AJR 2001; 176:233-234
© American Roentgen Ray Society
Placement of Transmediastinal Dialysis Catheters Using MR Imaging Guidance
Patrick E. Sewell, Jr.1,
Eric D. Lawson and
J. Dean Tanner
1
All authors: Department of Radiology, The University of Mississippi Medical
Center, 2500 N. State St., Jackson, MS 39216-4505
Received April 22, 1999;
accepted after revision June 12, 2000.
Address correspondence to P.E. Sewell, Jr.
Introduction
Placement of catheters to achieve vascular access in patients on
hemidialysis is increasingly performed in most interventional radiology
departments [1]. An aging
population on dialysis has presented new challenges because conventional
vascular access sites are exhausted
[1,2,3].
We were recently presented with a patient who had exhausted all conventional
vascular access possibilities. This case describes the use of a new
interventional imaging technique, interventional MR imaging, for placement of
a hemodialysis catheter.
Subject and Methods
Our case involves a 58-year-old man undergoing chronic hemodialysis. Having
used all surgically placed grafts as well as conventionally placed
percutaneous dialysis catheter sites, he presented with a malfunction of his
inferior vena cava twin Tesio dialysis catheter (MedComp, Harleysville, PA)
placed previously by our interventional radiology service. Physical
examination revealed that one limb of the twin dialysis catheter had been
dislodged. An inferior vena cavagram was obtained through the remaining limb
and revealed complete occlusion of the inferior vena cava at the intrahepatic
level, with venous outflow consisting of numerous inferior vena cava to
hepatic vein transhepatic collaterals. Search for an alternate percutaneous
venous access site in an effort to place a temporary or permanent dialysis
catheter consisted of bilateral supraclavicular venography and extensive
sonography. No suitable access was discovered; however, reconstruction of the
superior vena cava via numerous collaterals was seen
(Fig. 1A).
After the patient was placed in the supine position in the interventional
MR imaging unit, the anterior mediastinum was accessed percutaneously through
the right parasternal intercostal soft tissues. The anterior mediastinum was
traversed with a 21-gauge MR imaging histology needle (E-Z-EM, Westbury, NY)
under near real-time MR imaging guidance (axial spoiled gradient images), and
the tip of the needle was positioned in the lumen of the superior vena cava.
An 0.18-inch2 guidewire (Glidewire; Boston Scientific, Watertown,
MA) was advanced through this histology needle, and after removal of the
needle, a 4-French microcatheter (Micropuncture Introducer Set; Cook,
Bloomington, IN) was inserted over the guidewire. This technique was repeated
so that a second catheter was placed immediately adjacent to the initial
catheter access but through a separate puncture site and a separate entry site
in the superior vena cava (Figs.
1B and
1C). These catheters were
flushed with standard saline solution and capped and covered. The patient was
then transported to the angiography suite for completion of catheter
placement.
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Fig. 1B. —58-year-old man requiring chronic hemodialysis. Sagittal MR
image shows right parasternal transmediastinal path (arrows) of twin
dialysis catheters entering patient segment of superior vena cava.
|
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Fig. 1C. —58-year-old man requiring chronic hemodialysis. Axial MR
image reveals right parasternal transmediastinal path (arrows) of
twin dialysis catheters entering patient segment of superior vena cava.
|
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After the patient arrived in the interventional angiography suite, both
catheters and the skin surrounding them were reprepped and draped.
Introduction of the guidewires, dilatation of the tracts, placement of the
peel-away sheaths, and introduction of the twin dialysis catheters as well as
construction of the subcutaneous tunnels then proceeded using standard
techniques. The catheters were left unused for 24 hr, after which they were
used for hemodialysis. The catheters remained fully functional for
approximately 1 month, at which time the patient accidentally dislodged one
catheter. The catheter was replaced using the same technique approximately 24
hr after removal, and both catheters remain fully functional 18 months later
and comprise the only hemodialysis access in this patient at this time.
Our interventional MR imaging suite consists of the Signa SP magnet
(General Electric Medical Systems, Milwaukee, WI). This vertical dual-bore
donut configuration allows direct physical access to the patient during
imaging. MR imaging—compatible histology needles, an 0.01-inch
guidewire, and a 4-French microcatheter were used for percutaneous vascular
access. A MultiStar angiography suite (Siemens, Erlangen, Germany) was used
for guidance during dilatation of the transmediastinal access tract and final
placement of the twin dialysis catheters.
Discussion
Interventional radiologists are becoming increasingly involved with
hemodialysis access management
[3]. Our interventional
radiology service is frequently consulted to place tunneled subcutaneous
hemodialysis catheters in patients who have lost all conventional surgical and
percutaneous access sites. At our institution, this population of patients
frequently requires a translumbar inferior vena cava dialysis catheter for
long-term hemodialysis access. This case illustrates a new interventional
imaging modality and a new technique for placement of a dialysis catheter in
this problematic patient population. Our institution has a dedicated
interventional MR imaging suite, and the indications for its use are evolving.
This patient with severe venous occlusive disease and extremely difficult
vascular access presented an opportunity to explore another technique and
approach to hemodialysis treatment. Direct percutaneous access to the superior
vena cava via the anterior mediastinum could not be accomplished using
traditional imaging guidance. The unique requirements for this method of
access consist of the need to visualize the vascular system targeted, the
surrounding soft tissues of the mediastinum, and the nontargeted vascular
structures. Our interventional MR imaging unit satisfied all the requirements
because it provided near real-time imaging, direct physical access to the
patient, and the superior imaging capabilities of MR imaging. Of equal
importance was the availability of MR imaging compatible needles, guidewires,
and catheters.
With the improvements in image acquisition times, real-time interventional
MR imaging may be available in the near future. Further development of
interventional MR-compatible instruments (e.g., needles, guidewires, balloons,
and catheters) and the superior imaging capability of MR imaging suggest that
the current concerns and limitations of imaging-guided intervention will be of
lesser significance to the future interventional radiologist.
References
-
Noh HM, Kaufman JA, Rhea JT, et al. Cost comparison of radiologic
versus surgical placement of long-term hemodialysis catheters.
AJR
1999;172:673
-675[Abstract/Free Full Text]
-
Zaleski GX, Funaki B, Lorenz JM, et al. Experience with tunneled
femoral hemodialysis catheters. AJR
1999;172:493
-496[Abstract/Free Full Text]
-
Caridi JG, Grundy LS, Ross EA, et al. Interventional radiology
placement of twin Tesio catheters for dialysis access: review of 75 patients.
J Vasc Interv Radiol
1999;10:78
-83[Medline]
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Introduction
Subject and Methods
