| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Technical Innovation |
1
Department of Radiology, St. Louis University Health Sciences Center, 3635
Vista Ave. at Grand Blvd., St. Louis, MO 63110-0250.
2
Present address: Department of Radiology, University of Michigan Medical
Center, Rm. B1G 308, 1500 E. Medical Center Dr., Ann Arbor, MI
48109-0030.
Received June 10, 1999;
accepted after revision July 20, 1999.
Address correspondence to A. R. Forauer.
Introduction
 Top Introduction Subjects and MethodsResultsDiscussionReferences |
|---|
A patient has a finite number of vascular accesses for hemodialysis. Internal jugular vein occlusion often makes necessary the use of less desirable routes (e.g., translumbar, femoral, subclavian, and transhepatic). These approaches are considered less desirable because of increased technical difficulty, higher short- and long-term complication rates, or risks of infection. The percentage of patients with limited venous access options is increasing as the dialysis population grows and patients with end-stage renal disease live longer.
We report our experience with the placement of hemodialysis catheters through the external jugular vein and dilated cervical collaterals.
|
TopIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
The decision to pursue an external jugular vein or collateral approach was based on findings of bilateral internal jugular vein occlusion or unilateral internal jugular vein occlusion if future plans for creating an arteriovenous fistula or graft in the contralateral extremity were made. The presence or absence of dilated collaterals or an external jugular vein was noted. If the vessel could be followed to the confluence with the central portion of the internal jugular vein or subclavian vein and was of satisfactory caliber (>5 mm, the equivalent of a 15-French catheter), then the neck and anterior chest wall were prepared and draped in a sterile fashion.
The vein was accessed using sonographic guidance in the transverse imaging plane and a micropuncture technique (Micropuncture Set; Cook, Bloomington, IN). The 0.018-inch guidewire was maneuvered into the superior vena cava. After placement of a short 5-French dilator, a manual injection of contrast material was performed to determine patency of the central veins and the course of the vessel. If a tunneled catheter was placed, a subcutaneous tunnel was created inferiorly and laterally using blunt dissection techniques. The venotomy site was dilated with standard vessel dilators to the size of the peel-away sheath being used. The catheter was then inserted through the sheath and the catheter tip positioned in the right atrium. Temporary (nontunneled) catheters were inserted over a stiff 0.035-inch guidewire (Amplatz Super Stiff; Boston Scientific, Watertown, MA).
Follow-up data were obtained for each catheter including periprocedural complications, infection (exit site, bacteremia, or sepsis), average dialysis blood-flow rate, catheter dysfunction, and number of days indwelling. Periprocedural complications were defined as excessive bleeding or hematoma requiring transfusion, air embolus, pneumothorax, arrhythmia requiring treatment, carotid artery puncture, and inadequate dialysis flows (<300 ml/min). Catheter end points were defined as a catheter that is no longer needed (i.e., a mature graft or fistula), removal as a result of infection or sepsis, catheter dysfunction (not responding to standard therapy such as urokinase infusion or fibrin sheath stripping), or the patient's death.
|
TopIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Five tunneled catheters reached an end point and were removed with a functional upper extremity graft after an average of 78 days (range, 22-115 days). One catheter was removed as a result of bacteremia and positive blood cultures for gram-positive cocci after 115 days. Four catheters had been in place for a mean of 64 days (range, 7-91 days) with an average flow rate of 400 ml/min at the time of this writing. The single temporary catheter functioned well for 3 days before removal. During 608 days, no percutaneous interventions, such as stripping or urokinase infusions, were required.
|
TopIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Dialysis catheters require a large-caliber vein for adequate blood flow, whereas catheters designed for IV infusions (e.g., peripherally inserted central catheters [Hohn] can be placed in relatively small-caliber vessels such as intercostal veins [4]. Case reports and small studies have described the transhepatic [5] and translumbar [6] approaches to the inferior vena cava. These procedures are more technically demanding and carry certain risks specific to the route of the insertion, such as bleeding and extravascular catheter migration. Recently, a study larger than ours reported a high rate of technical success and acceptable complication rates for the femoral vein approach [7]. The rate of catheter infection was higher, 5.2/1000 days, with this approach. This is almost twice the rate seen in a study of 17 translumbar catheters [6] and significantly higher than that reported in a large study of internal jugular vein insertions (0.8/1000 days) [8]. To our knowledge, no published study describes dialysis catheter placements through the external jugular vein or dilated cervical collaterals, although the external jugular vein is cited as an alternative approach in the Dialysis Outcomes Quality Initiative guidelines [3].
No additional technical difficulty arose using the external jugular vein route. Central occlusion of the brachiocephalic vein or superior vena cava is a potential pitfall. Recent evidence suggests that Doppler waveform analysis may identify occlusions or significant stenoses [9]; therefore, with careful attention to the sonographic examination and preinsertion venogram, those patients with favorable vasculature can be easily selected for the external jugular vein approach. Patients possessing vessels that are too small or too tortuous can be identified and alternative accesses planned.
Although our study was small, the external jugular vein route did not compromise the catheter function. Five catheters remained functional for an average of 78 days until a functional upper extremity graft was available for use. Four others had been in use for a mean of 64 days with average flow rates of 400 ml/min at the time of this writing.
Because of the lateral location of the external jugular vein in relation to the internal jugular vein, the catheter apex actually has a more gentle curve than with standard internal jugular vein insertion.
Our results suggest that the external jugular vein can be considered for access in patients with thrombosis of the internal jugular veins. This approach can help to conserve the anatomically limited number of percutaneous access sites in each patient. Additionally, it can be used to allow maturing of an arteriovenous fistula or graft in the contralateral upper extremity when an internal jugular vein thrombosis exists.
|
TopIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  M. P. e Albuquerque A Modified Internal Jugular Vein Access for Long-Term Catheter Placement in Cancer Patients Ann. Surg. Oncol., February 1, 2007; 14(2): 937 - 941. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Falk Use of the brachiocephalic vein for placement of tunneled hemodialysis catheters. Am. J. Roentgenol., September 1, 2006; 187(3): 773 - 777. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Funaki Central Venous Access: A Primer for the Diagnostic Radiologist Am. J. Roentgenol., August 1, 2002; 179(2): 309 - 318. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
