Percutaneous, Non-Surgical Placement of Tunneled, Cuffed, External Jugular Hemodialysis Catheters: A Case Report

The right internal jugular vein is widely accepted as the vessel of choice for placement of long-term central venous catheters for hemodialysis. As vascular access sites become progressively depleted, alternate anatomic locations for access must be sought. We describe a non-surgical (fluoroscopy assisted, percutaneous) technique for placement of external jugular, tunneled, cuffed hemodialysis catheters, and provide long-term blood flow and dialysis adequacy data for EJV catheters.

A Retrospective Study of Preferable Alternative Route to Right Internal Jugular Vein for Placing Tunneled Dialysis Catheters: Right External Jugular Vein versus Left Internal Jugular Vein

Background

Right internal jugular vein (IJV) is a preferred access route for tunneled (cuffed) dialysis catheters (TDCs), and both right external jugular vein (EJV) and left IJV are alternative routes for patients in case the right IJV isn’t available for TDC placement. This retrospective study aimed to determine if a disparity exists between the two alternative routes in hemodialysis patients in terms of outcomes of TDCs.

Methods

49 hemodialysis patients who required TDCs through right EJV (n = 21) or left IJV (n = 28) as long-term vascular access were included in this study. The primary end point was cumulative catheter patency. Secondary end points include primary catheter patency, proportion of patients that never required urokinase and incidence of catheter-related bloodstream infections (CRBSI).

Results

A total of 20,870 catheter-days were evaluated and the median was 384 (interquartile range, 262–605) catheter-days. Fewer catheters were removed in the right EJV group than in the left IJV group (P = 0.007). Mean cumulative catheter patency was higher in the right EJV group compared with the left IJV group (P = 0.031). There was no significant difference between the two groups in the incidence of CRBSI, primary catheter patency or proportion of patients that never required urokinase use. Total indwell time of antecedent catheters was identified as an independent risk factor for cumulative catheter patency by Cox regression hazards test with an HR of 2.212 (95% CI, 1.363–3.588; p = 0.001).

Conclusions

Right EJV might be superior to left IJV as an alternative insertion route for TDC placement in hemodialysis patients whose right IJVs are unavailable.

Vascular Access for Placement of Tunneled Dialysis Catheters for Hemodialysis: A Systematic Approach and Clinical Practice Algorithm

The role of interventional radiology in the overall management of patients on dialysis continues to expand. In patients with end-stage renal disease (ESRD), the use of tunneled dialysis catheters (TDCs) for hemodialysis has become an integral component of treatment plans. Unfortunately, long-term use of TDCs often leads to infections, acute occlusions, and chronic venous stenosis, depletion of the patient's conventional access routes, and prevention of their recanalization. In such situations, the progressive loss of venous access sites prompts a systematic approach to alternative sites to maximize patient survival and minimize complications. In this review, we discuss the advantages and disadvantages of each vascular access option. We illustrate the procedures with case histories and images from our own experience at a highly active dialysis and transplant center. We rank each vascular access option and classify them into tiers based on their relative degrees of effectiveness. The conventional approaches are the most preferred, followed by alternative approaches and finally the salvage approaches. It is our intent to have this review serve as a concise and informative reference for physicians managing patients who need vascular access for hemodialysis.

Insertion of permanent hemodialysis catheters through the great saphenous vein

INTRODUCTION

In patients with end stage renal disease when there is inability for the creation of a direct arterio-venous fistula or by using a graft, the insertion of a permanent hemodialysis catheter in a central vein ensures the conduction of hemodialysis. We present a technique of placing a permanent catheter in the inferior vena cava through the great saphenous vein without the use of a guide wire.

PATIENTS-METHODS

Over the study period, 12 hemodialyzed patients, with a mean age of 73 years, were referred for placement of a dialysis catheter through the great saphenous veins. The procedure was performed under local anesthesia, ECG monitoring, and fluoroscopic control. The insertion of the tunneled hemodialysis catheters was accomplished with ease, through surgical exposure of the great saphenous vein, without the need for a guidewire.

RESULTS

The hemodialysis catheter's function was assessed intraoperatively. No intraoperative or immediate post operative complications were noted while during the study period 3 thromboses and an infection were detected (0,95 per 1000 catheter days). The primary catheter patency rates were 92%, 84%, 54% at 30, 90 and 180 days respectively, varying from 28 to 845 days (mean±SD = 294 ± 243,3).

CONCLUSION

The introduction of dialysis catheters in the inferior vena cava through the great saphenous vein is technically simple with rare complications and with higher patency rates compared to the traditional femoral approach.

A Comparison between Blood Flow Outcomes of Tunneled External Jugular and Internal Jugular Hemodialysis Catheters

Purpose

The right internal jugular (RIJ) vein is preferred for placement of long-term venous catheters (CVC) for hemodialysis (HD). Use of left IJ vein potentially depletes the access site for arteriovenous fistula (AVF) or arteriovenous graft (AVF) placement because of the high rates of central venous stenosis. The right external jugular (EJ) vein is a viable alternative to the LIJ. The purpose of this study is to compare blood flow outcomes in a series of percutaneously placed external jugular (EJ), LIJ and RIJ HD catheters.

Methods

Using a prospectively collected database, we identified 46 hemodialysis patients who received a tunneled catheter during a 4-year period. Blood flow outcomes of RIJ, LIJ, and EJ catheters that were date-matched over the study period were compared. Using ANOVA, the blood flow outcomes of the 3 tunneled catheter techniques at 30-d and 90-d were compared.

Results

The 90-d blood flow outcomes of the 3 groups did not differ significantly. The 30-d blood flow was found to be 348.5± 56.62, 341± 22.42, and 365.7± 71.76 mL/min for RIJ, LIJ, and EJ respectively (P<.05). Using multiple regression analysis, no covariates (age, sex, race, diabetes) were found to be associated with blood flow outcomes at 30-d or 90-d. No identifiable factors were found to be associated with the difference in blood flow between 30-d and 90-d either.

Conclusions

EJ blood flow outcomes at 30-d and 90-d were comparable to both LIJ and RIJ historic data. Further prospective investigation is required to define the role of EJ CVC placement as another potential long-term access modality.