Salvage insertion of tunneled central venous catheters in the internal jugular vein after accidental catheter removal.
ABSTRACT Tunneled catheters are widely used for intermediate to long-term hemodialysis (HD) access, but are prone to several complications that can require catheter replacement. Replacing malfunctioning catheters with a new line, placed in a different access site, can lead to problems with multiple vein occlusions. This has led many nephrologists to continue using the same vein as long as possible by guidewire catheter exchanges, to preserve other veins for future use. We describe a guidewire exchange technique for the Ash-Split catheter in the internal jugular vein.
In three patients, the exchange was performed because of partial catheter removal, as evidenced by the outward dislocation of the Dacron cuff. In these patients, the guidewire was inserted through the catheter. In two additional patients, the catheter had been completely removed by accident: the replacement of the dislodged tunneled venous catheters was attempted 5 hr and 1 day after accidental removal. In these patients, the guidewire was inserted through the previous tunnel. After guidewire placement, a skin incision was made in the supraclavicular region. The metal guidewire was easily located inside the fibrous structure that had previously surrounded the catheter. The guidewire was then extracted from the subcutaneous tunnel and used to insert a new catheter safely and easily after creating a new tunnel. Patients were routinely given antibiotic prophylaxis (1 g of cefazolin) immediately before the procedure. A strict aseptic technique was used, including several sterile glove changes.
No infections developed following this procedure, which has the potential for bacterial contamination. All procedures were successful. Only in one patient did we have to convert to a different catheter: it was not possible to replace the old Ash-Split catheter with the same dual-lumen catheter because of difficulties in inserting the peel away introducer-catheter complex. In this patient, rather than forcing it with larger dilators or trying to disrupt the fibrin sheath with balloon dilatation, a single lumen Tesio catheter was successfully placed. In both patients who completely lost the previous catheter, the guidewire was readily reinserted through the subcutaneous tunnel into the vein. Catheter function was excellent in all patients, with a test blood flow rate on the 1st catheter use >350 ml/min.
We described a new method for catheter exchange, which allows the easy insertion of a new catheter and the creation of a new and safer subcutaneous tunnel. In addition, we demonstrated that in cases of complete catheter removal, it is possible to reinsert a catheter in the same vein through a guidewire, even when reinsertion was attempted up to 1 day later.
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ABSTRACT: Over-the-wire exchange is a standard treatment for patients with tunneled hemodialysis catheters (THCs) that fail to maintain sufficient extracorporeal blood flow. However, this well-known procedure is unsuitable in the presence of exit-site infection (ESI). In such cases, a modified exchange technique with introduction of the new THC through a remote exit site and the preexisting subcutaneous tunnel may be a solution. Quality improvement report. Since 2005, a total of 28 consecutive dysfunctional THCs with ESI in 23 patients who did not have tunnel infection or bacteremia before the procedures was included. Introduction of the new THC through a remote exit site and preexisting subcutaneous tunnel. Technical success, perioperative complications, infection rates, and catheter function were recorded for analysis. There was only 1 failure, giving an overall technical success rate of 96%. The other 27 exchanged THCs achieved satisfactory flow during subsequent hemodialysis, and the ESI gradually resolved within 2 weeks. Although 8 episodes of new ESI occurred, no subcutaneous tunnel infection or bacteremia occurred within 120 days. Bedridden patients had more occurrences of new ESIs than nonbedridden patients (6 of 9 versus 2 of 13 patients; P = 0.03). Primary catheter patency rates were 100% at 30 days, 82% at 90 days, and 77% at 120 days. Secondary catheter patency rates were 100% at 30 days, 91% at 90 days, and 91% at 120 days. A small number of cases and comparison with previous studies of THC exchange. For dysfunctional THCs with ESI, exchange through remote exit sites and preexisting subcutaneous tunnels is feasible and can be used repeatedly for patients prone to ESI, such as the bedridden. This modified exchange technique is also preferable for operators who question the sterility of previous exit sites and are reluctant to use the over-the-wire technique.American Journal of Kidney Diseases 10/2008; 53(1):112-20. · 5.29 Impact Factor
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ABSTRACT: Reoperation for a malfunctioning central venous catheter (CVC) is technically demanding as a bedside procedure in premature infants, and general anesthesia and paralysis is usually required for such an operation. Herein, we describe a safe and simple reinsertion technique to treat CVC occlusion using the original tract. Using a previous incision, the subcutaneous tract was identified, and the anterior half circle of the tract was opened. The catheter was transected through the opening, and the distal part was removed. A new catheter was introduced through an empty subcutaneous tunneling pathway and skin exit site, where the old distal part had been recently removed. Using fine 6–0 monofilament suture, traction sutures were placed along the cut edge of the proximal tract. The proximal part was then removed, and a newly placed catheter tip was inserted into the tract opening. When CVC reinsertion is required in premature infants, reinsertion can be accomplished easily and safely using this technique as a bedside procedure without general anesthesia.Journal of Pediatric Surgery Case Reports. 04/2013; 1(4):65–67.