Jugular puncture for dialysis catheters using echo Ch. Bachvarov University hospital “St. Marina”, Varna

Intro Overview of our experience in placement of temporary and permanent catheters for hemodialysis Technical challenges Possible complications

Our experience 10 years period – more than 400 permanent tunneled catheters – more than 250 temporary catheters – most of them placed into the bed of the patient The puncture of the appropriate vein was made exclusively under ultrasound guidance. In patient group with permanent catheters – exchanging – extraction

Types of catheters Temporary catheters Permanent catheters 13 - 16 – 20 cm more rigid radiopaque tip no cuff diameter less 13 Fr Permanent catheters up to 36 cm build from silicone tunneled catheter cuff /distance from tip to cuff! preshaped diameter up to 15 Fr

Approaches Right internal jugular vein – the classical approach Left internal jugular vein – alternative option catheter on the right side Infection at puncture site Trombosis of the right IJV stenosis , compression, lymphadenomegaly vena innominata Infraclavicular subclavian approach For permanent catheters there are anecdotal approaches – transhepatic, translumbal, surgical exploration of inferior vena cava

Neck anatomy

Neck anatomy Vagus nerve

Puncturing under ultrasound guidance Machine / Probe Linear – up to 4 cm,high - resolution /frequency – 7,5 MHz or more B mode/ Colour mode / Doppler mode Sterile conditions Compression sonography Familiar with neck ultrasound anatomy a, common carotid artery i, thyroid isthmus l, longus colli muscle s, strap muscles scm, sternocleidomastoid muscle t, thyroid lobes T, trachea (note the acoustic shadow) v, internal jugular vein *, normal location of the parathyroid glands

Puncturing under ultrasound guidance

Puncturing under ultrasound guidance

Puncturing under ultrasound guidance LEFT IJV LEFT CCA LEFT IJV LEFT CCA LEFT IJV LEFT CCA

Puncturing under ultrasound guidance Right IJV

Puncturing under ultrasound guidance Right IJV

Puncturing under ultrasound guidance

Puncturing under ultrasound guidance Internal jugular vein thrombosis due to temporary catheter placement

Puncturing under ultrasound guidance Left internal jugular approach

Left internal jugular approach Longer route – possible rotation of the catheter through the long axis More kinking / in older patients/ –risk of perforation of vena innominata during introducing of the peel-away sheet- 14Fr or deflection of the sheet Malpositioned tip of the catheter – insufficient flow More difficult to calculate the appropriate length of the catheter – risk of cranial displacement and stenosis of SVC More difficult exchange

Left internal jugular approach Late phase

Left internal jugular approach PTA baloon 8 x 38 mm / 8 atm

Left internal jugular approach PTA baloon 8 x 38 mm PTA baloon 8 x 38 mm Inferior vena cava

Left internal jugular approach

Complications Haematoma / Puncturing of CCA Vein thrombosis after puncturing Arterio – venous shunt

Complications Muscle trauma during catheter placement Infection and lymphadenopathy

Opening a gate Central venous lines Hemoports Ultrasound -Guided Regional Anesthesia for surgical procedures - brachial plexus blockade has several advantages including decreased hemodynamic instability, avoidance of airway instrumentation, and intra-, as well as post-operative analgesia. for interventional pain management Biopsies of the neck region

Or ………………………… Doctor , can you come to hospital and help us. We have a patient, 40 days old baby, with malnutrition and congenital malformations. It is difficult to put a central venous catheter….. Jugular puncture under echo is : - easy and fast technique - can save time / patients in critical conditions/ - can avoid complications - it could be performed at the bed of the patient

Thank you for your attention!