Salvage insertion of tunneled central venous catheters in the internal jugular vein after accidental catheter removal
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.
Available from: Younglim Kim
- "Fixation methods were modified from previously published protocols . In brief, the animals were anesthetized using the same protocol described above. "
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ABSTRACT: The sequelae of a central venous cutdown usually include venous deformity causing venous stenosis or stricture. However, the cellular mechanisms causing these deformities have not been elucidated.
Silicone 2.7-Fr catheters were placed via the right external jugular vein of 16 rats with the cutdown method. After fixation with formalin at scheduled intervals (1week, 2weeks, 4weeks, and 8weeks; 4 rats in each group), the vein segment with the catheter in situ was harvested. Histological changes in the vein wall were studied and serially compared with light microscopy; standard hematoxylin-eosin staining, Masson's trichrome staining, van Gieson's elastin stain, and immunohistochemical stain against α-actin.
Pericatheter sleeve formation, circumferential smooth muscle cell proliferation and infiltration into the pericatheter sleeve by direct contact were noted in all 4 rats of 1-week model; this indicated the initiation of neointimal hyperplasia. The neointimal hyperplasia was located inside the elastin layer. At 2weeks, the SMCs stained faintly but the components of the vein wall were largely replaced by collagen. The proliferation and infiltration of SMCs stabilized at 4weeks and no SMCs were stained around the catheter. At 8weeks, luminal narrowing was noted and the venous wall was composed mainly of collagen.
Circumferential neointimal hyperplasia occurred after surgical cutdown of the external jugular vein in a rat model and was caused by SMC activation, proliferation, and infiltration into the pericatheter sleeve.
Copyright © 2015. Published by Elsevier Inc.
Journal of Pediatric Surgery 05/2015; 50(11). DOI:10.1016/j.jpedsurg.2015.04.019 · 1.39 Impact Factor
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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. DOI:10.1053/j.ajkd.2008.08.024 · 5.90 Impact Factor
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ABSTRACT: To determine the success rate for reinsertion of interventional radiology-placed catheters that were accidentally removed by using the existing percutaneous track and to investigate factors that influence success rate.
The authors performed a retrospective analysis of 225 patients who presented with dislodged catheters (24 tunneled central venous catheters, 170 gastrostomy/jejunostomy tubes, 25 nephrostomy catheters, five biliary catheters, and one transhepatic hemodialysis catheter) and underwent attempts for reinsertion between 1999 and 2007. Data obtained from the radiology information system included the type of catheter and the indwelling and reinsertion times.
The overall success rate for reinsertion was 87%. Success of reinsertion was associated with longer catheter indwelling times compared to patients who failed reinsertion (254 vs 100 days, P < .01). Success of reinsertion was associated with shorter reinsertion times compared to patients who failed reinsertion (1.1 vs 2.7 days, P < .05).
Reinsertion of catheters by using the cutaneous track can be performed successfully during the first days after dislodgement. Success rates vary on the basis of catheter type and indwelling and reinsertion times.
Journal of vascular and interventional radiology: JVIR 06/2010; 21(6):861-4. DOI:10.1016/j.jvir.2010.02.022 · 2.41 Impact Factor
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