Placement of tunneled hemodialysis catheters - interventional standard.

While the native arterio-venous fistula (AVF) remains the first choice in vascular access for most hemodialysis patients, tunneled hemodialysis catheters (tHDC) continue to be an option in selected patients. Since timely access to vascular surgery-due to delayed referral or resource limitations-is not always possible, nephrologists have to become more actively involved in planning, creation and monitoring of vascular access. Moreover, this approach could also strengthen patient-centered care in nephrology. This manuscript reviews the current standard in tHDC creation, patient selection and strategies to mitigate the risk of infectious complications and catheter thrombosis. Presentation of novel developments in catheter placement with ultrasound-guided or ECG-guided positioning, their benefits and possible disadvantages emphasizes the complexity of vascular access planning. We offer an approach for choice of insertion method, depending on selected side and existing resources and set focus on the necessity and required resources of 'interventional nephrology' training programs.

Feasibility Analysis of Ultrasound-Guided Placement of Tunneled Hemodialysis Catheters.

Introduction: Radiographic fluoroscopy is the current standard for placement of tunneled central venous catheters (CVCs) for hemodialysis. Radiographic fluoroscopy requires structural and personnel infrastructure and exposes the patient to ionizing radiation. Here, we investigate the feasibility of solely ultrasound-guided placement of tunneled central venous dialysis catheters (USCVCs). Methods: We evaluated prospectively collected single-center data regarding safety and catheter function of 134 consecutive patients who underwent USCVC implantation between 2020 and 2021. We used the inset guidewire to visualize the position of the catheter tip. In the case of inadequate visibility by ultrasound, we used intracardiac electrocardiography (ECG) recording or agitated saline. A total of 1844 catheter days were assessed. The optimal CVC position was defined as being within the upper right atrium (URA) and middle to deep right atrium. Results: Of the 134 USCVCs, 87% were placed on the right side. The primary success rate for optimal tip position and catheter function was 98%. Of the USCVCs, 97% were placed solely by ultrasound. Regarding positioning, 6% were in the vena cava superior zone, 70% in the URA and 24% in the middle to deep right atrium, resulting in a rate of 94% with optimal positioning. Effective blood flow averaged 292 ± 39 ml/min. There were no immediate procedure-associated complications. Conclusion: Placement of CVC for hemodialysis solely by ultrasound is an effective alternative to fluoroscopy-assisted placement.

Pseudo-arterial Temporary Hemodialysis Catheter Placement in the Left Internal Jugular Vein Ipsilateral to a Preexisting Brachio-axillary Arteriovenous Graft.

Internal jugular vein (IJV) cannulation was originally described by English et al. in 1969 as the safest approach. Carotid artery puncture had an incidence rate of 4-6% before ultrasound guidance. We encountered an unexpected sequence of events following the ultrasound-guided placement of a temporary HD catheter in the left IJV. The postprocedure chest radiograph was misinterpreted as an arterial misplacement, the blood return was correspondingly bright red, and simultaneous blood gas analyses from the left IJV catheter and a right radial artery were near mirror images. Subsequently, a transducer to the catheter showed a clearly venous waveform with a pressure of 40 mmHg. Thus, it was realized that the cacophony of missteps, misjudgments, and misinterpretations was due to the contiguous presence of a functional left brachio-axillary arteriovenous (AV) graft. To our knowledge, this is the first such report of this phenomenon of a pseudo-arterial central venous catheter placement in the IJV.