Hemodialysis using femoral vessel cannulation

Central Venous Catheterization: A Comprehensive Review, Part I

Central venous catheterization is an indispensable tech nique in today's practice of medicine. It was initially used to monitor central venous pressure; however, this method has become obsolete. Central venous access is now more commonly established to administer hyper tonic intravenous alimentation or to insert pulmonary artery catheters. The sites available for central venous catheterization include the antecubital veins, external and internal jugular veins, subclavian vein, and femoral vein. Many of these sites offer more than one method of insertion. Although the indications for central venous access are well known, there is a general lack of respect for the considerable incidence of associated complica tions. It is useful to separate complications into two categories: those associated with venipuncture and catheter insertion, which will vary greatly depending on the route chosen, and those associated with catheter maintenance, which tend to be similar. The various methods of central venous catheterization are com prehensively reviewed with regard to specific indica tions, technique, and complications.

Displacement of the Inferior Vena Cava as a Factor Limiting Catheter Performance in Long-Term Hemodialysis Patients

We report a case of a lady affected by autosomal dominat polycystic kidney disease who had been on hemodialyis for 24 years. She has exhausted all options for arterious-venous fistula. The presence of an acquired anatomical abnormality was an obstacle in order to get appropriate blood flow from standard tunnelled femoral catheters. The enlarged right kidney was pushing the inferior vena cava to the left side of the abdomen, and the abnormality was demonstrated by phlebography. Only after placing a cuffed catheter 53 cm long in her left femoral vein we could dialyze efficiently. Venography is mandatory before placing a cuffed catheter especially in uremic patients with long history of access failure, because it saves costs.

Femoral arteriovenous fistula: a complication of temporary hemodialysis catheter placement

The femoral vein is increasingly being used as a temporary route for dual-lumen hemodialysis catheter placement because it is thought to be safer than the internal jugular or subclavian vein sites. However, several factors preclude the wider use of indwelling femoral catheters for hemodialysis, including interference with ambulation and concern over bleeding, infection, and deep thrombosis. Herein we describe a case of right superficial femoral arteriovenous fistula as a complication of the insertion of a dual-lumen hemodialysis catheter into the right femoral vein. The arteriovenous fistula was successfully managed with surgical vascular repair. From this experience, we emphasize that it is important for physicians and nursing staff treating patients with indwelling central catheters to exercise vigilance to allow early detection and treatment of these potentially serious, albeit rare, complications.

Massive retroperitoneal hemorrhage associated with femoral vein cannulation

The right external iliac artery was inadvertently punctured during attempted right femoral vein catheterization. Severe hypotension developed several minutes after the arterial puncture. Concurrently, a large right lower abdominal quadrant swelling (approximately 5 cm in diameter) became apparent. Laparoscopic observation of the retroperitoneal region immediately revealed massive retroperitoneal hemorrhage. Abdominal computerized tomographic scan indicated development of a huge (approximately 10 cm in the maximum diameter) retroperitoneal hematoma along the right psoas muscle from the level of the right external iliac vessels up to the level of the upper pole of the right kidney. Consideration of the anatomy of the "right" femoral and retroperitoneal vessels (ie, mediolateral relationship between the vein and artery) led us to conclude that the site for insertion of the needle was too proximal and the angle for advancement of the needle too low in our patient, allowing the needle to reach and injure the "incompressible" external iliac artery, thereby causing massive retroperitoneal hemorrhage. Although femoral vein catheterization has generally been considered a relatively safe method of intravenous access, a life-threatening serious complication can occur with the inappropriate technique used in our case.

Successful use of indwelling cuffed femoral vein catheters in ambulatory hemodialysis patients

Three hemodialysis patients with multiple upper extremity vascular access complications and central vein stenosis were treated for as long as 3 months using an indwelling femoral vein catheter having a buried felt cuff in its subcutaneous tunnel. Four catheters were placed in these three patients. In one case, initial failure due to poor flow and clotting occurred using a straight catheter with its tunnel crossing the inguinal ligament and exiting caudally on the anterior thigh. Otherwise, each patient had successful placement of a 180-degree, curved catheter that exited the femoral vein in the usual fashion but had a subcutaneous tunnel and skin exit pointing cephalad in the inferior portion of the right lower quadrant. The three successful devices functioned immediately after placement, having acceptable outflow pressures and recirculation values. One of three catheters was removed 3 weeks after placement when persisting infection was thought to reside on the device. No other bleeding, thromboembolic, or infectious complications occurred in these patients. In conclusion, short-term indwelling femoral vein access may be feasible in ambulatory hemodialysis patients with previous access difficulties that complicate temporary dialysis treatment.

Introduction of percutaneous arteriovenous femoral shunt: a new access for continuous arteriovenous hemofiltration

In most critically ill unstable patients, continuous arteriovenous hemofiltration (CAVH) and continuous arteriovenous hemofiltration with dialysis (CAVHD) offer significant advantages over dialysis and ultrafiltration. Improvements in CAVH methodology have occurred since its introduction, but an ideal vascular access has yet to be designed. Scribner shunts may result in loss of a future access site, while femoral artery and vein catheterization render the patient immobilized. We have developed a percutaneous external arteriovenous femoral shunt to overcome this difficulty. The catheter consists of two single-lumen flexible polyurethane catheters with a subcutaneous Dacron cuff. A percutaneous Seldinger technique is used with a peel-away sheath to insert one catheter in the artery and one in the vein. To minimize infection and ensure durability, a 10-cm tunnel is created so that the exit of the catheters on the upper thigh is away from the groin. Like the Scribner shunt, a connecting tube is used between the catheters to maintain the patency when the shunt is not in use. Our experience with this technique is limited to seven treatments in seven patients (five CAVH, two CAVHD). Good blood flow (average, 80 mL/min), ultrafiltration rate (7 mL/min), and biochemical studies demonstrated the efficiency of the access. The average treatment was 10 days and patients were allowed to do moderate movement without resulting thrombosis or infection of the access. The major advantages of this new and efficient access for CAVH and CAVHD include simple introduction by a nephrologist, lack of potential serious complications, avoidance of sacrifice of major vessels, early ambulation and movement without compromising function, and a design for prolonged usage.