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

Internal jugular veins

The internal jugular veins are the preferred sites of access for the placement of TDCs. The internal jugular veins are superficial and have the largest radii of the neck veins, making them the easiest veins to access technically. The use of US guidance for placement of the catheters reduces the risk of complications.[1516] It is an accepted fact that due to their large radii, the internal jugular veins have low risk of thrombosis.[1718] Also, thrombosis in the internal jugular veins is not clinically apparent. This is mainly due to the isolation of the thrombosis from the high outflow drainage of the upper extremities, as well as due to the development of collaterals. However, access through the internal jugular veins has been associated with central venous stenosis.[19]

The RIJV is preferred over the LIJV. The RIJV provides a short, direct, and linear route into the right atrium (RA) in contrast to the perpendicular route of the left-sided access. This asymmetry is proposed to be an etiological factor in the relatively increased incidence of LIJV stenosis.[20] Since the left arm is the predominant vascular access site for AVFs in right-handed people, placing a catheter in the contralateral RIJV reduces the risk of thrombosis in the left-sided venous drainage system, which could be harmful to functioning of the graft.[21] Other advantages of an RIJV access include minimal chance of damage to the thoracic duct,[22] which is anatomically located on the left side and technical ease of puncture due to better responsiveness to Valsalva maneuver.[23] A randomized study by Sulek et al., compared 60 RIJV and 60 LIJV catheters and found that the US-guided cannulation times were significantly longer (138 s vs. 58 s), the attempts were significantly more (2.3 vs. 1.5 needle passes), and the complication rates were significantly higher (20% vs. 10%) for LIJV catheters compared with RIJV catheters.[23] Fry et al., compared median survival times and found that patients with RIJV catheters survived longer (630 days vs. 430 days).[14] Figures 1 and 2 depict patients with the placement of TDCs via the RIJV and the LIJV, respectively.

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Figure 1

61-year-old male with hypertension (HTn) and hepatitis C presented with ESRD, requiring hemodialysis. The RIJV was patent. (a) Frontal fluoroscopic spot image of the upper chest shows a 0.035-inch wire (arrow) was advanced through the RIJV into the right atrium (RA). (b) Frontal fluoroscopic imaging of the upper chest shows a TDC placed via the RIJV (arrow).

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Figure 2

19-year-old female with glomerulonephritis presented with ESRD, requiring dialysis. A single incision technique was chosen. (a) Fluoroscopic spot image of the right upper chest and neck shows the distal end of the needle in its course through a subcutaneous tunnel from an infraclavicular location to the site of RIJV puncture. The distal end of the needle was manually bent to create a favorable angle (arrow in a). (b) Fluoroscopic spot image of the right upper chest after insertion of a 0.035-inch guidewire shows the dilatation of the tract d (arrow in b). (c) Frontal fluoroscopic spot image after a 23-cm cuff-to-tip TDC is placed (arrow). The patient had only one incision in the infraclavicular region, avoiding scarring in the neck.

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Single incision technique

A novel technique that has gained popularity recently is the single incision technique. Various reports have labeled it as a feasible and safe alternative to the conventional internal jugular vein technique. Contractor et al., successfully placed 72 TDCs with the advantages of fewer procedural steps and a superior cosmetic result.[24] Figure 2 shows a patient with a TDC placed into the RIJV using a single incision technique.

External jugular vein

When the RIJV cannot be used and the patient has or will have a left arm AVF or AVG, the use of right external jugular vein (REJV) is optimal.[25] In their experience with 49 catheters placed through the external jugular veins, Beigi et al., indicated that the external jugular veins were a safe and reliable vascular access option with no procedural complications in 81.6% of the patients and a mean duration of sufficient performance of 324 days. Thrombosis (36%), accidental removal (22%), and infection (14%) were the main complications noted at the end of 1 year.[5] As the external jugular veins have smaller diameters than the internal jugular veins, adequate flow would be a concern for dialysis. This concern was successfully addressed by Vats et al., who found that external jugular vein blood flow outcomes at 30 days and 90 days were comparable to both LIJV and RIJV historical outcomes, suggesting a role for the external jugular veins as a potential long-term access site.[25] A disadvantage of the use of the external jugular veins is that they are very superficial and have smaller radii than the internal jugular veins; hence, access using US can be more challenging.[26]

Figure 3 depicts patients with placement of TDCs via the REJV.

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Figure 3

61-year-old female with HTn, hypoglycemia, and Type II diabetes mellitus (DM), ESRD, needing hemodialysis. (a) Frontal fluoroscopic spot image of upper chest shows TDC in the RIJV (arrow). Two years later, patient presented with bacteremia, requiring catheter removal. Reattempt to access the RIJV was unsuccessful. Instead, REJV was accessed and a TDC was placed. (b) Frontal fluoroscopic imaging of upper chest shows small amount of extravasation of contrast (arrow). Recurrence of bacteremia resulted in need for catheter removal. (c) Frontal fluoroscopic venogram of the upper chest reveals occlusion of the REJV (arrow). (d) Frontal fluoroscopic spot image of upper chest reveals a TDC placed via the LIJV (arrow).

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Etiology

Some of the major reasons for catheter malfunction are fibrin sheath formation, catheter kinking or malposition, and thrombosis, both acute and chronic.[28] Central vein stenosis due to endothelial injury, associated with the placement of central venous catheters, can endanger AVFs or AVGs in either extremity. Usually asymptomatic, these manifest clinically when challenged by increased flow, commonly from AVFs or AVGs. The risk factors include multiple catheters, longer duration, subclavian venous location, and placement on the left-hand side of neck.[29]

Management

Catheter fibrin sheaths can be easily disturbed by disruption during guide wire exchange or use of balloon angioplasty.[30] In case of acute thrombosis, various thrombolysis or thrombectomy techniques can be used to restore patency, albeit with a small risk of bleeding during these procedures.[31] Endovascular interventions like percutaneous angioplasty are the mainstay in the management of the more chronic central vein stenosis, with stent placement reserved for recurring lesions.[2729]

Femoral vein

Due to their large diameters and easy access, the femoral veins are a useful option for vascular access. Zaleski et al., in their experience with 41 tunneled femoral vein catheters, concluded that femoral vein catheters are more susceptible to infection as well as occlusion, thus requiring frequent catheter care. They suggested the use of an anterolateral upper thigh site of tunnel to avoid contamination of the skin exit site by groin infection. To improve patency, they suggested the tip of the catheter should be placed above the level of the confluence of the common iliac veins.[32] Placement of femoral catheters has the distinct drawback of restricting the mobility of the patient during walking and exercise.[32]

If a femoral access is chosen, the right femoral vein (RFV) is preferred over the left femoral vein (LFV) as it allows a left-sided AVF or AVG in the leg, if needed.[2133]

Figure 4 depicts a patient with placement of TDC via a right common femoral vein.

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Figure 4

47-year-old female with HTn, Type II DM, coronary artery disease presented with ESRD, requiring hemodialysis. (a) Frontal fluoroscopic spot image reveals a TDC placed via the RIJV (arrow). However, bacteremia necessitated catheter removal. US revealed occlusion of RIJV (image not shown). (b) REJV was attempted, but a digital subtraction venogram of the chest reveals outflow venous occlusions (arrow). Access via the RFV was chosen instead. (c) Frontal fluoroscopic spot image in the region of right groin shows a TDC in place (arrow). (d) Frontal fluoroscopic spot image of the abdomen shows the catheter coursing through the IVC (arrow).

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Subclavian vein

The DOQI recommends avoiding the SCV when upper extremity options for peripheral hemodialysis shunts remain viable in patients with renal failure (DOQI guidelines 5 and 6).[34] Occlusion/stenosis occurs commonly and results in clinically symptomatic venous outflow obstruction in the arm, as well as the loss of future access options for upper extremity AVF creation.[2835] Another major complication is pneumothorax (seen in 0.1–15% of cases).[36]

Figure 5 depicts a patient with placement of a TDC via the right SCV (RSV).

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Figure 5

57-year-old male presented with ESRD, requiring hemodialysis. (a) Frontal fluoroscopic imaging of the upper chest shows the patient had a previous TDC placement at the RIJV (arrow) that had been subsequently removed due to persistent malfunction. (b) Frontal fluoroscopic spot image of the upper chest again shows a TDC placed into the RA via the RSV (arrow).

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Collateral and small veins

Mediastinal, chest wall, and thyrocervical collaterals that develop secondary to occluded jugular veins have been used for vascular access in patients with huge success.[37] There are many benefits of using collateral veins in the neck region in preference to larger veins in the lower half of the body. First, the path to the superior vena cava (SVC) or RA is relatively direct. Second, the catheter care is similar to the jugular vein TDCs, and thirdly, patients tend to find them more comfortable. However, the most convincing reason for using these veins is that the other access sites are preserved for future use. The downside is that accessibility of these veins depends on the individual patient's anatomy and sometimes may not be technically easy.[34]

An antegrade approach via access in a vein in the chest is preferred by some authors due to ease of access. However, choosing a vein with a straight course is important for adequate long-term functioning of the TDC.[34] Others favor a retrograde transfemoral approach citing the potential for increased risk of bleeding due to use of the already compromised venous return of the upper half of the body in the antegrade approach.[28] In the retrograde approach, it is of paramount importance that the small collateral vein is patent and superficial, without intervening structures such as muscle or artery, so that snaring is technically possible via a fluoroscopy-guided antegrade percutaneous puncture.[28]

Funaki et al., reported primary patency rates of 90%, 71%, and 25% after 1, 6, and 12 months, respectively, in a study of 25 catheters placed in the neck region. They, in fact, favor the use of recanalized veins over femoral veins.[37]

Translumbar inferior vena cava

The TDCs can also be placed via a translumbar approach into the inferior vena cava (IVC). The anatomic position of the IVC is reliable and due to the large radius, thrombosis is rare. Although it is technically more challenging and time consuming compared to other techniques, the procedure is relatively safe, with the only important structure in the vicinity being the ureter.[38] Complications are avoided by performing in the prone position with a longer length, yet smaller gauge needle to reach the IVC. Although fluoroscopic guidance is commonly used to access just above the iliac crest just to the right of L3 vertebral body, US may sometimes be useful in lean patients.[28] Liu et al., reported catheter patency rates of 43%, 25% 5, and 7% after 3, 6, and 9 months, respectively, in a study of 84 translumbar TDCs. The main complications were poor blood flow (40%) and catheter-related infection (36%), which led to high incidence of catheter removal. Data from this study suggest that although translumbar catheters might serve as a safe, alternate access for dialysis patients, they function well for a short term as their use is limited by frequent exchanges.[39] Biswal et al., in their study, reported catheter dislodgement due to excess adipose tissue in the tunnel area, as well as dislodgement due to movement or catching on adjacent objects to be an important cause of catheter failure.[40]

Figure 6 shows placement of a TDC in the transhepatic IVC.

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Figure 6

41-year-old female with ESRD, needing hemodialysis. (a) Frontal fluoroscopic spot image of the upper chest shows a malfunctioning IJV (arrow). TDC's (b) arm and (d) coronal CT venography of chest reveals SVC stenosis (arrow in b, d), left brachiocephalic vein stenosis (white arrow in c), and collaterals (white arrow in e). Femoral veins were occluded. (f) Frontal fluoroscopic spot image of the abdomen shows a translumbar IVC TDC (arrow in f). (g and h) Axial CT abdominal images show the course of catheter through abdominal wall (arrow in g) and into the IVC (arrow in h). Patient returned due to catheter dysfunction (i and j). Frontal fluoroscopic imaging shows balloon dilation of IVC stenosis (arrow in i); as it failed, stent was placed (midline horizontal arrow in j). Incidentally noted is a Transjugular intrahepatic portosystemic shunt (TIPS) stent (oblique arrow in right hypochondrium).

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Hepatic vein

In spite of being the last resort vascular access in patients with infrarenal IVC occlusion, the transhepatic approach is advantageous.[41] In 2003, Stavropoulos et al., studied 36 transhepatic catheters and reported a primary patency of just 24.3 days, the major reason being a high rate of late thrombosis.[42] Recently, Younes et al., in a study of 127 transhepatic catheters, reported a much higher patency of 87.7 days. Although catheter-related maintenance in the form of exchanges was high (mean of 7.5 exchanges per patient), they were of the opinion that transhepatic catheters provide a potentially viable long-term access for patients with exhausted access options.[43] Smith et al., opined that hepatic vein TDCs are associated with a high rate of catheter malfunction. As these catheters have a long intrahepatic path, they move with liver excursions during respiration, resulting in either proximal migration/dislodgement or distally potentially contacting the tricuspid valve or the right atrial wall.[44] It should be noted placement of hepatic vein TDCs can result in liver hemorrhage in about 29% of the cases.[44]

Figure 7 shows a patient with a TDC placed in the hepatic vein.

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Figure 7

49-year-old female with metastatic breast cancer, coagulopathy, and renal insufficiency and a malfunctioning LIJV catheter. (a) Frontal fluoroscopic spot image of the chest shows TDC in LIJV (arrow). (b) Frontal digital subtraction venography after injection of contrast via the right brachial vein venography reveals right-sided central venous occlusion at the level of the RSV (arrow). Transhepatic catheter placement was decided. (c) Frontal digital subtraction venography of the right hypochondrium shows the venous access that was obtained into the hepatic vein (arrow in c). (d) Frontal fluoroscopic spot image of the abdomen shows a TDC placed via the hepatic vein (arrow), with the tip in the right atrium.

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Uncommonly used veins

Brachiocephalic veins

The brachiocephalic approach is used in cases of bilateral jugular venous occlusions. Falk evaluated the placement of TDCs in 33 right brachiocephalic veins and 11 brachiocephalic veins, and reported a 68.2% patency rate after 30 days, with a mean survival time of 92 days for those catheters that remained patent. The author opined that though US-guided visualization of the brachiocephalic vein is a challenging aspect of the procedure, in experienced hands, 100% technical success rate can be achieved.[45]

Figure 8 shows a patient with a TDC placed in the left brachiocephalic vein.

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Figure 8

54-year old female with ESRD, needing hemodialysis. (a) Frontal fluoroscopic spot image of the chest shows TDC in RIJV (arrow). (b and c) Few months later, digital subtraction venograms of the chest revealed SVC stenosis (arrow). (d) Frontal fluoroscopic spot image of the chest shows balloon angioplasty of the stenosis (arrow), which was unsuccessful. RFV TDC was placed. Few months later, patient had a catheter malfunction. (e) Fluoroscopic spot image of the upper abdomen shows venoplasty of the suprarenal IVC stenosis (arrow), which was again unsuccessful. (f) A hypertrophied anterior jugular vein was accessed. Frontal digital subtraction venography shows the anterior jugular vein (arrow) that appears to empty into the left brachiocephalic vein. (g) Frontal digital subtraction venography shows access of the left brachiocephalic vein (arrow). (h) Frontal fluoroscopic spot image of the chest shows a TDC in place.

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Obturator vein

The obturator vein is a particularly challenging vein for hemodialysis due to its very small radius. The risk of using the obturator vein includes hemorrhage, infection, thrombosis, and stenosis. The obturator artery, vein, and nerve course through the obturator canal, a small arched opening in the superior aspect of the obturator foramen, a potential site of vascular or nerve injury during placement of TDCs via a obturator vein approach (Salsamendi et al., in press).[46]

Figure 9 shows the placement of a TDC via the obturator vein.

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Figure 9

21-year old male with congenital renal dysplasia needing dialysis. Frontal digital subtraction venography of the chest via a right arm (a) and left arm (b) contrast injection reveals occlusion of the right (arrow in a) and left (arrow in b) brachiocephalic veins. Multiple superficial collaterals were seen in the right groin, one of which was accessed using US. (c) Frontal digital subtraction venography of the abdomen reveals a tiny collateral vein draining into right obturator vein. (d–f) Frontal fluoroscopic imaging shows dilatation of the tract (arrow in d) and advancement of the TDC (arrow in e). Tip of the catheter in the suprarenal IVC/right atrial junction (arrow in g). (g and h) 3D-CT volume reconstruction images show TDC through the obturator foramen (arrows in g, h).

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External iliac vein

The external iliac vein has been described in a patient with femoral vein occlusion. However, in general, it should be avoided, as the puncture of the external iliac vein is a higher puncture as compared to that of the femoral vein, and thus has a higher risk of retroperitoneal bleeding.[47]

Renal vein

A renal vein approach has been described, but renal veins are undesirable in patients with kidney disease.[48]

Sharp recanalization technique

When the techniques for venous access described above have failed, sharp recanalization technique (SRT) can be attempted. However, it is associated with a high risk of morbidity and mortality. Although a detailed discussion of the techniques is beyond the scope of this article, a few points are noteworthy.

The ultimate goal of SRT is to find an accessible neck or chest vein in very close proximity to a remnant central vein with direct communication to the RA. Prior assessment with detailed “roadmap” venogram to image all collateral veins can be enhanced by a review of all available cross-sectional imaging studies. Based on location, distance, and orientation, the veins are then assessed for the risk of perforating vital mediastinal structures during “blind” needle puncture. Many authors have described the use of a sheathed transjugular intrahepatic portosystemic shunt needle or stiff end of a glide wire to traverse the chronic stenosis. Once access is obtained and through-and-through guide wire access is achieved, subsequent balloon dilatation is performed to enable placement of a TDC.[284950]

The Hemoaccess Reliable Outflow vascular access device

In 2008, the US Food and Drug Administration approved the Hemoaccess Reliable Outflow (HeRO) vascular access device (Hemosphere, Inc., Minneapolis, MN, USA) as a method to establish access in dialysis patients with severe central venous disease.[515253] The HeRO device is an expanded polytetrafluoroethylene (ePTFE) graft placed in the upper arm over the biceps muscle and attached to a nitinol-reinforced silicone outflow component placed in the RA via titanium connector placed subcutaneously. Thus, it bypasses central venous stenosis.

Early results suggested that the infectious complications and re-intervention rates were significantly lower for the HeRO device as compared to TDC. The secondary patency rates approximated AVGs.[5455] In 2009, Katzman et al., implanted HeRO in 36 patients. The infection rate was 0.70/1000 days with bacteremia occurring prior to HeRO's implantation, when a TDC was still present. They recorded high primary patency rates of 38.9% and secondary patency rates of 72.2%, thus suggesting a major role of HeRO device in patients who are chronically dependent on dialysis.[53]

Although initial experience demonstrated excellent patency rates, subsequent studies were not very encouraging. In 2013, based on their experience in 19 patients, Wallace et al., reported high technical success but poor patency (12-month primary and secondary patency rates of 11 and 32%, respectively) and a high rate of infection (0.5 bacteremic events per 1000 HeRO-days) that required many re-interventions. Also, a high rate of arterial “steal syndrome” (24%) was noted that required ligation.[56] More recently in 2014, Torrent et al., have reported better secondary patency rates (81.6% at 6 months and 53.7% at 12 months). However, of note was that the re-intervention rate was 2.84 procedures per HeRO vascular access device year, which resulted in a high cost of maintenance ($34,713.63 per patient/year).[57]

Thus, although the HeRO device appears effective,[515253] its use should be reserved to create a “salvage” access for those who fail all other traditional AVF and graft options and should be offered as an alternative to the leg AVG.[5657]

Surgery

When all the above options fail, a few surgical alternatives may be available. Direct right atrial catheterization[58] and extra-anatomic surgical venous bypass[59] have been described in case reports.