Dialysis Access · IR Playbook

Tunneled Hemodialysis Catheter Placement and Salvage (HD catheter)

Tunneled hemodialysis catheter placement provides cuffed, high-flow central venous access when an arteriovenous access is unavailable, unsuitable or not yet usable. Dysfunction persisting after conservative measures and intraluminal thrombolysis is managed by catheter exchange, usually with assessment and balloon disruption of an associated fibrin sheath; femoral snare stripping is a less durable rescue option.

Indications

Hemodialysis is required while an arteriovenous fistula or graft matures or recovers from a complication.
Long-term catheter-dependent dialysis is required because durable arteriovenous access is unsuitable, exhausted or declined after informed discussion.
Existing tunneled catheter has refractory poor flow, malposition, damage or inadequate length requiring exchange.
Clinically significant fibrin sheath causes persistent catheter dysfunction despite conservative measures and intraluminal thrombolysis.

Equipment

High-frequency linear ultrasound transducer with sterile cover
21 G micropuncture needle, 0.018-inch wire and coaxial introducer
0.035-inch hydrophilic and stiff guidewires of adequate length
Approximately 14–15.5 Fr dual-lumen cuffed tunneled dialysis catheter
Serial dilators and appropriately sized peel-away sheath
Contrast, syringes, catheter locking solution and sterile dressings
Approximately 10 mm angioplasty balloon and femoral loop snare when fibrin-sheath treatment is required

Procedure steps

Review the patient's dialysis life-plan and previous access history. Confirm venous patency with ultrasound and select the right internal jugular vein unless anatomy or future access planning dictates otherwise.
Position the patient supine with mild Trendelenburg if tolerated. Use maximal sterile-barrier precautions, chlorhexidine-based skin preparation and local anaesthesia.
Puncture the vein under real-time ultrasound guidance. Exchange the micropuncture wire for a 0.035-inch guidewire and confirm its course into the inferior vena cava under fluoroscopy.Pearl: Never dilate until the guidewire course is unequivocally venous.
Select a clean anterior chest exit site and infiltrate the tract with local anaesthetic. Tunnel the catheter between the exit site and venotomy with the cuff entirely within the subcutaneous tract.
Serially dilate the venotomy, insert the peel-away sheath and advance the catheter under fluoroscopy. Remove the sheath while preventing air entry.
Position the functional catheter tip in the mid-right atrium without contacting the atrial floor. Confirm an un-kinked course, aspirate and flush both lumens, instill the prescribed locking solution and secure the catheter.
After conservative measures and intraluminal thrombolysis have failed, pass one or two 0.035-inch wires through the catheter into the inferior vena cava. Free the cuff by blunt dissection, remove the catheter while maintaining wire access and perform contrast assessment when fibrin sheath or central stenosis is suspected.
Disrupt a clinically significant fibrin sheath with a vein-sized angioplasty balloon, commonly approximately 10 mm, along the previous intravascular catheter tract before placing the new catheter. Femoral loop-snare stripping may be used when selected alternatives are unsuitable, but it is generally less durable than catheter exchange.Pearl: Fibrin sheath requires treatment only when associated with catheter dysfunction or infection.

Complications

Exit-site bleeding or hematoma
Pneumothorax, hemothorax or arterial injury
Catheter malposition or early dysfunction
Catheter-related bloodstream or tunnel infection
Central venous thrombosis or stenosis
Venous injury or embolization during fibrin-sheath disruption

Exam pearls

Catheter dysfunction is failure to maintain the prescribed extracorporeal blood flow without prolonging dialysis treatment; it is not defined solely by one universal flow threshold.
Thrombolytic treatment precedes mechanical salvage when intraluminal thrombosis is suspected.
Exchange alone may leave the new catheter within the same fibrin sheath; assess and disrupt the sheath when clinically significant.
Femoral snare stripping is less durable than catheter exchange and is now a selective rescue technique.

Viva questions

What is the preferred vein for a tunneled dialysis catheter?: The **right internal jugular vein** is preferred because it provides a relatively straight course to the right atrium and generally offers better function and patency.
Where should the dialysis catheter tip lie?: The functional tip should lie in the **mid-right atrium**. A proximal tip encourages dysfunction and fibrin-sheath formation, whereas an excessively deep tip may cause arrhythmia or cardiac injury.
What is the first treatment for catheter dysfunction?: Exclude mechanical causes and use an intraluminal thrombolytic such as alteplase or urokinase. Mechanical exchange is considered when these measures fail.
How is a fibrin sheath treated?: A dysfunctional catheter is exchanged over guidewire with optional balloon disruption of the sheath, commonly using an approximately 10 mm balloon selected for the vein.
Why is subclavian access avoided?: It has a higher risk of central venous stenosis, which may compromise future ipsilateral fistula or graft creation and function.