| Abstract|| |
Central venous catheters are widely used for both temporary and long-term angioaccess for hemodialysis. Insertion of these catheters is commonly performed using anatomic landmarks to guide vessel cannulation. Using traditional landmark-techniques, internal jugular venous catheter insertion is successful 82-88% of the time, with successful first-attempt cannulation of only 35-38%. Variations in anatomic relationships between the vein and surrounding structures may contribute to difficulty in venous cannulation using these traditional techniques. Real-time ultrasound guidance permits direct visualization of the target vein during catheter placement and is associated with increased successful cannulation (78-83% on first pass; 97-100% overall), a decreased number of attempts and a decreased complication rate. For this reason, we believe that real-time ultrasound-guided catheter insertion is superior to the traditional anatomic-landmark techniques and is emerging as the new standard of care
Keywords: Hemodialysis, Central venous catheter, Ultrasound.
|How to cite this article:|
Aslam N, Palevsky PM. Insertion of Temporary Dialysis Catheters with the Aid of Real-time Ultrasound. Saudi J Kidney Dis Transpl 2001;12:375-81
Adequate vascular access is essential for extracorporeal renal replacement therapy. Although an arteriovenous fistula (AVF) is the optimal angioaccess for chronic dialysis, temporary dialysis catheters are frequently required when a permanent access is not mature at the time of initiation of hemodialysis or in the setting of access malfunction or thrombosis. Temporary dialysis catheters are also needed for the management of patients with acute renal failure requiring hemodialysis or continuous renal replacement therapy and for extracorporeal detoxification with hemoperfusion or hemodialysis for the treatment of toxic ingestions and poisonings. Catheter access may also be necessary for the provision of therapeutic plasma exchange.
|How to cite this URL:|
Aslam N, Palevsky PM. Insertion of Temporary Dialysis Catheters with the Aid of Real-time Ultrasound. Saudi J Kidney Dis Transpl [serial online] 2001 [cited 2020 Feb 24];12:375-81. Available from: http://www.sjkdt.org/text.asp?2001/12/3/375/33561
Catheter access for these extracorporeal therapies is usually achieved through cannulation of one of the three easily accessible central veins, namely the internal jugular, subclavian, or femoral veins. Subclavian venous cannulation is associated with high rates of central venous stenosis and thrombosis. , This may result in severe venous hypertension in the ipsilateral arm and jeopardize the ability to use the arm for more permanent angioaccess. For this reason, the subclavian vein should be avoided for temporary access in patients with chronic renal disease.  Femoral venous catheters are associated with high rates of infectious and thrombotic complications and require limitation of ambulation.  For these reasons, the internal jugular veins provide the most desirable site for placement of temporary dialysis catheters.
The traditional approach to catheter insertion relies on the use of anatomic landmarks to guide the cannulation of the desired vein. This approach assumes a consistent anatomic relationship between the vein and the associated artery and other surrounding structures. The use of this traditional approach for cannulation of the internal jugular veins is successful in 82 to 88% of patients. ,, Successful cannulation is highly dependent on the experience of the operator.  Even in experienced hands, however, the success rate for placement of a dialysis catheter on first puncture attempt using the traditional landmark techniques is only 35-38%. ,, As a result, most patients require multiple attempts at venous cannulation prior to successful placement of the catheter. It is not surprisisng that the risk of complications increases with the number of cannulation attempts, in part as the result of the development of small hematomas, which distort the usual anatomic relationships, following each unsuccessful cannulation attempt.
The complications associated with placement of internal jugular catheters in general and dialysis catheters in particular are summarized in [Table - 1]. The most common complications include local hematoma 0.6-11.7%, ,, carotid artery puncture 0.87.6%, , and pneumothorax 0.3%.  Less frequent complications include hemothorax,  irritation of brachial plexus,  laryngeal hematoma,  vocal cord paralysis,  carotid arteriovenous fistula,  venous laceration,  arrhythmia, 8 cardiac perforation,  pericardial tamponade,  and even death. 
The successful placement of internal jugular dialysis catheters using the traditional landmark techniques depends upon a consistent relationship between the internal jugular vein and other anatomic structures, the patency of the vein, and its caliber.  It is often very difficult to access the central vein by using the landmark technique in patients who are obese, have neck swelling which makes landmarks difficult to recognize, or who have had had multiple prior catheters which may have had distorted the anatomy of the target vein. 
Lin et al  studied the anatomic variation of the internal jugular (IJ) vein in 104 consecutive patients with renal failure who presented for placement of IJ vein dialysis catheters. After placing the patients in the same position for catheter insertion as used for the landmark technique, a real time, two dimensional ultrasound device was used to localize the internal jugular vein. According to the anatomy of IJ vein, the patients were divided into four groups: Group 1 had normal anatomy with regard to size and location (61% on the right side and 58% on the left side); Group 2 had a normal caliber IJ vein with overriding of the carotid artery (21% on right side and 26% on left side); Group 3 had a small (< 5 mm) IJ vein (9% of patients bilaterally); and Group 4 had a variety of findings including displacement of the IJ vein more than 10 mm from the carotid artery, small caliber (< 5 mm) with overriding of the carotid artery, localization medial to the carotid artery or absence of the IJ vein (10% on the right side, 8% on the left side). Although the anatomic relationship in Group 2 is considered "near normal", the overriding of the carotid artery is associated with high risk for arterial puncture. The small vein caliber in Group 3 made the vein a small target for cannulation. The variable anatomy in Group 4 makes the vessel inaccessible using landmark techniques. Unilateral IJ vein variations were discovered in 17.3% of patients with bilateral variations in 8.7% of the patients.
In another study, Denys and Uretsky  evaluated the anatomy of the IJ vein using a similar ultrasound device in two hundred consecutive patients in a cardiac catheterization laboratory, coronary care unit and intensive care unit who required IJ vein cannulation for varying indications.
They estimated that in 8.5% of the patients the IJ vein anatomy was abnormal to the extent that it would have lead to complications using traditional landmark methods. These variations in the anatomy of the internal jugular vein can partially explain the 12-18% failure rate in the placement of central venous catheters using landmark techniques even in experienced hands. ,
Recently, Forauer et al  evaluated the significance of IJ vein ultrasound prior to placement of dialysis catheters in 79 longterm hemodialysis patients. In 28 patients (35%) there was a significant ultrasound abnormality, including total occlusion (n=18), non-occlusive thrombus (n=11), stenosis (n=5) and anatomic malposition (n=1). More importantly, these findings required a change in access approach in 21 patients.
Ultrasound guidance has been used for cannulation of central veins for over a decade.  It has been used for central venous access in cardiac catheterization laboratories, intensive care units, coronary care units, and emergency departments. , The use of real time ultrasound for placement of dialysis catheters was recently reported in different studies and its usefulness was compared with traditional landmark techniques. ,,, Real-time ultrasound is used to define the anatomy of the central veins and to provide direct guidance of the needle insertion during venous cannulation, thereby facilitating successful catheter placement.
Due to the superficial position of the internal jugular vein, a high-frequency (7.5 MHz) ultrasound probe, is used. , The ultrasound probe is usually placed perpendicular to the long axis of the vein, visualizing the vessel in its short axis as a circle.
The internal jugular vein can easily be differentiated from the carotid artery by the following characteristics: the vein is usually larger in diameter than the artery, it normally lies lateral and anterior to the artery, and it is easily compressible by the ultrasound probe [Figure - 1]. Using real-time ultrasound, the course of the needle can be visualized during venous cannulation, allowing directed insertion into the venous lumen and avoiding perforation of the posterior vessel wall. Theoretically, realtime ultrasound should increase the accuracy of cannulation and decrease the risk of damage to nearby structures, such as the carotid artery.
| Comparison of Landmark and Ultrasound Guided Techniques|| |
Various studies have demonstrated that ultrasound guided technique is associated with increased "first-pass" as well as overall cannulation rates, a reduced number of attempts required to achieve venous cannulation, a reduced procedure duration for catheter placement, and fewer complications in both the general and chronic dialysis populations as compared to the traditional landmark insertion techniques. These studies are summarized in [Table - 2].
Denys et al  reported the largest study comparing the landmark technique (302 patients) with real-time ultrasound-guided catheter insertion (928 patients) in a nondialysis population. The overall success rate was 88% using the traditional landmarkguided approach as compared to a 100% success rate in the ultrasound group (p<0.001). More importantly, the "firstpass" success rate was only 38.4% in landmark group as compared to 78% in ultrasound group (p<0.001). The average number of passes needed to achieve successful cannulation was 2.5 ± 2.7 using the traditional landmark-guided technique as compared to 1.3 ± 0.8 attempts using real-time ultrasound guidance. Access time (defined as time between penetration of skin and aspiration of venous blood into the syringe) was shorter in the ultrasound group (9.8 ± 14.3 seconds vs. 44.5 ± 129.5 seconds p<0.001). Complication rates were also significantly lower in the ultrasound group; hematomas were observed following realtime ultrasound-guided catheter insertion in 0.2% of patients as compared to 3.3% of patients following landmark-guided catheter insertion. Similarly, carotid artery puncture was reported in 1.7% of patients using realtime ultrasound as compared to 8.3% of patients with the landmark-guided technique and brachial plexus irritation was reported in 0.4% of patients with ultrasound as compared to 1.7% of patients with landmark guidance.
Lin et al  prospectively compared the landmark technique (86 patients) with the ultrasound technique (104 patients) in uremic patients undergoing IJ vein cannulation for placement of hemodialysis catheters. The overall success rate was 86% and 99% (p<0.01) in the landmark and ultrasound groups, respectively. Most striking was the difference in the first attempt success rate: 34.9% with landmarkguided insertion as compared to 80.8% with real-time ultrasound-guidance. The access time was also significantly less in ultrasound group (15.8 vs 43.7 seconds). Overall complication rate were also markedly reduced with the use of real-time ultrasound (11.6% in landmark group as compared to 1.9% in ultrasound group).
In a study comparing real-time ultrasound guidance to "blind" insertion following vein localization by ultrasound, Nadig et al  showed the superiority of the real-time ultrasound technique. There were 87 unsuccessful attempts in 37 patients when catheter insertion was attempted without real-time guidance following IJ vein localization as compared with only 10 unsuccessful attempts in 36 patients using real-time ultrasound guidance (p<0.001). In that study, first attempt success rate was also superior in the real-time ultrasound group as compared with ultrasound localization alone group (83% vs 35% p<0.01).
Farrell et al  retrospectively analyzed the data on 99 patients who underwent the placement of dialysis catheter either in internal jugular or femoral vein. The overall success rate and first pass success rate for internal jugular vein was better in ultrasound group. They also showed 100% salvage rate of failed cannulation using the landmark based technique by real-time ultrasound guidance (7/7). There was no difference in the overall success rate using either technique for femoral vein cannulation but there was a higher first attempt success rate (85.7 vs 56.2%) and fewer femoral arterial punctures (0 vs 6.25%) using ultrasound.
Kwon et al  prospectively evaluated real time ultrasound guidance in 28 patients undergoing femoral vein cannulation for placement of dialysis catheters in comparison to 38 patients in whom catheter insertion was performed using landmark techniques. Overall success rates were 89.5% and 100% for the landmark and ultrasound methods, respectively. Cannulation was successful on the first attempt in 55% of the patients in the landmark group and 92.9% of patients in the ultrasoundguided group. Access time and total procedure time were also shorter in the ultrasound group and arterial punctures were less than a half as frequent with the ultrasound-guided technique (7.1 vs. 15.8%).
These studies clearly demonstrate a significant advantage of real-time ultrasound guidance as compared to traditional anatomic landmark techniques for the insertion of central venous catheters. Realtime ultrasound guidance provides a better overall success rate for catheter placement. In addition, real-time ultrasound increases the success rate of the first attempt at cannulation from approximately 35-38% to over eighty percent and reduces the total number of attempts required to successfully achieve venous cannulation. The reduction in the number of attempts not only decreases the risk of complications but also reduces patient discomfort.
The use of real-time ultrasound guidance identifies patients with variations in the position of the IJ relative to the carotid artery and other anatomic structures. Since dialysis patients frequently have had prior internal jugular catheters for venous access, they are predisposed to tissue scarring and distortion of the venous anatomy. Real-time ultrasound guidance is therefore of particular value in this population in reducing the risk of arterial puncture, hematoma formation and other complications of catheter insertion.
The use of real-time ultrasound decreases the access time, the elapsed time between the penetration of the skin and aspiration of venous blood into the syringe, which compensates for the increased time required to place the transducer in a sterile sheath. In addition, one study has demonstrated wastage of fewer catheter sets using realtime ultrasound. 
Any assessment of the benefits of a new technique must be balanced by an assessment of its costs. Use of real-time ultrasound is associated with the cost of purchase and maintenance of the equipment and accessories, as well as training of the personnel. Light-weight, portable ultrasound devices designed for this purpose are commercially available for about $ 10,000 to $15,000. The ultrasound technique is easy to learn and rapidly produces an improvement over the anatomic landmark method. In the study by Deny et al 7 twentynine operators participated, performing less than 20 procedures. There was, however, no significant difference in the number of attempts or access time in low-volume operators as compared to the high-volume practitioners, suggesting that the procedure can be mastered with relative ease and rapidity. There is always a concern of increased infection rate when new equipment is introduced into the cannulation field. Lin et al  studied the infective complication rate in ultrasound and anatomic landmark groups and found no statistical difference in the rate of infection (2.9% vs. 2.3% with real-time ultrasound and landmark methods, respectively; p=0.589).
In conclusion, real-time ultrasound guided catheter insertion is superior to the traditional anatomic-landmark techniques for the placement of dialysis catheters and is emerging as the new standard of care. Ultrasound-guidance improves the success, safety and speed of catheter insertion. Although we believe the costs incurred for the acquisition of an ultrasound device and the requisite sterile sheaths for the ultrasound probe are more than balanced by the improved success in catheter insertion and increased patient safety, further studies are needed to rigorously address this issue.
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Paul M Palevsky
Chief, Renal Section (111F-U), VA Pittsburgh Healthcare System, University Drive Division, Pittsburgh, PA 15240
[Figure - 1]
[Table - 1], [Table - 2]