Practical Preprocedure Measurement to Estimate the Required Insertion Depth and Select the Optimal Size of Tunneled Dialysis Catheter in Uremic Patients

Safety of bedside placement of tunneled dialysis catheter in COVID-19 patients

COVID-19 patients admitted to the ICU have high incidence of AKI requiring prolonged renal replacement therapy and often necessitate the placement of a tunneled dialysis catheter (TDC). We describe our experience with two cases of COVID-19 patients who underwent successful bedside placement of TDC under ultrasound guidance using anatomical landmarks without fluoroscopy guidance. Tunneled dialysis catheter placement under direct fluoroscopy remains the standard of care; but in well selected patients, placement of tunneled dialysis catheter at the bedside using anatomic landmarks without fluoroscopy can be safely and successfully performed without compromising the quality of care and avoid transfer of COVID-19 infected patients outside the ICU.

A method to accurately estimate the catheter length needed for a tunneled central catheter placement

A typical method of placing a tunneled central catheter utilizes C-arm fluoroscopy for insertion and estimation of the length of the catheter needed. We describe a new technique to estimate the length more accurately using a C-arm fluoroscope.

Transjugular tunnelled dialysis catheter tip placement into the inferior vena cava upper segment after length overestimation

PURPOSE

The right atrium is preferred over the superior vena cava (SVC) for tunnelled dialysis catheter (TDC) tip placement as it offers the best compromise between optimal catheter performance and complications. However, clinical practice guidelines are not all unanimous on this as a universal recommendation. Right atrial tip placement may also fail due to variations in body surface area, venous anatomy or TDC designs and lengths. Moreover, the presence of recurrent long intra-cardiac fibrin sheath or cardiac rhythm management device leads serves as contraindications. Extra-cardiac tip placement in the azygous, hepatic veins and lower segment of the inferior vena cava (IVC) is an alternative but is invariably associated with poor blood flow and shortened patency.

METHODS

We report the concept of extra-cardiac tip placement into the larger calibre hepatic segment IVC via a transjugular approach in two diabetic haemodialysis patients with overestimated TDC length out of 380 insertions.

RESULTS

Blood flow was maintained above 250 ml/min for 5-6 months and no tip migration ensued.

CONCLUSIONS

The IVC upper segment is a reliable site for extra-cardiac tip placement in select cases but its safety and efficacy need to be further studied in larger clinical trials.