A Novel Technique for Tethered Dialysis Catheter Removal Using the Laser Sheath

Traction and cutdown techniques can successfully remove a tunneled dialysis catheter (TDC) in a great majority of patients. However, these methods may not be successful in patients with catheters that are tethered or attached to the central veins or the atrium. A forceful application of traction can lead to catheter breakage with subsequent retention of the broken piece and carries a potential risk of vascular and atrial wall avulsion. Open thoracotomy has been employed to remove an attached TDC. However, this procedure is invasive and bears a significant morbidity. This report presents three cases of tethered TDCs that underwent laser sheath extraction. The TDCs had been in place for an average of 26 months. The patients underwent initial unsuccessful removal attempt using the traction method with surgical exploration all the way to the venotomy site. The laser technique that is used to remove pacemaker/implantable cardioverter defibrillator leads was then applied to these stuck catheters. All three catheters were successfully removed without any damage to the catheter, central veins, or the right atrium. There were no retained catheter fragments left in the central veins or the atrium. One patient demonstrated a significant thrombus that extended from the tip of the catheter all the way to the right ventricle. The external sheath of the laser device successfully aspirated the thrombus. There were no procedure‐related complications. In this small series, a laser sheath successfully extracted tethered dialysis catheters. The study found the procedure to be effective, easy to perform, and minimally invasive. We suggest that this approach be considered for the removal of tethered catheters that cannot be removed using traditional approaches.     

Supraclavicular Catheterization of the Superior Vena Cava

In seeking to develop a simple and safe technique of central vein catheterization, a supraclavicular route to the superior vena cava was chosen. Advancing from a point above the medial portion of the clavicle, the needle punctures the wall at the confluence of the subclavian and internal jugular veins, and a siliconized catheter is introduced straight into the superior vena cava. The technique is described in detail.
The results of 600 catheterizations are reported. Unsuccessful attempts at cannulation were recorded in 6.3%, malposition of the tip of the catheter in 1.7%, pneumothorax in 0.3% and other complications in altogether 3.3% of the cases. Attention is drawn to the potential dangers inherent in cannulation of major central veins. The supraclavicular route described seems to provide a straightforward, reproducible approach to the superior vena cava, and it seems to have a low incidence of technical failures and early and late complications.     

Central venous access for long-term haemodialysis

Long-term central venous catheterization has been used as the sole method of vascular access in nine chronic dialysis patients with severe access difficulties. The catheters were inserted into the right atrium via external or internal jugular veins by a simple operative technique and have remained in situ for 1-33 months. Although three catheters required replacement for incorrect positioning (two patients) and catheter-associated thrombosis (one patient) no patient failed with the technique. Catheter-related complications were infrequent. The study demonstrates that it is possible to undertake adequate and safe haemodialysis through a permanently indwelling central venous catheter in patients in whom conventional methods of vascular access, and other modes of renal replacement therapy, have failed repeatedly.     

Long-term hyperalimentation in children through saphenous central venous catheterization

During a 3.5 year period, 151 Silastic central venous catheters were inserted into the inferior vena cava through the saphenous vein in 132 children younger than age 19 years at UCLA Hospital. The major indications for catheter insertion included inflammatory bowel disease, cancer or bone marrow transplantation, and short bowel syndrome. The 151 catheters were used for a total of 13,288 days of fluid administration (mean 88 days). Complications requiring removal of the catheter occurred in 31 patients, but there were no deaths attributable to complications from the catheters. The total incidence of complications was one per 225 days of catheter use, less than that occurring in catheters placed in the external jugular and cephalic veins in young children in our hospital. The ease of insertion, the low complication rate and the simplicity of patient management when catheters are placed into the vena cava through the saphenous vein appear to make this an optimal site for administering parenteral nutrition in infants and children.     

Use of the gonadal vein in children with difficult central venous access: a novel technique

In children who require multiple central venous catheterization, the commonly used veins can become thrombosed making central venous access a challenging problem. The authors report on a patient with a rare metabolic disorder who had extensive thrombosis of the superior vena cava and iliofemoral veins, in whom the right ovarian vein was cannulated using a retroperitoneal approach for the placement of a SILASTIC((R)) (Dow Corning, Midland, MI) catheter with an implantable port. This is a useful and reliable technique in children who have difficult venous access.     

Use of the Tesio catheter for hemodialysis in patients with end-stage renal failure: a 2-year prospective study

BACKGROUND: The Tesio catheter system has been proposed to be a reliable source of vascular access for the dialysis patient with low rates of infection and other complications. Whether such catheters provide reliable short- and long-term access remains undetermined. METHODS: This study prospectively examined all Tesio lines inserted over a 2-year period in patients with end-stage failure with careful recording of all catheter complications and reasons for catheter loss. RESULTS: 100 catheters were inserted in 82 patients giving a total experience of 13,749 catheter days; 74 catheters were inserted into the jugular veins, the remainder into the femoral veins; 82 insertions were covered with antibiotics. At the end of the study, 29 catheters remained in situ. Of the remaining 71 catheters, 27 catheters were removed because of fashioning of definitive access. Nine catheters were lost due to infection and 10 were lost due to non-function; 19 patients died with a functioning catheter. Episodes ofnon-function were the major complications, although catheter patency was restored in 90% of cases utilizing urokinase and warfarin. Overall 80% of femoral and 16% of jugular catheters required anticoagulation. CONCLUSIONS: Tesio catheters inserted into the jugular or femoral veins can provide excellent access whilst awaiting definitive dialysis access. They are well-tolerated with a low complication rate compared to standard temporary central venous catheters. Non-function remains a significant problem, especially in femoral catheters, which should be anticoagulated following insertion. Because of our results we suggest that these catheters be used as part of the co-ordinated approach to the management of vascular access in end-stage renal failure patients without definitive access.     

Ultrasound-guided infraclavicular axillary vein cannulation

Background and objectivePercutaneous central venous cannulation is a challenging procedure. Traditionally, an external landmark technique has been used to identify puncture site. We wanted to evaluate an ultrasound-guided technique for the axillary vein cannulation, looking specifically at the ease of use, success rate and decreased complications.MethodsSixty consecutive surgical patients scheduled for central venous catheter placement were registered. An ultrasound scanner made for guiding an in plane puncture of axillary vein was used. After locating the vessels, an echo-guided sterile procedure was performed to cannulate the vein.ResultsCannulation was successful in all patients, and there were no complications during insertion of the catheters. Both axillary veins were cannulated, and the vein was punctured successfully at first attempt in 95% of the patients. The median time from the start of the first puncture (of the skin) until the aspiration of blood was 15 (7– 135) seconds.ConclusionThis ultrasound-guided technique for inserting central venous catheters in axillary vein was easy to apply. This procedure could increase precision and safety in patients undergoing axillary vein cannulation.     

Central venous septic thrombosis managed by superior vena cava Greenfield filter and venous thrombectomy: a case report

Operative management of a patient with septic thrombosis from Candida organisms of the subclavian and central veins is described. Diagnosis was suspected on the basis of positive blood and catheter tip cultures, indium-labeled leukocyte scan, and bilateral upper extremity phlebograms. Venous thrombectomy with a Fogarty catheter of the upper extremity central veins was performed after a superior vena cava Greenfield filter had been placed to prevent pulmonary embolism. The thrombus culture was positive for Candida albicans, and the reestablishment of vein patency in conjunction with amphotericin B therapy resulted in cure. This technique allows a definitive diagnosis of septic central thrombosis to be made and reestablishment of vein patency may also enhance antibiotic therapy.     

Vascular Access for Therapeutic Plasma Exchange

Abstract: Adequate venous access is an essential component of therapeutic plasma exchange (TPEX). The simplest kind of venous access is venipuncture of antecubital veins, but this technique may be limited by venous size or scarring following the procedure, requiring the placement of a specialized vascular access device (VAD). VADs provide reliable central venous access and may remain in place for several weeks or months, depending on the VAD and the venous site chosen. Their use, however, is potentially limited by the risk of complications. We discuss indications for insertion, choice of catheter and access site, and complications of VAD placement for TPEX.     

Vascular access surgery: a 2-year study and comparison with the Permcath.

The results of a 2-year prospective study of primary and secondary vascular access surgery for haemodialysis have been compared with a retrospective study of central venous access via a flexible silicone catheter (Permcath). Cumulative patency for 61 primary fistulae in 57 patients was 64.8% at 1 year and 57.7% at 2 years. The patency of 55 secondary procedures in 43 patients was 48.1% at 1 and 2 years. Cumulative survival of 64 Permcaths inserted into 51 patients was 74% at 1 year and 43% at 2 years. Surgical complications included explorations for bleeding (2), haematomas (4), swollen arms (4), and inadequately dilated veins (4). Permcath complications included explorations for bleeding (3) and a temporary recurrent laryngeal nerve palsy (1). Exit site infection and septicaemia rates were 4.95 and 3.36 per 1000 catheter days respectively, but 20.6% of septicaemic episodes occurred in a patient who refused catheter removal. For haemodialysis, the Permcath is comparable with secondary vascular access. The Permcath may have a primary access role in patients with limited life expectancy.     

Central venous cannulation: ultrasound techniques

Central venous cannulation is commonly undertaken by a range of specialties in diverse clinical settings. Central veins may be cannulated by the landmark, ultrasound-guided or open surgical cut-down techniques. Complications of central venous catheter (CVC) insertion are common and may lead to significant morbidity and very occasional mortality. Two-dimensional ultrasound-guided central venous catheter placement has been shown by randomized controlled trials to be superior to the landmark technique. It reduces both the number of needle passes required for successful placement and the incidence of complications. Constant needle-tip visualization is a challenge for the novice operator.The UK National Institute for Clinical Excellence (NICE) has recommended since 2002 that following appropriate training, clinicians should use ultrasound wherever practical in both elective and emergency internal jugular vein catheterization. Most clinicians would now recommend its use for all routes of access.     

Alternate Routes for Children with Difficult Central Venous Access

Background: Some children requiring chemotherapy, total parenteral nutrition, or repeated blood sampling for long periods have no more axillary, internal jugular, external jugular, saphenous, or femoral veins available for cannulation. In such patients, the central venous system can still be accessed via alternate routes e.g. the azygos vein, the gonadal vein or the inferior epigastric vein. Patients and Methods: We report the use of:

1) The inferior epigastric vein for placement of the catheter into the IVC in 20 patients. 2) The right gonadal vein for placement of the catheter using a retroperitoneal approach in five pediatric patients. 3) The second and third right intercostal veins for placement of the catheter by right intrapleural thoracotomy in five pediatric patients. Pre-procedural assessment of the patency of these veins was done using colour Doppler ultrasonography and confirmation of occlusion of common sites used for central venous access.

Results: A total of 38 implantable venous access devices (IVAD) were inserted in 30 patients. The average age at operation was 1.4 years (range 1 month to 12 years). Infection was seen in two patients, venous thrombosis in two. The average longevity of IVAD is 6.5 months. Recovery from the procedure was uncomplicated and the patients were able to receive complete intravenous medication or nutritive mixtures after the insertion of the catheter. Conclusion: The knowledge of alternate routes to obtain central venous access for children requiring chemotherapy, total parenteral nutrition, or repeated blood sampling for long periods is critically important, and the azygos system, right gonadal vein or the inferior epigastric vein can be used when standard accessible veins are unavailable.     

Techniques and tips for quick and safe temporary catheter placement

Nephrologists have to place temporary dialysis catheters for hemodialysis in emergency situations. Since there is a dearth of literature on this subject, the authors have written guidelines for the safe and successful placement of these catheters. These instructions should be of help to nephrology trainees who want to master the art of central venous line placement. Based on their experience, the authors have provided a number of tips and techniques for temporary catheter placement in the femoral, internal jugular, and subclavian veins, with and without ultrasound guidance. Patient positioning, preparation of the catheter insertion tray, handling of ultrasound probe, cannulation of the central veins, and guide wire and dilator insertion are described in detail. These guidelines should assist the novice in placing temporary catheters with ease and with minimal complications.     

The significance of the material of vascular catheters in the development of thrombotic complications in cava catheterization

Based on 210 cases of putting polyurethane catheters through the subclavian vein the authors substantiate the significance of the catheter material for the development of the most frequent complications. In addition to the absence of clinically diagnosed thrombotic complications, the advantages of this material were confirmed in US investigation of tributaries of the vena cava superior in 27 patients with polyurethane cava catheters staying in the same position during 3 weeks. In all the patients there were no signs of a reaction of a central veins to the catheter.     

Venography at insertion of tunnelled internal jugular vein dialysis catheters reveals significant occult stenosis.

BACKGROUND: Tunnelled catheters are widely used to provide vascular access for haemodialysis. Percutaneous insertion of these catheters requires large calibre tissue dilators with the potential to cause trauma to central veins, particularly if anatomical abnormalities are present. METHODS: We evaluated the use of venography to identify central vein anatomical abnormalities in 69 consecutive patients undergoing percutaneous placement of tunnelled right internal jugular vein catheters. The internal jugular vein was entered under ultrasound guidance and venography was performed prior to insertion of a guide-wire. Images were evaluated on-screen by the operator and a decision made regarding the need for additional fluoroscopy during insertion of the catheter. RESULTS: In 29 cases (42%), venography showed evidence of unexpected stenosis and/or angulation of the central veins of sufficient severity to warrant additional fluoroscopy during insertion of the dilators, or abandonment of the procedure. Patients who had previously had tunnelled internal jugular catheters had more than double the incidence of such abnormalities than those who had not [15/23 (65%) vs 14/46 (30%); P = 0.009]. In two patients the procedure was abandoned due to severe stenosis. No patient suffered central vein trauma or pneumothorax. There were no adverse reactions to contrast injection. CONCLUSIONS: Venography performed immediately prior to tunnelled internal jugular dialysis catheter insertion detects unexpected, clinically significant anatomical abnormalities of the central veins in a substantial proportion of patients, particularly those with a history of previous tunnelled catheter insertion. We suggest that the use of venography may help to minimize the risk of complications from this procedure.     

Combined endovascular and surgical recanalization after central venous catheter-related obstructions

Central venous occlusion in children is a challenging problem that can occur after a central venous catheter insertion. Long-term catheter-related complications include sepsis and venous thrombosis with consequent loss of central access. We describe 2 cases of children younger than 1 year who were dependent on a central venous catheter for total parenteral nutrition. They developed a chronic extensive obstruction of the right and left brachiocephalic veins with a superior vena cava syndrome. The patients' survival was dependent on the restoration of central venous access until the planned intestinal transplantation could be performed. Retrograde recanalization of the superior vena cava was successfully achieved using a pathway created under general anesthesia from the femoral vein to, respectively, the right thyroid vein and the right subclavian vein.     

Catheter malplacement during central venous cannulation through arm veins in pediatric patients

For successful catheter placement, central venous cannulation (CVC) through internal jugular vein and subclavian vein has been recommended in both adult and pediatric patients. But it carries a risk of serious complications, such as pneumothorax, carotid, or subclavian artery puncture, which can be life-threatening, particularly in critically ill children. So a prospective study was carried out to determine the success rate of correct catheter tip placement during CVC through antecubital veins in pediatric neurosurgical patients. A total of 200 pediatric patients (age 1-15 years) of either sex were studied. Basilic or cephalic veins of either arm were selected. All the patients were cannulated in the operation room under general anesthesia. Single lumen, proper size catheters (with stillete) were used for cannulation. The catheter was inserted in supine position with the arm abducted at right angle to the body and neck turned ipsilaterally. The length of insertion was determined from cubital fossa to the right second intercostal space. The exact position of the tip of the catheter was confirmed radiologically in ICU. Correct catheter tip placement was achieved in 98 (49%) patients. Multivariate logistic regression analysis of data shows that there was no statistically significant difference among correct and incorrect catheter tip placement in relation to factors including sex, side of cannulation (left or right), and type of vein (basilic or cephalic). The analysis of correct catheter tip placement in relation to age showed that the highest success rate was achieved in children of age group 6 to 10 years (60.2%) followed by 30.6% in the 11 to 15 year group. The lowest success rate of tip placement of only 9.2% was observed in younger children of age 1 to 5 years, which is statistically significant (P = 0.001). Of 102 incorrect placements reported, 37% were in 1 to 5 year age group versus 9.2% correct tip placements. The most common unsatisfactory placements were either in the ipsilateral internal jugular vein (N = 38, 37.2%) or in the ipsilateral subclavian vein (N = 27, 26.4%). In 10 patients the catheter crossed over to the opposite subclavian vein, in 16 patients the catheter tips were found in the axillary vein, and in 10 patients each the catheter tip was observed in right atrium and right ventricle. No major complication during and following CVC was observed. To conclude, CVC using single orifice catheter through arm veins in pediatric patients is easy to perform, but the proper catheter tip placement is highly unreliable, particularly in younger children 1 to 5 years of age.     

Catheter cerebral angiography in little children. Review of 71 examinations on 59 children under the age of 7 years (author's transl)]

Although the role of the cerebral angiography in the diagnosis of the central nervous system disorders in children is well established, there exists some reluctance to perform angiography in little children, probably due to technical difficulties and possible occurrence of side effects. For the last several years, we have performed catheter cerebral angiography on children with various disorders of central nervous system utilizing Seldinger's transfemoral technique. Our technique has been described in detail with special reference to the dilator catheter and double replacement technique, and the results of 71 catheter angiographies on 59 patients under the age of 7 years have been reviewed. No neurological complication or systemic reaction to contrast medium was noted. Circulatory disturbance at the site of femoral puncture was occasionally noted. Transient circulatory disturbance of several hours' duration was not uncommon in this age group. There were three cases which developed thrombus formation at the puncture site with resultant successful thrombectomy utilizing balloon catheter. The causes of these complications were analysed, and the need for systemic heparinization or heparin coated catheter during catheterization in little children was stressed. Comparison was made with other methods of cerebral angiography applied to children. It has been pointed out that this is a relatively convenient and safe technique applicable to little children, in whom multivessel study is often needed.     

Comparison of saphenous versus jugular veins for central venous access in children with malignancy.

A retrospective analysis was carried out to compare the performance and complications of central catheters inserted into either the saphenous (27) or jugular (52) veins. The saphenous route may be preferred in certain circumstances including extensive mediastinal pathology, prior neck surgery, previous catheter(s), and cosmetic reasons. There was no difference in complications (local or systemic catheter-related infections, catheter occlusions, or venous thrombosis). The incidence of catheter removal due to complications was also not different between sites. Hence, the saphenous route can provide an additional portal of vascular access in selected patients.     

Central venous catheterization: complications of different placements]

STUDY AIM: The aim of this prospective multicentric non-randomised trial was to report the complications of the central venous catheter insertion with different techniques and to assess the advantages of the low lateral approach to the internal jugular vein, according to the technique originally described by Jernigan et al, with our own modifications. PATIENTS AND METHOD: From January 1993 to August 1997, 2,290 CVC (2,286 by percutaneous puncture and 4 by surgical approach) were placed. The following complications were analysed prospectively: pneumothorax, accidental arterial puncture, more than two punctures of the same vein, necessity to shift to another venous approach, complete failure, malposition of catheter. RESULTS: The veins the most frequently used were internal jugular vein (48.7%), femoral vein (27%) and subclavian vein (24.2%). Internal jugular vein was punctured especially by low lateral approach (75%) and subclavian vein by infraclavicular approach (92%). With these two placements, the rate of pneumothorax was 0% and 3.1% respectively (p < 0.001), the rate of accidental arterial puncture was 1% and 2.7% respectively (p < 0.03) and the rate of more than two consecutive punctures was 3.1% and 6.3% respectively (p < 0.008). CONCLUSION: On our experience, we advocate the low lateral approach to the internal jugular vein as first choice technique for venipuncture in both adults and children for both short and long-term central venous approach, because it is associated to high rate of outcome and to low rate of complications in comparison with other techniques.