Peritoneal dialysis catheters: repositioning with new fluoroscopic technique

Complications of Peritoneal Dialysis Part I: Mechanical Complications

Peritoneal dialysis (PD) is a form of KRT that offers flexibility and autonomy to patients with ESKD. It is associated with lower costs compared with hemodialysis in many countries. However, it can be associated with unexpected interruptions to or discontinuation of therapy. Timely diagnosis and resolution are required to minimize preventable modality change to hemodialysis. This review covers mechanical complications, including leaks, PD hydrothorax, hernias, dialysate flow problems, PD-related pain, and changes in respiratory mechanics. Most mechanical complications occur early, either as a result of PD catheter insertion or the introduction of dialysate and consequent increased intra-abdominal pressure. Late mechanical complications can also occur and may require different treatment.

SAGES peritoneal dialysis access guideline update 2023

BACKGROUND

Minimally invasive surgery has been used for both de novo insertion and salvage of peritoneal dialysis (PD) catheters. Advanced laparoscopic, basic laparoscopic, open, and image-guided techniques have evolved as the most popular techniques. The aim of this guideline was to develop evidence-based guidelines that support surgeons, patients, and other physicians in decisions on minimally invasive peritoneal dialysis access and the salvage of malfunctioning catheters in both adults and children.

METHODS

A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons reviewed the literature since the prior guideline was published in 2014 and developed seven key questions in adults and four in children. After a systematic review of the literature, by the panel, evidence-based recommendations were formulated using the Grading of Recommendations Assessment, Development and Evaluation approach. Recommendations for future research were also proposed.

RESULTS

After systematic review, data extraction, and evidence to decision meetings, the panel agreed on twelve recommendations for the peri-operative performance of laparoscopic peritoneal dialysis access surgery and management of catheter dysfunction.

CONCLUSIONS

In the adult population, conditional recommendations were made in favor of: staged hernia repair followed by PD catheter insertion over simultaneous and traditional start over urgent start of PD when medically possible. Furthermore, the panel suggested advanced laparoscopic insertion techniques rather than basic laparoscopic techniques or open insertion. Conditional recommendations were made for either advanced laparoscopic or image-guided percutaneous insertion and for either nonoperative or operative salvage. A recommendation could not be made regarding concomitant clean-contaminated surgery in adults. In the pediatric population, conditional recommendations were made for either traditional or urgent start of PD, concomitant clean or clean-contaminated surgery and PD catheter placement rather than staged, and advanced laparoscopic placement rather than basic or open insertion.

Salvage of Malfunctioning Peritoneal Dialysis Catheters: An Algorithm for Recanalization and Repositioning

A peritoneal dialysis catheter salvage algorithm was developed and performed for 40 patients with documented catheter malfunction (obstruction and/or malposition) referred to the interventional radiology suite. This procedure utilized a metallic stiffener for repositioning and rotating dual guide wires for recanalization. A retrospective analysis of 35 cases of fluoroscopic manipulation showed that in 83% of the cases, the catheters were successfully repositioned and/or recanalized, and in 59%, they remained patent at 30 days. No major adverse events occurred. The results suggest that this algorithm is a safe and effective approach to salvage malfunctioning peritoneal dialysis catheters and that a trial of fluoroscopic salvage can be considered prior to surgical intervention.

Usefulness of the alpha maneuver in the peritoneal catheter displacement: review and experience

INTRODUCTION AND OBJECTIVES

Peritoneal catheter displacement is one of the most common complications of peritoneal dialysis. The alpha manoeuvre has been proposed as a repositioning technique, which involves returning the catheter to its correct position using rigid guidewires under fluoroscopic guidance. The aim of this study is to analyse the 107 procedures performed at our Centre to identify factors that may predict the success of the technique.

MATERIAL AND METHODS

The alpha manoeuvre method was used in 86 patients, with a total of 107 procedures (70 patients underwent one manoeuvre only, 16 patients underwent two or more manoeuvres).

RESULTS

The overall success rate of the technique was 60%. There were no differences in success rate in terms of gender (60% male vs. 40% female, p = 0.104), time of catheter failure (early 60% vs. late 62%, p = 0.849), type of catheter (75% self-locating vs. 58% spiral, p = 0.633) or the initial position of the catheter. There was only one case of peritonitis related to the procedure.

CONCLUSIONS

The alpha manoeuvre is an effective and safe method for correcting peritoneal catheter displacement.

Fluoroscopically-Guided Manipulation of Malfunctioning Peritoneal Dialysis Catheters

Objective

To review our experience with fluoroscopic evaluation and manipulation of malpositioned, malfunctioning, peritoneal dialysis (PD) catheters.

Materials and Methods

Thirty-one patients, over a 5-year period (1 May 1992 to 30 April 1997) with malfunctioning PD catheters, who had fluoroscopically-guided manipulation were reviewed. Catheters were manipulated using a malleable aluminum bar and, if necessary, guide wires or other stiffeners. Technical success was assessed on the basis of adequate, fluoroscopically verified, catheter placement at the time of the procedure and improved flows. A functional PD catheter at 30 days post manipulation was considered to be a clinically successful manipulation.

Results

There were 41 manipulations [33 initial (IM) and 8 remanipulations (RM)] for malpositioned or kinked catheters. In 31 (19 male, 12 female) patients ranging in age from 31 to 76 years (mean age 60 years), the initial technical success rate was 85% for IM ( n = 28/33) and 63% ( n = 5/8) for RM. The overall clinical success rate, or 30-day primary patency, was 55% for IM ( n = 18/33) and 63% for RM. Catheter function (combined IM and RM) continued for a median 869 days (95% CI: 118, 1620). No early complications were noted.

Conclusions

Fluoroscopic manipulation, including attempts at remanipulation, of PD catheters is a safe procedure. The technique is a simple, inexpensive, and effective way of prolonging PD catheter life, thereby reducing the number of surgical interventions.

Double Guidewire Method: A Novel Technique for Correction of Migrated Tenckhoff Peritoneal Dialysis Catheter

Twenty-two consecutive patients with a continuous ambulatory peritoneal dialysis (CAPD) catheter malfunctioning due to catheter migration were treated with a novel radiological manipulation technique, the “double guidewire method.” The first guidewire is used to correct the direction of the catheter tip and the second wire is used to anchor the CAPD catheter so that an ideal course of the catheter can be maintained during removal of the first guidewire. Immediate catheter repositioning was achieved in 19 of 22 patients, and durable repositioning success was achieved in 13 patients.

In conclusion, the “double guidewire method” is a simple but effective technique for prolonging CAPD catheter life in patients with malfunction due to catheter migration.

Laparoscopic management of malfunctioning peritoneal dialysis catheters

OBJECTIVES

Continuous ambulatory peritoneal dialysis (CAPD) is an established alternative method to hemodialysis for treating end-stage renal disease patients. Malfunction of the peritoneal catheter is a frequent complication in peritoneal dialysis (PD). Laparoscopy is a minimal invasive technique that allows rescue therapy of malfunctioning catheters and consecutive immediate resumption of PD. The purpose of this study is to present our experiences with laparoscopic repair of peritoneal catheter dysfunction

METHODS

Between April 2006 and March 2010, 21 cases of laparoscopic interventions were performed for the salvage of malfunctioning CAPD catheter. Two trocars (5 mm) were used. Recorded data included patient demographics, catheter implantation method, date of malfunction, cause of dysfunction, procedure performed and complications.

RESULTS

The primary etiology of dysfunction was omentum and/or small bowel wrapping with adhesions in fifteen cases, malpositioning in four cases, and tunnel infection in the remaining two cases. Adhesiolysis was performed in cases with adhesions. In the cases with malpositioning but no adhesions, the catheters were repositioned in the pelvic cavity. Two catheters had to be withdrawn and exchanged because of infection. There were no mechanical or infection problems. The overall success rate of catheter function (>30 days after laparoscopy) was 100%, except for two cases in which the catheters had to be removed.

CONCLUSION

Laparoscopy is a safe, highly effective and successful method for the evaluation and management of peritoneal dialysis catheter dysfunction.

The adequacy of laparoscopy for continuous ambulatory peritoneal dialysis procedures

The aim of this study was to determine the safety and efficacy of diagnostic/therapeutic laparoscopy in the management of peritoneal Tenchoff catheter placement in end-stage renal disease patients who had previous abdominal surgery and malfunctioning peritoneal dialysis catheters. From 1999 to 2004, 16 videolaparoscopic procedures were performed in 16 patients who had previous laparotomies. Laparoscopy was performed before peritoneal catheter placement in seven (group 1) and in 9 patients with peritoneal dialysis catheters in place, laparoscopy was performed for the management of catheter dysfunction (group 2). All laparoscopic procedures were performed under general anesthesia. The mean follow-up was 31.5 (range, 11 to 60) months. In group 1, six patients (85.7%), and in group 2, seven patients (77.7%) are still on peritoneal dialysis. Laparoscopy resulted in the placement/salvage of peritoneal dialysis catheter dysfunction. Placement of catheter was accomplished in patients who would have been previously designated as unsuitable candidates. Laparoscopy is a useful tool in every step of a peritoneal dialysis program.

Peritoneal dialysis access-related procedures by nephrologists

Traditionally the placement of a peritoneal dialysis (PD) catheter in a patient with end-stage renal disease (ESRD) has been accomplished by a surgeon and using general anesthesia. This approach often introduces delays in starting PD, incurs additional costs in utilizing an operating room as well as anesthesia services, and introduces the mortality risk associated with general anesthesia. Recent data have emphasized that interventional nephrologists can safely and successfully perform PD access procedures. In this context, operating room facilities and staff and anesthesia services are not required and catheter insertion can be performed in a procedure room using local anesthesia, thereby reducing costs and completely bypassing the mortality risk associated with general anesthesia. When performed by a nephrologist, the catheter insertion can be accomplished swiftly and dialysis therapy initiated in a timely manner. Once begun, the success of PD hinges on reliable and long-term access to the peritoneal cavity. Prospective randomized and nonrandomized studies have shown that PD catheters peritoneoscopically placed by nephrologists have fewer complications (infection, exit site leak) and longer catheter survival rates than those inserted surgically. Although PD offers a variety of advantages, it remains an underutilized form of renal replacement therapy. To counteract PD underutilization, at least two separate centers have demonstrated a positive impact on the growth of the PD population when catheter insertion is performed by nephrologists. This article presents PD access-related procedures currently performed by interventional nephrologists. Furthermore, some of the complicating issues (bowel perforation, catheter migration, prior abdominal surgery) related to PD catheter insertion and management are also discussed.

Peritoneal dialysis underutilization: the impact of an interventional nephrology peritoneal dialysis access program

Peritoneal dialysis (PD) is an underutilized form of renal replacement therapy. Recent data have emphasized that only 12% of end-stage renal disease (ESRD) patients are initiated on this form of therapy in the United States. Patients requiring PD have most often been referred to general surgeons for catheter placement. This has incurred additional delays in starting treatment and loss of decision-making control by the referring nephrologist. To address this issue, we developed and incorporated our own PD access placement program into the preexisting chronic kidney disease (CKD) education program. To date, 46 patients have undergone 71 procedures. These included 51 (72%) PD catheter insertions, 14 (20%) removals, and 6 (8%) repositioning procedures for poor drainage. PD catheter insertion was performed peritoneoscopically under local anesthesia and a Fogarty catheter was used to reposition a migrated catheter. All of the procedures were performed by nephrologists in a dedicated interventional nephrology (IN) laboratory. All six repositioning procedures failed to restore optimal drainage. Five of these patients had the catheter removed and a new catheter placed during the same procedure. Of these five patients, one had recurrence of poor drainage and opted for hemodialysis (HD). The sixth patient declined reinsertion and chose HD. Of the remaining seven removal procedures, three were due to fungal peritonitis, one due to bowel perforation, one due to severe depression, one due to transplant, and one catheter was removed at the request of the primary physician in a terminally ill patient. Eight of the 51 catheter insertions were during the initial admission of a catastrophic dialysis start. Two of these patients started acute PD and avoided catheter placement for HD. Thirty-seven of 46 patients have a functional PD catheter with a follow-up of 8.6 +/- 0.8 (mean +/- SE) months. During an 18-month period our PD population has increased from 43 to 80 patients. We conclude that a dedicated PD access placement program coupled with a CKD education program can have a dramatic impact on patient choice and PD growth.

Diagnostic and interventional nephrology

The fragmented care of nephrology patients that results from referral to a radiologist for renal ultrasound (US) and biopsy, a surgeon for dialysis access placement, and an interventional radiologist for dialysis catheter placement and vascular access procedures often leads to delays in the treatment of these patients. Many specialists perform and interpret sonograms particular to their specialty rather than relying on technicians for performance and radiologists for interpretation, and nephrologists recently have begun to embrace this technology as an aid in the diagnosis and treatment of their patients. By combining an understanding of the pathophysiology of renal disease with the ability to perform clinical correlation and apply the laboratory data, the nephrologist is ideally suited to perform and interpret renal US and US guidance for percutaneous renal biopsies. Additionally, patients requiring peritoneal dialysis (PD) access have traditionally been referred to a general surgeon for catheter placement, which incurs additional delay in therapy and loss of decision-making control by the referring nephrologist. Recent data has emphasized that the peritoneal dialysis access procedure can be performed safely and effectively by a nephrologist trained in PD access procedures. Nephrologists also successfully perform tunneled hemodialysis catheter placement and vascular access procedures on an outpatient basis. The medical needs of patients with renal disease can be safely and efficiently delivered by a nephrologist trained in interventional nephrology (IN). This growing area of expertise will minimize delays, reduce cost, and allow physicians with training in the management of end-stage renal disease (ESRD) patients to be involved in the procedural aspects of their patients' care. An aggressive approach to the development of IN training programs at academic centers is warranted.

Laparoscopic management of malfunctioning peritoneal dialysis catheters

BACKGROUND

Continuous ambulatory peritoneal dialysis (CAPD) is an established alternative method to hemodialysis for treating end-stage renal disease patients. However, this method is associated with a significant number of complications, such as catheter malposition, omental wrapping, and infection. The purpose of this study was to determine the efficacy of laparoscopy in the treatment of malfunctioning CAPD catheters.

METHODS

Between November 1994 and June 1999, a total of 16 patients with CAPD underwent laparoscopy for the evaluation and management of CAPD catheter dysfunction. Two trocars (10-mm and 5-mm) were used. Recorded data included patient demographics, catheter implantation method, date of malfunction, cause of dysfunction, procedure performed, complications, and catheter outcome.

RESULTS

The primary etiology of dysfunction was omentum and/or small bowel wrapping with adhesions in eight cases, malpositioning in five cases, and infection in the remaining three cases. Adhesiolysis was performed in the eight cases with adhesions. In the five cases with malpositioning but no adhesions, the catheters were repositioned in the pelvic cavity. Two catheters had to be withdrawn because of infection. In one case with tunnel infection, the catheters were exchanged simultaneously. There was only one perioperative complication, consisting of temporary dialysate leakage. There were no mechanical or infection problems. The overall success rate of catheter function (>30 days after laparoscopy) was 100%, except for two cases in which the catheters had to be removed.

CONCLUSION

Laparoscopy is a highly effective and successful method for the evaluation and management of peritoneal dialysis catheter dysfunction.

Role of Fogarty catheter manipulation in management of migrated, nonfunctional peritoneal dialysis catheters

Peritoneal dialysis (PD) catheter migration to the upper abdomen is not an uncommon cause of catheter failure. We prospectively examined the role of the Fogarty catheter manipulation technique to reposition the PD catheter in the pelvis and regain patency. All patients with PD catheter malfunction caused by migration, confirmed by abdominal radiograph, underwent the same protocol. The patient was placed flat on the back, and the Fogarty was advanced into the PD catheter to a premarked point at which the end of the Fogarty was near the end of the PD catheter. The Fogarty balloon was inflated with 0.5 mL of sterile saline, and manipulation was performed by tugging movements until proper placement of the PD catheter into the pelvis was suspected. Infusion and drainage of dialysate was performed to determine patency. The return of the PD catheter into the pelvis was then confirmed by repeated radiograph. Success rates of Fogarty catheter manipulation, early and late recurrence (remigration < or =90 days or >90 days), and complications were prospectively examined in 232 patients over a 6-year period. Catheter migration occurred in 34 of 232 patients (15% incidence). All patients had curled-end, double-cuffed, non-swan-neck PD catheters. Successful repositioning occurred in 24 of 34 patients (71%). None of the 24 repositioned catheters had early recurrence, and 1 of 24 catheters (4%) had late recurrence. None of the patients had procedure-related peritonitis, bowel perforation, or exit-site trauma. These results show that PD catheter migration is relatively common (15%). The Fogarty manipulation technique is a simple, cost-effective way to prolong PD catheter life and preserve its long-term patency. This eliminates the need for surgical intervention in approximately 70% of patients with PD catheter migration.

Guide wire directed manipulation of malfunctioning peritoneal dialysis catheters: a critical analysis

PURPOSE

To evaluate patency rates after guide wire directed manipulation of malfunctioning continuous ambulatory peritoneal dialysis (CAPD) catheters.

MATERIALS AND METHODS

During a 58-month period, 23 patients underwent 34 outpatient guide wire directed manipulations of their CAPD catheter to improve function (n = 30) or reduce pain and improve function (n = 4) during dialysis. Catheter patency rates were subsequently determined by review of departmental, hospital, and dialysis center charts; procedural reports; and patient telephone interviews.

RESULTS

Among 12 patients who underwent a single guide wire directed manipulation, long-term (> 30 days) catheter patency was achieved in seven (58%). With use of the Kaplan-Meier survival method, the 3-, 6-, and 12-month probability of patency after a single guide wire manipulation was 0.61, 0.54, and 0.11, respectively. The mean duration of patency achieved in this group was 131 days (range, 2-421 days). In those patients (n = 8) who underwent multiple catheter manipulations (n = 19), 11 (58%) procedures resulted in long-term patency, with each patient (100%) achieving at least one such period. The Kaplan-Meier survival method determined the probability of patency in this group at 3, 6, and 12 months to be 0.75, 0.69, and 0.54, respectively. The mean secondary catheter patency was 235 days (range, 2-646 days). Overall, 75% of patients followed up achieved at least one period of long-term catheter patency during the time of this study. One (3%) episode of postprocedure peritonitis occurred.

CONCLUSION

Guide wire directed CAPD catheter manipulation is a relatively simple outpatient procedure that restores long-term catheter function for most patients with minimal risk for a major complication. Patients with nonfunctioning CAPD catheters who do not have peritonitis or sepsis will most likely benefit from at least one attempt at radiologic manipulation of their catheter.