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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2004  |  Volume : 15  |  Issue : 3  |  Page : 321-332
Radiological Placement of Hemodialysis Central Venous Catheters: A Practical Guide


1 Department of Diagnostic Imaging, Peter Lougheed General Hospital, University of Calgary, Canada
2 Department of Diagnostic Imaging, Foothills Hospital, Calgary, Alberta, Canada

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How to cite this article:
Schemmer D, Sadler D, Gray R, Saliken J, So B. Radiological Placement of Hemodialysis Central Venous Catheters: A Practical Guide. Saudi J Kidney Dis Transpl 2004;15:321-32

How to cite this URL:
Schemmer D, Sadler D, Gray R, Saliken J, So B. Radiological Placement of Hemodialysis Central Venous Catheters: A Practical Guide. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2020 Aug 3];15:321-32. Available from: http://www.sjkdt.org/text.asp?2004/15/3/321/32981

   Introduction Top


Typical indications for central venous cathe­ters (CVCs) are hemodialysis (HD), apheresis, total parenteral nutrition, analgesia, chemo­therapy, long-term antibiotic therapy and cases of difficult or absent peripheral venous access. [1],[2],[3],[4],[5] One of the largest medical services requesting CVC insertion is nephrology for HD patients.

Demographics dictate that the demand for CVCs will continue to grow over the next few decades, placing striking demands on inter­ventional radiology departments. [4],[6],[7],[8] In our centre, interventional radiologists now place nearly all percutaneously inserted HD CVCs. Radiologists provide rapid access to CVC services with significantly fewer complications than CVCs placed by other clinicians. [4],[6],[7],[8],[9] With the demand for CVC management in­creasing, and available operating room time decreasing, many clinicians now refer CVC insertions to radiologists. [4],[7],[9],[10] Also, clinicians who ordinarily place their own lines often refer high-risk patients, such as those who are obese or uncooperative and those with burns or coagulopathy.


   Background Information Top


CVC Classification

CVCs can be either temporary, for short­term therapy, or permanent, where a portion of the CVC is tunneled under the skin. The indications for temporary HD CVC are: new­onset renal failure, sudden loss of, or throm­bosis and occlusion of a fistula or graft, temporization until fistula or graft maturation, limited venous access of difficult patients (large body habitus) and patient choice. Permanent CVCs, which are more durable and more resistant to infection and inadvertent removal or dislodgement, may be indicated for patients in need of HD for longer than six weeks, for temporization until fistula or graft maturation and for uncooperative patients.


   CVC Types and Composition Top


Permanent and temporary CVCs are manu­factured straight or pre-curved, with or with­out subcutaneous cuffs, often of Dacron, and may also have an antimicrobial coating [Figure - 1],[Figure - 2]. [4] The most common compo­sition of double-lumen CVCs for HD patients, both temporary and permanent, is polyure­thane or silicone. Pre-curved catheters are designed to support acute angles from the jugular approach without kinking. The curve imposes a predefined puncture-to-catheter tip length, which was originally designed for blind surgical or bedside placement. Blind punctures typically assume a higher puncture on the neck than those used by radiologists with real-time image guidance and result in a potentially low superior vena cava (SVC) location of the catheter tip. Newer radiological techniques are the impetus for the redesign of CVCs by medical supply companies.

Pre-Procedural Work-Up

Obtaining the history of previous access sites, interventions, procedures, (i.e.: angioplasties, stents, occlusions or stenoses, inferior vena cava filter insertions), remaining known access sites, medications and allergies are important. [1]

Bleeding parameters also require investi­gation. Optimally, platelets should be > 50 X 10 3 /L for tunneled CVCs, although a lower platelet count is acceptable for temporary CVCs. In our experience, international norma­lized ratio and partial thromboplastin time values of < 1.3 and < 60 secs, respectively, are preferable, but < 3 and < 80 are tolerated for temporary CVC insertions. Of course, clini­cians may, on occasion, demand the placement of temporary HD CVCs, even in the presence of significant coagulopathy. Platelet function is often impaired in HD patients and may be improved by desmopressin administration.


   The Procedure Top


Site Selection

A variety of sites for CVC insertion are available: right internal jugular vein (IJV), left IJV, subclavian vein and femoral vein [Figure - 3] Venous access can also be gained by means of recanalization of occluded veins, translumbar and transhepatic hepatovenous approaches, but these are uncommon. [9] IJVs are preferable to subclavians (SCV) for central access sites because stenosis rates are as high as 50% in the latter. [3],[5],[6],[8],[10] The right IJV is preferred because the path to the superior vena cava - right atrium (SVC-RA) is shorter and straight and is commonly larger in caliber than the left; [8] this reduces the difficulty encountered when inserting left CVCs, around several curvatures. [2],[7],[8] [Figure - 4] If the caliber of the right IJV is suboptimal or occluded, the left IJV should be used. In HD patients, the order of decreasing preference of potential CVC access is: IJV, SCV, femoral (right then left) and, lastly, the IVC by means of a trans­lumbar approach. [4] There are lower rates of thrombosis, stenosis and occlusion with ind­welling tunneled IGV CVCs than with SCV CVCs. [11]

Imaging of Venous Access

An initial high-resolution real-time ultra­sound (US) examination of the proposed access site improves cannulation success rates, redu­ces the number of passes, the procedure time and the complication rates, ultimately making it superior to blind attempts. [1],[2],[3],[4],[5],[7] Veins can be analyzed using gray-scale and color Doppler interrogation, making note of venous caliber, position of veins relative to arteries, Doppler wave form, presence of thrombus and potential collateral vessels.

Patient Preparation

Patients, wearing a sterile bonnet, should be placed in the supine position with their heads turned away from the side about to be punctured when entering the IJV [Figure - 5]. The prospective surgical site should then be cleansed with antiseptic, usually iodine, and a standard sterile surgical draping technique is used to ensure an aseptic surgical field and to reduce infection. Catheter placement in anxious patients can be facilitated with administration of a mild sedative (i.e. intravenous benzodia­ zepines and narcotics). The department of anesthesia can provide superb levels of com­fort and markedly improve the ease of the CVC insertion in difficult-access cases or uncooperative patients.

Making the Venous Puncture

The use of sterile jelly and a probe cover allows for real-time high-resolution visuali­zation of the vein (ideally with a 7.5-10 MHz linear array probe). The linear US probe is positioned parallel to the clavicle but perpen­dicular to the vein [Figure - 6] [12] The site and angle of the local anesthesia needle (1% lidocaine without epinephrine) and subsequent trocar puncture should be approximately 2­3 cm cephalad to the clavicle [Figure - 5],[Figure - 6],[Figure - 7]. Operators early in the learning curve should recognize that low punctures can cause SVC or artery punctures or pneumothorax, and that slightly higher punctures are safer. Ideally, the US probe is centered over the vein and perpendicular to the skin surface [Figure - 8]. The direction of local anesthesia admini­stration, all subsequent punctures and dilator advancements should be in the same plane close to the vein's long axis [Figure - 9]. A horizontal skin incision the size of the anti­cipated CVC should then be made with a scalpel, lifting and slicing the skin with the beveled side up and bluntly dissecting the subcutaneous tissues. Stabbing of the skin should not be performed.

With the US probe securely held in the non-dominant hand, the 19-gauge trocar is advanced, in real-time, into the IJV at approxi­mately 45 o -60 o , using negative pressure in a sterile saline-filled 10mL syringe. [2],[3],[4] Some institutions may use a blind micropuncture needle set, but we feel that with real-time visualization, this is unnecessary and adds cost as well as complications to the procedure. An attempt to make a single anterior wall pun­cture is always encouraged to reduce the risk of an arterial puncture or transgression of the pleura. The needle tip obviously should be placed through the skin incision to avoid a tissue-band that may kink the CVC. [6] It is helpful to remember in a low-pressure venous system that the needle usually indents the anterior wall before penetration and may readily advance well into the vein, sometimes as far as the posterior wall [Figure - 10]. The trocar may have to be pulled back into position with the needle tip properly into the epicenter of the vein [3] [Figure - 11].

Tipping the trocar needle toward the hori­zontal plane will help advance the wire. Not uncommonly, the vein to be punctured can be small in caliber because of the inspiratory phase of the patient [Figure - 12]. In either case, when using real-time US, the patient can be instructed to perform a Valsalva's maneuver, or assistants may lift the patient's legs or tilt the patient into the Trendelenburg position to help dilate and successfully cannulate the IJV [Figure - 13]. [13]

How to Avoid Air Embolus

To maintain a closed venous system, when removing the saline syringe, the thumb should be placed over the trocar end-hole to prevent the aspiration of air. The two most common situations for air embolism are when the CVC lumen is left open and when the tunneled CVC is introduced through the sheath.

Inserting the Guide Wire and CVC Selection

Using fluoroscopic guidance, a 0.035 mm J-guide wire is introduced into the IJV and advanced toward the SVC-RA junction or lower, often into the IVC [Figure - 14]. To assist in catheter measurement, a 5-Fr dilator may be advanced over the J-wire until the curve is straight [Figure - 15]. Some interventional radiologists find it useful to measure the skin to SVC-RA distance by crimping the plastic dilator with straight snaps to properly select the CVC length needed.


   Overcoming Guide Wire Problems Top


Dealing with Difficult Guide Wire Insertion

When a successful venous puncture has been made and a flash of blood is withdrawn into the 10-mL syringe but there is difficulty advancing the guide wire, several procedures can be attempted. Often the needle tip is simply beyond the vein in tissue, and a simple retra­ction is the solution. Confirmation of an intravascular needle tip can be made by care­fully injecting contrast medium, which can reveal central stenoses [Figure - 16]. A 0.035 mm Terumo wire, with or without a 4-5 Fr. Dilator, may also be used under fluoroscopic guidance to negotiate venous stenoses, or diag­nostic "road maps" can be used (where avail­able) to negotiate beyond curved or stenotic veins.

How to Redirect and Place Guide Wires Securely

If the guide wire inadvertently passes into the SCV, it can be redirected by shaping the dilator to redirect it into the SVC-RA [Figure - 17],[Figure - 18]. Ideally, before further dilation maneuvers are started, the guide wire should be manipulated into the IVC to ensure that the wire does not inadvertently stimulate the heart, or worse, entangle in the chordae tendinae or valves [Figure - 19]. The patient can be asked to inspire to elongate the media­stinum, bringing the RA-IVC orifice into a vertical orientation. If this is not possible, the guide wire can be left in the RA and its position monitored with intermittent fluoro­scopy. However, emphasis must be placed on ensuring that the guide wire dilator system is closed so that air is not aspirated. The guide wire external to the patient can then be secure to the sterile drapes with artery forceps.

Making the Tunnel

The permanent catheter can be laid over the chest wall to map out the tunneling track, but this invariably underestimates the required tract length by 1-2 cm. Patients with generous soft tissues and large breasts require shorter tunnels because with erect positioning, gravity pulls excess tissue down, drawing the distal CVC tip away from the SVC-RA. Three potential sites can be used [Figure - 20]. Once the curvature of the CVC is placed on the skin with its apex at the initial puncture site, the length and cuff exit site can be ascertained. Again, local anesthesia is administered, in an oblique medial and cephalic direction, toward the supraclavicular puncture site.

Advancing the CVC Through the Tunnel

The CVC is then advanced through the tunnel using the tapered CVC trocar [Figure - 21]. Commonly, the maximum resistance encountered through the tunnel is at the clavipectoral fascia or where the platysma inserts on the clavicle. Steady and firm pressure is required to control any forceful maneuvers and prevent inadvertent trocar advancements. Then, the trocar tip is manipulated out of the skin puncture site. The hub of the tunneled CVC should be buried up to the skin entry site, further into the tunnel than required, allowing for subsequent partial withdrawal should a CVC kink occur. [6] This allows the CVC tip position to be altered. It is important to confirm the correct orientation of the tip of the CVC; the venous (blue) port is the laterally positioned port on the anterior thoracic surface.

Dilating the Venous Access

Venous access is dilated using a series of progressively larger dilators, usually from 7 Fr. to 13 Fr. It is vitally important to ensure that the direction of dilator insertion, and eventually the CVC, is exactly parallel to the guide wire to prevent vascular trauma, extravascular dilatation or loss of access. It is essential that the dilator slide freely over the guide wire in situ and that the wire and dilator are not advanced as a unit.

When left IJV CVCs are inserted, directing patients to inspire will elongate the media­stinum and minimize the degree of angulation at the union of the left IJV-innominate veins and the left and right innominate veins.

Kinked Catheters and Sheaths

Occasionally, a kink can manifest at the apex of the curved CVC. This can be prevented by making thorough blunt dissection at the initial supraclavicular incision site. A single guide wire, or two wires with regular stiff­ness or greater, can be inserted through the distal port(s) to help straighten the catheter irregularity [Figure - 22],[Figure - 23].

Left-sided sheaths and CVCs are more prone to kink and, if insertion of extra-stiff wires through the CVC does not help, patients can be asked to inspire to help straighten the sheath-CVC unit. If this is unsuccessful, the sheath can be pulled back slowly and care­fully, ensuring that the CVC stays in situ. If the guide wire through the CVC is in the IVC, the CVC can then be readily advanced.

Removing the Peel-away Sheath and Protecting the Closed Venous System

Eventually, the final dilation is made using a peel-away sheath, which ideally is advanced beyond the azygous vein to prevent CVC misplacement. Enough sheath is left to pinch the distal sheath [Figure - 24]. The following series of steps are the most prone to serious complications: extraordinary care should be taken to ensure that air is not aspirated in through the large caliber sheath. Various methods are employed to ensure the removal of the sheath introducer and guide wire and subsequent insertion of CVC tip is a rapid exchange.

Some interventional radiologists request that the patients voluntarily inhale, hold their breath, and then perform the Valsalva man­euver while the introducer-CVC exchange is made. However, others do not rely on patient compliance, and instruct their surgical nurse to remove the guide wire and sheath introducer en bloc. This allows the radiologist the opportunity to readily pinch and occlude the hub of the sheath in one hand while the dilator is removed and to insert the tip of the CVC with the other (which lies millimeters away from the sheath orifice. [Figure - 25])

Unreliable and uncooperative patients may require the use of the latter process, but longer sheaths that extend into the IVC, a supra­atmospheric environment, a Trendelenburg position or having someone lift the patient's legs will help raise central venous pressures. The safest method would be to use a peel­away sheath with a one-way hemostatic valve. Eventually, the CVC is inserted and the peel­away sheath is separated and removed, pulling the opposing sides away from one another with a digit on the apex of the CVC.

Assessing CVC Patency and Prophylactic Anticoagulation

The patency of the CVC ports, both aspiration and injection phases, should be assessed to ensure satisfactory function using 2 to 5 ml normal saline syringes. Subsequent anticoagu­lant instillation should ensue using heparin or, less commonly, sodium citrate. The volumes and dosing are usually provided by the res­pective CVC manufacturers.

Both the supraclavicular and exit skin sites should be closed with sutures. We use silk because it is readily and easily tied, although there is an argument for using a synthetic monofilament (i.e. that they may be less likely to harbor infection). We have not found this to be the case. The exit wound may benefit from first suturing in place a securing knot in the skin, and then knotting several loops around the hub of the CVC to prevent early accidental dislodgment [Figure - 26]. Finally, an image should be acquired to confirm a smooth CVC course, appropriate CVC tip orientation and distal tip location at, or adjacent to, the SVC-RA junction or upper third of the atrium [1] [Figure - 27].

The cuff of the tunneled CVC should remain subcutaneous and ideally just inferior to the clavicle.

Post-procedural Orders and Management

A routine check of vital signs every 15 minutes for the first hour, and then every 30 minutes for two hours for bleeding and patient stability is indicated. If the patient is bleeding from the wound sites, direct pressure usually provides hemostasis. The patent may also be positioned upright to decrease hydrostatic pressure, or thrombin can be applied locally. Desmopressin, which is used to augment dysfunctional platelets, is commonly admini­stered to HD patients on arrival to the dialysis ward. Mild analgesia (acetaminophen, NSAIDS) for pain control and when concern arises, a chest radiograph, can be ordered. Routine chest radiographs are unnecessary when CVCs are placed using the techniques described. The patient can be discharged home or to the dialysis unit after two hours if all evaluations are satisfactory.

 
   References Top

1.Silberzweig JE, Sacks D, Khorsandi AS, Bakal CW. Reporting standards for central venous access. J Vasc Interv Radiol 2000; 11:391-400.  Back to cited text no. 1    
2.Sadler DJ, Gordon AC, Klassen J, Saliken JC, So CB, Gray RR. Image-guided central venous catheters for apheresis. Bone Marrow Transplant 1999;23:179-82.  Back to cited text no. 2    
3.Gordon AC, Saliken JC, Johns D, Owen R, Gray RR. US-guided puncture of the internal jugular vein: complications and anatomic considerations. J Vasc Interv Radiol 1998; 9(2):333-8.  Back to cited text no. 3    
4.Mauro MA, Jaques PF. Radiologic place­ment of long-term central venous catheters: a review. J Vasc Interv Radiol 1993;4:127-37.  Back to cited text no. 4    
5.Caridi JG, Hawkins IF Jr, Wiechmann BN, Pevarski DJ, Tonkin JC. Sonographic guidance when using the right internal jugular vein for central vein access. AJR Am J Roent­genol 1998;171:1259-1263  Back to cited text no. 5    
6.Funaki B, Szymski GX, Leef JA, Burke R, Hackworth CA, Rosenblum JD. Radiologic placement of tunneled central venous catheters: Techniques and pitfalls. Applied Radiology 1988;8-13.  Back to cited text no. 6    
7.Mauro MA, Jaques PF. Insertion of long­term hemodialysis catheters by interventional radiologists: the trend continues. Radiology 1996;198:316-7.  Back to cited text no. 7    
8.Macdonald S, Watt AJB, McNally D, Edwards RD, Moss JG. Comparison of technical success and outcome of tunneled catheters inserted via the jugular and subclavian approaches. J Vasc Interv Radiol 2000;11:225-31.  Back to cited text no. 8    
9.Getrajdman GI, Brown KT, Brody LA, Susman J. Simple central venous catheter placement in patients with occluded central veins. J Vasc Interv Radiol 2000;11:1043-6.  Back to cited text no. 9    
10.Lund GB, Trerotola SO, Scheel PF Jr et al. Outcome of tunneled hemodialysis catheters placed by radiologists. Radiology 1996;198: 467-72  Back to cited text no. 10    
11.Trerotola SO, Kuhn-Fulton J, Johnson MS, Shah H, Ambrosius WT, Kneebone PH, Tunnelled infusion catheters: increased incidence of symptomatic venous throm­bosis after subclavian versus internal jugular venous access. Radiology 2000;217(1):89-93.  Back to cited text no. 11    
12.Gomes MR, Nazarian GK. Central venous access, In: Ferrel H, Bjarnason H, Qian A (eds). Synopsis of Castandeda's: inter­ventional radiology. New York: Lippincott Williams & Wilkins; 2001. p.225-35.; 11(10):1315-1318.  Back to cited text no. 12    
13.Forauer AR, Alonzo M. Change in peri­pherally inserted central catheter tip position with abduction and adduction of the upper extremity. J Vasc Interv Radiol 2000; 11(10):1315-1318.  Back to cited text no. 13    

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Correspondence Address:
Drew Schemmer
Peter Lougheed General Hospital, University of Calgary, 3500-26th Ave, NE, Calgery, Alberta, T2N-1A4
Canada
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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12], [Figure - 13], [Figure - 14], [Figure - 15], [Figure - 16], [Figure - 17], [Figure - 18], [Figure - 19], [Figure - 20], [Figure - 21], [Figure - 22], [Figure - 23], [Figure - 24], [Figure - 25], [Figure - 26], [Figure - 27]



 

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