Salvage of the existing venotomy site and tunnel: Redeeming the “Fallen dialysis catheter”

Abstract

Accidental extrusion of tunneled hemodialysis (HD) catheter leaves the dialysis patient without a vascular access and creates an emergency. The common practice is to insert a new catheter via a new venotomy site and a new tunnel. We highlight a lesser-known intervention technique that helps preserve the limited central venous vascular access sites needed to provide dialysis. A 42-year-old man with end stage kidney disease on HD through a right internal jugular vein (RIJV) tunneled hemodialysis catheter (TDC) was referred 1-day after he accidently pulled his catheter following the removal of butterfly wing sutures. The TDC had been in place for 2 months. On examination, the catheter exit site was not infected. After sterile skin preparation the exit site and the tunnel were cleaned with betadine impregnated Q-tips. An 0.035″ hydrophilic guidewire was advanced through the existing venotomy site over a 5F directional catheter under fluoroscopic guidance. The catheter over the guidewire was advanced through the tunnel towards the previous venotomy site in the RIJV. The exact position of the guidewire and catheter was confirmed by injecting contrast. The angled catheter was then maneuvered inferiorly towards the superior vena cava and the wire was placed in the inferior vena cava. A new TDC was advanced over the guidewire through the existing tunnel and the catheter tip was positioned into the mid-right atrium. The procedure was uneventful and TDC was functioning well at 1-month follow-up review. In conclusion, the case highlights the safety of an underutilized practical approach to achieving safe and quick access for dialysis in patients with accidental loss of TDC. The technique described herein, avoids the need to select a new venotomy site, improves patient satisfaction by minimizing procedure related discomfort due to alleviating the need to create a new tunnel, and optimizes resources used for the procedure.