117 Dual Lumen Catheters for Dialysis 5 Fig. 5.21. This adhesive device supplied in the Tesio kit is taped to the patient’s chest to prevent catheters from being pulled and only lasts a few days. Patients must be taught to care for their catheters to minimize complications. Catheters should not hang down freely, which causes slow migration and eventually dacron cuff migration/exposure/in- fection. Catheters can be taped in a loose curvilinear fashion or secured in the bra (females) to allow free movements at the exit site, avoiding pulling. Removal of Cuffed Catheters Removal of cuffed catheters is indicated for tract infection, sepsis, positive blood cultures and is the catheter is no longer needed. Depending on where the cuff is located, two techniques are used. 1. The cuff is located immediately adjacent to the exit site. In this case, the exit site is anesthetized with 1% lidocaine (Fig. 5.22A). The exit site is dilated slightly with a mosquito hemostat or incised with a knife, and the catheter may be lodged out with this simple procedure (Fig. 5.22B). In some cases where the cuff is more incorporated, a small skin incision longitudinal to the catheter is used with sharp and blunt dissection around the cuff, which will release the catheter. Usually there is back bleeding which is temporarily stopped by finger pressure (Fig. 5.22C). Compression of the exit site for about 30 minutes with the patient sitting up will usually prevent further bleeding. However, the author recommends a Figure-of-eight suture with nylon or PDS to prevent backbleeding (Fig. 5.22D). The patient is asked to keep pressure on the site for the next 1-2 hours, and avoid strenuous physical activity for the next 24-48 hours (Appendix IV). 2. In cases where the cuff is located further up the subcutaneous tract, the area on top of the dacron cuff is infiltrated with 1% Lidocaine. A transverse inci- sion is made (Fig. 5.23A). The catheter is isolated distal to the cuff, clamped with a hemostat (Fig. 5.23B) and divided distal to the hemostat (Fig. 5.23C). The catheter may now fall out from the exit site. The cuff is dissected free, exposing the catheter proximal to the cuff. Often there is a sheath of tissue surrounding the catheter at this point. A pursestring suture is placed around the catheter, grabbing the tissue around the tract (Fig. 5.23D). This pursestring suture of PDS is tied as the catheter is pulled out to prevent backbleeding. 118 Access for Dialysis: Surgical and Radiologic Procedures 5 Fig. 5.22A. Removal/exchange of cuffed dual lumen catheters; in this case, the cuff is immediately adjacent to the outside. After infiltration of lidocaine 1% and removal of concentrated heparin in the ports, the cuff is dissected free with a knife, hemostat or sharp scissors. Fig. 5.22B. When the cuff is free, the catheter is pulled out in its entirety (Appendix IV). 119 Dual Lumen Catheters for Dialysis 5 Fig. 5.22C. Usually there is back bleeding, which is temporarily stopped by finger pres- sure. Compression by the patient of the exit site for 30 minutes usually prevents further back bleeding. Fig. 5.22D. The author recommends a figure-of-eight suture to prevent any future back bleeding. In addition, the patient is asked to keep pressure on the site for the next 1-2 hrs and avoid strenuous physical activity for 24-48 hours. 120 Access for Dialysis: Surgical and Radiologic Procedures 5 Fig. 5.23A. When the cuff is at a distance from the exit site, a cut down over the cuff is necessary. (When the cuff is at skin level blunt dissection is all that is needed around the cuff). Fig. 5.23B. The catheter is clamped distal to the cuff and cut/divided. 121 Dual Lumen Catheters for Dialysis 5 Fig. 5.23C. The cuff is dissected free to expose the catheter proximal to the cuff. Fig. 5.23D. A pursestring suture, i.e., 4-0 PDS’ is placed around the catheter and tied as the catheter is pulled to prevent back bleeding. Lastly, the suture (if present) at exit site is cut and the catheter pulled out of the exit site. 122 Access for Dialysis: Surgical and Radiologic Procedures 5 Fig. 5.24. Correctly placed, the catheter will make a smooth, lateral curve at the neck level, avoiding kinking. The skin incision is closed with one or two subcuticular PDS sutures and covered with a 4x4 dressing and bio-occlusive dressing (Tegaderm ® ). The patient is asked to keep pressure for the next 1-2 hours and avoid strenuous exercise for 24-48 hours (Appendix IV). The Ideal vs Kinked Catheter The ideal catheter on chest X ray describes a smooth right-side, lateral curve without kinking (Fig. 5.24). The catheter lines end at the right atrium/SVC level. Kinking usually occurs at the internal jugular vein insertion site (Fig. 5.25A-F). When removed, this stiffer catheter also describes the central vein anatomy (Fig. 5.25C). Kinking may involve both ports, or as in this case only the arterial (red) port (Fig. 5.25C-D). Ways to avoid a kinked catheter include wide smooth subcuta- neous tunnel achieved by bending the tunneler. Also a lower jugular approach less- ens the likelihood of kinking at the vein entrance level. Rarely, despite optimal placement, kinks may occur (Fig. 5.25E-F). Exchanging Cuffed, Tunneled Catheters The indications for changing catheters are outlined in Table 5.2 and vary with the type of catheter. Generally, changing cuffed catheters over a guidewire using the same exit site is not recommended. The authors prefer the following technique, if technically feasible. A skin incision is made at the neck level, close to or at the previous neck inser- tion site (Fig. 5.26A). The catheter is dissected free and surrounded with a vessel loop (Fig. 5.26F). The new catheter is inserted from the upper chest using a new exit 123 Dual Lumen Catheters for Dialysis 5 Fig. 5.25A. Classic kink of catheter with a sharp angle at the IJ exit. This is caused by too sharp a “turn” of catheter at the IJ vein. Fig. 5.25B. Close up view of same catheter. 124 Access for Dialysis: Surgical and Radiologic Procedures 5 Fig. 5.25D. Close up view of the kink at the neck IJ level. Fig. 5.25C. The removed catheter outlines the central vein anatomy. site, usually lateral to the previous one. The new catheter is tunneled and brought into the neck wound. The catheter to be removed is guidewired, either from the end by making a small incision in one of the catheter lines at the neck wound. It is not recommended to completely divide the catheter at this level since it may be lost, causing foreign body embolization (Fig. 5.26C). A guidewire is inserted, and the catheter can now be removed. Back bleeding is prevented by finger pressure. The guidewire is pulled out of the old catheter. The tract may be dilated over the guidewire, 125 Dual Lumen Catheters for Dialysis 5 Fig. 5.25E. Despite a smooth curve of this catheter, an undulation involving one lumen was seen immediately after placement. The kink is magnified in image F. Patient under- went uneventful dialysis with >300 ml/min flow the following day. (No follow-up x-rays of this catheter available!) Fig. 5.25F. Close up view of kinked catheter. 126 Access for Dialysis: Surgical and Radiologic Procedures 5 Fig. 5.26A. Make an incision at the previous neck insertion site; the catheter is mobilized. Fig. 5.26B. The catheter is pulled up. Catch the catheter with a vessel loop. At this point the catheter may be partially divided to allow guidewire insertion. This will also prevent losing the catheter into the blood stream. [...]... months per site.3 Thus for most ESRD patients, the six upper extremity access sites (one forearm and two sites above the elbow in each arm) will most likely be exhausted within 10 years For the 58% of ESRD patients between the ages of 40 and 70 preservation of access function and access site usefulness is or will become a critical issue Access for Dialysis: Surgical and Radiologic Procedures, 2nd ed.,... superior to stripping (Table 5.6) 1 34 Access for Dialysis: Surgical and Radiologic Procedures 5 Fig 5.28E The guidewire is now retrieved into the neck incision wound using the vessel loop 5 These procedures may be combined with thrombolytic treatment, i.e., t-PA injected as a bolus or infusion over 2 -4 hours 6 Balloon dilatation to 1 2-1 4 mm of the innominate vein, SVC and the rightatrium in order to disrupt... 5-0 PDS The Moncrief catheter placement, where the external portion of the catheter is placed subcutaneously for 4- 6 weeks allowing skin ingrowth of dacron cuffs prior to externalization, is outlined in Fig 6.9A-B 6 144 Access for Dialysis: Surgical and Radiologic Procedures 6 Fig 6.5 The double cuffed Tenckhoff catheter has been inserted into the peritoneal cavity The guidewire has been retracted and. .. continued for 1 0-1 4 days In patients with purulent drainage around catheter and clinical signs of sepsis, the catheter must urgently be removed New access can be placed when the patient has been afebrile for >48 hours or blood cultures are negative Dialysis is delivered through temporary femoral percutaneous catheters 130 Access for Dialysis: Surgical and Radiologic Procedures 5 Fig 5.27C And inserted... red port and secured Dual Lumen Catheters for Dialysis 131 5 Fig 5.27E The split ash catheter is now inserted into the IJ and positioned under fluoroscopy Fig 5.28A The skin is marked for (in this case) split ash subcutaneous tract and exit site Skin incision is marked for catheter exposure 132 Access for Dialysis: Surgical and Radiologic Procedures 5 Fig 5.28B The catheter is mobilized and surrounded... (PTA) of dysfunctional but not thrombosed accesses, and 1,600 tunneled cuffed catheter accesses I have performed over 1,000 procedures on native arterio-venous fistulae (AVFs) Success for thrombosed accesses is 95% for grafts and 88% for AVFs, both with a significant complication rate of less than 2% Success with both AVFs and grafts that underwent angio/PTA for dysfunction was 99% with less than 1%... catheters should be used Therefore, the straight catheters have been excluded from the table The curled catheter comes in left- and right-sided configurations The only difference between the two is the orientation of the radiopaque line on the Access for Dialysis: Surgical and Radiologic Procedures, 2nd ed., edited by Ingemar J.A Davidson ©2002 Landes Bioscience Abdominal Catheters for Peritoneal dialysis... given general anesthesia HIV positive individuals, in the author’s view, are candidates for epidurals or general anesthesia to protect the OR personnel  140 Access for Dialysis: Surgical and Radiologic Procedures 6 Fig 6.2B The swan neck (proximal), pigtail (distal), 62.5 cm double cuffed Quinton peritoneal dialysis catheter The parts of the catheter are marked as follows: PT: Pigtail; PPC: Preperitoneal... When the wound is clean and granulating, the catheter is rerouted to a new exit site and the clean cavity allowed to granulate from the bottom 6 150 Access for Dialysis: Surgical and Radiologic Procedures 6 Fig 6.10 PD catheter obstructed by overlying omentum, with contrast injected in the catheter Peritonitis is caused by a break in sterility, and is characterized by pain, fever and cloudy or bloody... Quinton Quinton Quinton Moncrief-Popovich Table 6.2 Commercially available curled peritoneal dialysis catheters 138 Access for Dialysis: Surgical and Radiologic Procedures Abdominal Catheters for Peritoneal dialysis 139 6 Fig 6.2A There are several types of Tenckhoff’s catheters available, with one or two dacron cuffs The innermost cuff is placed between the peritoneum and the posterior fascia; the outermost . PDS sutures and covered with a 4x4 dressing and bio-occlusive dressing (Tegaderm ® ). The patient is asked to keep pressure for the next 1-2 hours and avoid strenuous exercise for 2 4- 4 8 hours (Appendix. figure-of-eight suture to prevent any future back bleeding. In addition, the patient is asked to keep pressure on the site for the next 1-2 hrs and avoid strenuous physical activity for 2 4- 4 8 hours. 120 Access. the following day. (No follow-up x-rays of this catheter available!) Fig. 5.25F. Close up view of kinked catheter. 126 Access for Dialysis: Surgical and Radiologic Procedures 5 Fig. 5.26A. Make