This document discusses the insertion and management of tunneled dialysis catheters. It begins with an overview of venous anatomy and various sites for catheter insertion. Details are provided on equipment, catheter length selection, and the procedure for right internal jugular insertion. Potential acute complications during insertion like arterial puncture, pneumothorax, and air embolism are reviewed along with preventative measures. Subacute issues such as malposition, clotting, and fibrin sheath formation that can cause reduced flow are described. Management of tunnel tract infections is also covered. The document emphasizes safety throughout catheter procedures.

1. HD Catheters
Dr.Mohamed Abd El Gawad
Nephrology Specialist at New Mansoura
General Hospital

2. Anatomy of venous system

3. Venous system of the neck

4. Venous system of LLs

8. Insertion of Tunneled Dialysis Catheter

9. Sites of CVC insertion:
B
A
C
D
E F
A - Central IJV approach
B - Subclavicular subclavian
vein approach
C – Posterior IJV vein approach
D - Supraclavicular subclavian
vein approach
E – Low IJV approach
F – Innominate vein approach
Insertion of Tunneled Dialysis Catheter

10. Equipment
Will be provided during the workshop
Insertion of Tunneled Dialysis Catheter

11. In general, in patients with a body
surface area of 1.5 to 2.0 m2
-A 12-15 cm catheter should be
selected for the jugular vein in the low
right position and
-A 15-19 cm catheter for the left
jugular vein.
-A 14 to 17 cm catheter should be
used for the right subclavian vein and
A17 to 22 cm catheter for the left
subclavian vein.

12. Length of Cuffed Catheters:
Length:
• Rt IJC: 24, 28 cm
• Lt IJC: 28, 32 cm
• Rt femoral/iliac CATH 36, 42 or 55 cm
• Lt femoral/iliac CATH 55 cm
There are many variations according to patient size and CATH availability

13. Introduction:
• Insertion of a central venous catheter for hemodialysis is an interventional procedure in
which many principles of endovascular techniques are applied.
• It involves obtaining vascular access under real time ultrasound guidance, wire
manipulations and sheath placements.
Insertion of Tunneled Dialysis Catheter

14. Right Sided IJ Tunneled Catheter Insertion
Insertion of Tunneled Dialysis Catheter
Catheter insertion will be provided
during the practical part of the
workshop

15. Complications of
Tunneled Dialysis Catheter Insertion
Insertion of Tunneled Dialysis Catheter

16. • Regardless of how “minor” or “simple” the procedure, never underestimate the
complications that may arise during the procedure.
• Obeying the “rules” and developing good habits during training can go a long way to
decrease procedure related complications.
Acute Complications of Tunneled Dialysis Catheter Insertion
The following are some of the complications that one may encounter during dialysis
catheter placement, and the precautions and steps to treat them if they occur:

17.  Prevention:
1. Always access the vein under real time ultrasound guidance and pay attention to the
depth and ultrasound plane.
2. Always use the micro puncture set to access the vein initially as cannulation created
using the micro puncture needle is small and bleeding can be stopped readily by
compression.
3. Always verify the position of the micro puncture wire by fluoroscopy.
A. Arterial Puncture:
 Treatment :
It depends on which stage of the procedure the complication is discovered:
1. If the complication is discovered before dilatation of the venotomy tract, the wires
and micro-puncture sheath can be safely removed and direct compression applied to
arrest the bleeding.
2. If the complication is discovered after dilatation of the venotomy tract, leave the
dilator in-situ to tamponade the vessel and call for help. The arterial puncture can be
closed either by open surgical repair or using an arterial closure device.

18. C. Hemothorax:
In the event of a hemothorax, surgical
intervention is often necessary to stop the
bleeding and evacuate the blood.
B. Pneumothorax:
In the event of a
pneumothorax, chest
tube insertion is often
necessary to evacuate
the air leak

19.  Preventive measures:
1. Identify high risk patients. Patients who are dehydrated are at increased risk of air
embolism during line insertion. Their veins may be collapsed or show variation in size
with the respiratory cycle on ultrasound. Give fluid boluses and perform the insertion
with the patient in the Trendelenburg position to minimize the risk of air embolism.
2. Always occlude the hub of the needle and close the hemostatic valve of the peel away
sheath during the procedure. As an added precaution, pinch the peal away sheath
between your fingers after you have removed the inner dilator.
3. Instruct the patient to hold his/her breath during puncture of the IJ vein and insert the
wire though the needle rapidly after successful puncture to avoid this complication.
4. The patient should be instructed to hold his/her breath during exchanges over the
wire.
D. Air Embolism:

20.  If there is significant air embolism
1. Immediately place the patient in the left lateral decubitus and Trendelenburg position. If
cardiopulmonary resuscitation is needed, place the patient in a supine and head down
position.
2. Administer 100 % oxygen and do endotracheal intubation if necessary.
3. Attempt removal of air from the circulation by aspirating from the central venous
catheter.
4. Fluid resuscitate the patient and consider hyperbaric oxygen treatment.
D. Air Embolism:

21. E. Cardiac Arrhythmia:
To prevent the wire from triggering
arrhythmias during the procedure,
always pass the guide wire tip into the
IVC during the procedure.

22. Subacute Complications of Tunneled Dialysis Catheter
Suboptimal Flow
Fibrin
Sheath
Clots
Mal-
Position

23. Mal-position/kink:
If the tunneled catheter has poor flow within a week of placement, it is often due to
suboptimal positioning of the catheter tip, migration of catheter tip or kinking of catheter.
A. Check the position of the catheter tip on a chest x ray, in particular, look for any
kinks in the catheter (Next Fig)
B. Withdraw the catheter if the tip of the catheter is distal to the mid atrium. If the
tip of the catheter is proximal to the mid atrium, advancing the catheter carries
the risk of contaminating the subcutaneous tunnel tract and infection.
In the latter situation, exchanging the catheter over a guide wire is preferred.
Subacute Complications of Tunneled Dialysis Catheter
 Suboptimal Flow:

24. ( a ) Catheter is too short. Arrow shows that the of catheter is in the superior vena Cava.
( b ) Tip of catheter is in an optimal position but the arrow shows that catheter is “kinked”
by the purse string suture at the exit site.
( c ) Arrow shows that the catheter is “kinked” at the venotomy site
ba c
Subacute Complications of Tunneled Dialysis Catheter
 Suboptimal Flow:
Mal-position/kink:
c

25. Clots:
If the catheter tip is in the correct position, a trial of a thrombolytic agent may be
attempted.
A. The procedure should be carried out in a sterile manner. Clean and drape the
patient.
B. Remove the caps of the catheter ports and aspirate 5 ml of blood from each lumen
to remove the locking agent.
C. Instill 2 ml of TPA (1 mg/ml) into each lumen and allow it to dwell for half an hour.
D. Aspirate both catheter ports and discard the initial 5 ml of blood.
E. Test catheter flow with a 20 ml syringe. If the flow remains suboptimal, schedule
for catheter exchange over a guide wire.
Subacute Complications of Tunneled Dialysis Catheter
 Suboptimal Flow:

26. Fibrin Sheath:
If the catheter develops poor flow more than a month after placement, it is probably
secondary to obstruction from fibrin sheath formation around the tip of the catheter.
A trial of tPA may be attempted. If unsuccessful, exchanging the tunneled catheter over a
guide wire with or without disruption of the fibrin sheath is the treatment of choice.
A. Check the position of the catheter tip on chest x ray.
B. Aspirate both catheter ports and discard the initial 5 ml of blood which contains the
locking agent
C. Insert a 0.035 in. angled stiff guide wire through the venous port of the catheter into
the inferior vena cava.
D. Free the preexisting catheter cuff by blunt dissection and withdraw the catheter gently
by approximately 3 cm. Gently inject 10–15 ml of contrast material into the arterial
port to visualize the fibrin sheath.
E. Remove the preexisting catheter and insert the 12–14 mm angioplasty balloon
catheter over the wire via the subcutaneous tunnel tract, and inflate the balloon in the
SVC to disrupt the fibrin sheath.
Subacute Complications of Tunneled Dialysis Catheter
 Suboptimal Flow:

27. F. Exchange a new-tunneled dialysis catheter over the guide wire and place the tip
within the proximal SVC. Inject 10–15 ml of contrast via the arterial port to check for
residual fibrin sheath. If fibrin sheath is still present, repeat the angioplasty. If there is
no residual fibrin sheath, advance the catheter tip to the desired position in the mid
atrium.
Subacute Complications of Tunneled Dialysis Catheter
 Suboptimal Flow:
Stripping of Fibrin Sheath
Will be provided during the workshop

28.  Tunnel Tract Infection:
1. Tunnel tract infection is defined as infection of the portion of the subcutaneous tunnel that
extends between the catheter cuff and the venotomy site.
2. Broad spectrum antibiotics are required accompanied by removal of the tunneled dialysis
catheter.
3. Temporary dialysis catheter is often required for dialysis access. A new tunneled catheter is
placed at a new site after the tunnel tract infection is treated

29. Removal of Tunneled Dialysis Catheter

30. ''Fistula First, Catheter Last''
My Access, My
Life

31. THANK YOU