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

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

3. 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

4. Types of catheters Temporary catheters Permanent catheters
– 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

5. 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

6. Neck anatomy

7. Neck anatomy
Vagus nerve

8. 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

9. Puncturing under ultrasound guidance

10. Puncturing under ultrasound guidance

11. Puncturing under ultrasound guidance
LEFT
IJV
LEFT
CCA
LEFT
IJV
LEFT
CCA
LEFT
IJV
LEFT
CCA

12. Puncturing under ultrasound guidance
Right IJV

13. Puncturing under ultrasound guidance
Right IJV

14. Puncturing under ultrasound guidance

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

16. Puncturing under ultrasound guidance
Left internal jugular approach

17. 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

18. Left internal jugular approach
Late phase

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

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

21. Left internal jugular approach

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

23. Complications Muscle trauma during catheter placement
Infection and lymphadenopathy

24. 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

25. 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

26. Thank you for your attention!