cuff is placed too far from the exit site.
Unable to reach cuff with hemostat
Palpate for the cuff in the subcutaneous
tunnel.
Make a small incision over the cuff. Using a
hemostat and a forceps, remove the cuff
using blunt dissection techniques
Cuff became separated from the catheter
and was left behind in the subcutaneous
tunnel after removal of the catheter
Potential Problems and Troubleshooting
Removal of Tunneled Dialysis CatheterRemoval of Tunneled Dialysis Catheter
Palpate for the cuff in the subcutaneous
tunnel.
Make a small incision over the cuff. Using a
hemostat and a forceps, remove the cuff
using blunt dissection techniques
Cuff became separated from the catheter
and was left behind in the subcutaneous
tunnel after removal of the catheter

Stage 1&2
Stage
3a,b
Stage 5
Stage 4
30 ml/min
Inform
1- You have reduced kidney
function and you may need
kidney replacement therapy
(KRT) to save your life.
2- Describe modalities of KRT.
3- Spare forearm and upper
arm veins from injections.
Dorsum of hands is the
preferred site for injections and
cannulation. This will save
these veins for creation of AVF.
٣١
Stage 1&2
Stage 5
30 ml/min
Inform
1- You have reduced kidney
function and you may need
kidney replacement therapy
(KRT) to save your life.
2- Describe modalities of KRT.
3- Spare forearm and upper
arm veins from injections.
Dorsum of hands is the
preferred site for injections and
cannulation. This will save
these veins for creation of AVF.
20 ml/min ……. Create
This is the optimal time for creation of AVF/
preparation for preemptive kidney
transplantation

''Fistula First, Catheter Last''''Fistula First, Catheter Last''
''Fistula First, Catheter Last''''Fistula First, Catheter Last''
My Access, My Life

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