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Translumbar and Transhepatic Placement of Hemodialysis Catheters

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Translumbar and Transhepatic Placement of Hemodialysis Catheters ASDIN 7th Annual Scientific Meeting Translumbar and Transhepatic Translumbar and Transhepatic Placement of Hemodialysis Placement of Hemodialysis Catheters Catheters Onlyyp in patients without other medical options. Abigail Falk, MD, FSIR American Access Care Not a primary means of central New York, NY venous access. Translumbar Catheter Placement Translumbar Puncture into IVC On a method of translumbar catheter angiography of the thoracic aorta and the aortic arch arteries. Schmitz-Drager HG. Fortschr Geb Rontgenstr Nuklearmed. (1963) 99:36-40. Put patient prone (right is right) U/S or CT gu idance…or Translumbar inferior vena cava Hickman catheter placement for total parenteral nutrition. Denny DF. AJR (1987) 3:621-2. Puncture 10 cm above iliac crest and 10 cm right of midline Aim for L2/L3 Translumbar Puncture into IVC Translumbar Puncture into IVC Aspirate to confirm entry into IVC 21G 15cm needle advanced 45 degrees cephalad and medial towards IVC under flouro Inject contrast to confirm needle placement May touch vert body and redirect anterior then place .018 wire If fem cath, put in wire to mark IVC 1 ASDIN 7th Annual Scientific Meeting Translumbar Puncture into IVC Translumbar Puncture into IVC Pull catheter through tunnel Catheter into peel away sheath Remove sheath Tunnel laterally A coaxial dilator with an inner metal Long tunnel to exit side stiffener is used to access IVC, stiff wire Choose a long catheter then placed into IVC Translumbar Puncture into IVC Translumbar Puncture into IVC Risks - infection, fibrin sheath, IVC thrombosis, dislodgement (13%) Can place catheter above/through IVC filter (target) Cannot get hemostasis at puncture site 60-80cc blood loss typical around IVC Can perform catheter exchange over wire Final image with tip at cavoatrial junction Biswal R. CVIR (2000)1:75-8. Translumbar High Inferior Vena Cava Access Translumbar central venous catheters for Placement in Patients with Thrombosed Inferior long-term haemodialysis. Vena Cava Filters Retrospective study 26 patients 39 translumbar catheters 1 retroperitoneal hematoma 1 year cumulative assisted primary patency rate 73% 2.84/1000 catheter days infection rate (2.02/1000 catheter days exit site infection**) Oblique view of needle and 0.018-inch Ash Split hemodialysis catheter guide wire being advanced into IVC (14 F, 40 cm) positioned with patient in prone position. within the atrium. Thrombosed IVC filter. Right renal artery passes posterior to IVC at this level….do not puncture it !!! Power A. NDT (2010) 5:1588-95. Kinney TB. JVIR (2003)12:1563-8. 2 ASDIN 7th Annual Scientific Meeting Azygos Vein Dialysis Catheter Placement Using the Transhepatic Guidance of Translumbar Translumbar Approach in a Patient with Inferior Vena Cava Occlusion Hemodialysis Catheter Placement Translumbar placement of Tip in upper portion the catheter into the right of azygos vein. Occluded jugular, ascending lumbar vein. subclavian, femoral, renal and IVC. Transhepatic vein access with target/snare into IVC at left renal vein. Prone venography shows right ascending lumbar (A), prominent azygos (B), accessory hemiazygos (C), and hemiazygos (D) veins. Jaber MR. CVIR (2008) Suppl 2:S206-8. Lorenz ML, CVIR (2010)33:635–638. Transhepatic Catheter Placement Transhepatic Catheter Placement Much less common for hemodialysis catheter Transhepatic cannulation of the inferior vena cava. placement than translumbar placement. Kaufman JA. JVIR (1991) 3:331-4. More commonlyyp described in the pediatric Percutaneous translumbar and transhepatic inferior vena literature. caval cat heters for pro longe d vascu lar access in c hildren. Azizkhan RG. J Pediatr Surg (1992) 2:165-9. Alternatiave puncture site of implantable permanent haemodialysis catheters. Apsner R. NDT (1996) 11:2293-5. Transhepatic Catheter Placement: Transhepatic Catheter Placement: Approach Approach Similar to biliary work, except the goal is to opacify a Dilute contrast injected under fluoroscopy as needle hepatic vein instead of the biliary tree withdrawn U/S guidance … or Opacify hepatic vein Mid-axillary approach through the level of ribs 10-12 0.018-inch wire advanced into IVC 15-cm long 22-gauge Chiba needle (Cook, Inc) advanced Place dilator with inner metal stiffener (Accustick, Boston above the rib into the liver parenchyma Scientific) 3 ASDIN 7th Annual Scientific Meeting Transhepatic Catheter Placement: Approach Transhepatic Catheter Placement Exchange for standard 0.035-inch stiff guidewire Dilate tract and place peel-away sheath Create tunnel superiorly (?) Longer catheter required Place tip in RA Younes HK. JVIR (2011) 22:183-191. Percutaneous transhepatic Transhepatic Catheter Placement venous access for hemodialysis. Retrospective study Risks - hepatic vein and IVC thrombosis, 12 patients dislodgement, intraperitoneal hemorrhage, 36 catheters (17 new, 19 over the wire exchanges) cardiac tamponade secondary to right Translumbar catheter placement exhausted atrial erosion Mean primary patency 27 days Secondary patency 70 days Painful if intercostal placement 21 replaced or removed due to catheter thrombosis 2.2/1000 catheter days infection rate 5 (14%) respiratory migration Schmiege LM 3rd. SID (2006) 5:434–437. Stavropoulos SW. JVIR (2003) 9:1187-90. Transhepatic catheter access Transhepatic hemodialysis catheters: functional outcome and comparison between early and late failure. for hemodialysis. Retrospective study Retrospective study 22 patients 16 patients 127 catheters (tips in 105 RA, 15 IVC, 4 SVC, 1 21 catheters hemiazygous, 1 hepatic, 1?) 30 exchanges in 10 patients 24 trans hepat ic access s ites 5 (24%)dislodged 105 exchanges in 14 patients (high maintenance rate) 6 (29%) complications, including one death from 37% migration intraperitoneal hemorrhage 22% sepsis 17% catheter thrombosis Cx’s: bleeding, intercostal pain, 1 death due to MI Smith TP. Radiology (2004) 1:246-51. Younes HK. JVIR (2011) 22:183-191. 4 ASDIN 7th Annual Scientific Meeting Other Placement Sites Other Placement Sites Collateral thyrocervical and other neck veins Brachiocephalic Vein U/S of neck - multiple collaterals, no jugular, assume stenosis/occlusion Can access collateral under U/S Place snare from below and use as target Hold transducer at very steep Clamp marks needle entry angle posterior to clavicle. site into skin. Arrow entry Puncture without needle guide. site into vein. Final image. Snare into collateral Fem punct Grab wire with snare Cath in subcl branch Falk A. AJR (2006) 187:773–777. Funaki B Radiology (2001)2:471-6. Hagen P JVIR (2001)4:493-5. Other Placement Sites Other Placement Sites Femoral Vein Transrenal access into IVC * Insertion site asterisk. Left transrenal wire into IVC/RA Final CT image Tunnel arrows. Tip in perirenal IVC. Arterial lumen Occl’d IVC at filter (arrow) faces medial, away from IVC wall. Falk A. JVIR (2007) 18:217–225. Murthy R. JVIR (2002) 10:1043-6. Other Placement Sites Other Placement Sites External iliac vein access into IVC Direct SVC puncture 48 yo F with bilateral subclavian, bhihlidfbrachiocephalic and femora lil vein occlusions. Surgical exposure (retroperitoneal approach) of external iliac vein with catheter placement. Tokgoz H. J Vasc Access (2005) 4:200-2. 5 ASDIN 7th Annual Scientific Meeting Summary Review all radiological studies involving central veins. Identify occluded vessels, collaterals, etc…stenoses and occlusions can be crossed. Pick best site - least discomfort, least risk of infection, thrombosis, dislodgement. 6.
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