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Direct US-guided Puncture of the Innominate Veins for Central Venous Access
Direct US-guided Puncture of the Innominate Veins for Central Venous Access Te-Neng Lau, MBBS, FRCR, MRCP, and Thomas B. Kinney, MD Maintenance of functioning venous access is recognized as the Achilles heel of long-term hemodialysis treatment. In patients who require catheter-directed hemodialysis, the internal jugular veins are recognized as the optimal veins for insertion of dialysis catheters. When these sites are no longer available, alternative venous access sites are required. The authors describe two hemodialysis patients with limited access sites in whom hemodialysis catheters were successfully inserted directly into the innominate veins with use of ultrasound-guided punctures. Index terms:
Innominate vein
•
Central venous access
•
Veins, stenosis or obstruction
J Vasc Interv Radiol 2001; 12:641– 645
A continually growing population of patients with end-stage renal disease, coupled with the chronic lack of kidneys available for transplantation, has swelled the ranks of patients requiring hemodialysis. Although long-term access via an arteriovenous fistula or polytetrafluoroethylene grafts is preferred, most patients are temporarily, and in some chronically, reliant on double-lumen catheters for hemodialysis. The traditional access sites are the internal jugular and subclavian veins. However, these may be complicated by stenosis or occlusions. The incidence of catheter-related stenosis in the subclavian veins has been reported to be as high as 40% (1,2). Alternative means of central venous access that have developed include the femoral vein (3), inferior vena cava (4 – 6), and intercostal and hepatic veins (7,8). Attempts have also been made to recanalize occluded venous segments in an effort to extend the usefulness of an access (9 –13). However, each of these approaches has its attendant risks and difficulties. Venograms obtained in patients with occluded subclavian and jugular From the Department of Radiology, University of California San Diego Medical Center, 200 W. Arbor Dr., San Diego, CA 92013-8756. Received September 15, 2000; revision requested November 2; revision received November 20; accepted November 21. Address correspondence to T.B.K.; E-mail: tbkinney @ucsd.edu © SCVIR, 2001
veins often show reconstitution of the more central veins (innominate vein and superior vena cava) beyond the level of obstruction. In two such patients, we explored the feasibility of direct puncture and placement of a large-bore hemodialysis catheter via the innominate veins. The purpose of this article is to indicate that direct ultrasound (US)-guided puncture of the innominate vein can be performed in patients with limited access sites.
CASE REPORTS Case 1.—A 24-year-old woman with end-stage renal disease of unknown etiology was referred to our department for placement of a tunneled hemodialysis catheter. She had been undergoing dialysis for 11 years with multiple catheter placements. Multiple upper extremity arteriovenous grafts had also failed. Just before a third request for another catheter placement, she was undergoing dialysis through a left thigh arteriovenous graft that had clotted. Despite valiant attempts at declotting and surgically revising the graft twice, the graft remained nonfunctional. Doppler US had demonstrated stenosis of the subclavian and internal jugular veins. Venography performed via a vein in the right neck confirmed occlusion of the distal right internal jugular vein with reconstitution of the more central right and left innominate veins. Through a suprasternal acoustic
window, we were able to visualize with US the patent central veins (Fig 1a). The confluence of the right and left innominate veins was accessed with freehand technique with use of a 21-gauge micropuncture needle (Cook, Bloomington, IN) and a venogram was obtained (Fig 1b). With use of a 5-F Cobra catheter (Cook) and a 0.035-inch Glidewire (Boston Scientific/Meditech, Watertown, MA), the wire and catheter were successfully manipulated into the right atrium and then into the inferior vena cava. The wire was then exchanged for an Amplatz Super Stiff guide wire (Boston Scientific/Meditech). When the Amplatz guide wire was in place, the rest of the procedure continues as a routine tunneled hemodialysis catheter placement. An exit site in the infraclavicular region was chosen so the subcutaneous tunnel would form a gentle curve over the anterior chest wall. A tunneled 19-cm 14-F Circle C hemodialysis catheter (Neostar Medical Worldwide, Manchester, GA) was placed, with the tip of the catheter positioned in the mid right atrium (Fig 1c). The catheter was used effectively the next day, providing flow rates of 354 mL/sec. It continued to function well for dialysis three times a week without complications until it was removed electively 76 days later because of a working left thigh arteriovenous graft. Removal of the catheter was similar to that of any other tunneled he-
641
642
•
Direct US-guided Puncture of the Innominate Veins
May 2001
JVIR
Figure 1. Coronal US image (a) obtained with a 7.5-MHz transducer positioned in the suprasternal notch. A widely patent left innominate vein is seen coursing across the superior mediastinum. The thoracic aorta (AO) lies deep to it. (b) Contrast venogram obtained after direct puncture of the confluence of the right and left innominate veins demonstrating the patency of the left innominate vein. However, there is a mild stenosis at its junction with the superior vena cava. Filling of the superior vena cava and right atrium were better demonstrated on subsequent images. Note the enlarged collaterals of the azygos system. (c) Chest radiograph after catheter placement showing tip of the catheter in the middle of the right atrium. The catheter is tunneled across the right anterior chest and exits below the clavicle.
modialysis catheter, with use of a combination of blunt and sharp dissection to free the cuff of the catheter from its subcutaneous tunnel. Firm digital pressure was held over the suprasternal region as the catheter was pulled out and for the ensuing 10 minutes to ensure hemostasis. The only departure from our normal practice was to observe the patient for an additional 30 minutes after catheter removal. Case 2.—The patient was a 24year-old man with prune belly syndrome and end-stage renal disease secondary to obstructive uropathy and renal dysplasia. He had been un-
dergoing dialysis since infancy. At one stage, he was undergoing peritoneal dialysis, but it had been complicated by peritonitis. Renal transplantation had failed twice. After the failed transplantations, he underwent hemodialysis through multiple access sites in both arms and groins. As a consequence, both internal jugular and subclavian veins, as well as his left common femoral vein, were occluded (Fig 2a). On two occasions, we had also placed a hemodialysis catheter in his inferior vena cava through a translumbar approach. A request for yet another hemodialysis
catheter placement arose because his right groin arteriovenous graft had become infected. A CT scan of his chest previously obtained to evaluate for sepsis had demonstrated patent innominate veins arising from collaterals in the neck and chest. This was visualized and confirmed on a subsequent US examination (Fig 2b). With a suprasternal approach, the left innominate vein was punctured under US guidance with a 21-gauge micropuncture needle (Cook). Venogram was performed to confirm position of the needle in the left innominate vein (Fig 2c). A 5-F Kumpe catheter (Cook) and a 0.035-
Volume 12
Number 5
Lau et al
•
643
Figure 2. Right internal jugular venogram (a) shows distal occlusion with reconstitution of the central veins via collaterals. (b) Coronal US image of the superior mediastinum showing a patent left innominate vein (arrowhead) as well as several collateral vessels. The aortic arch (arrow) is seen in transverse cross section as it courses anteroposteriorly. (c) Venogram obtained after obtaining access to the distal left innominate vein which demonstrates its patency and free flow of contrast material into the superior vena cava. (d) Chest radiograph after successful placement of a tunneled hemodialysis catheter directly into the left innominate vein.
inch Glidewire (Boston Scientific/Meditech) were negotiated into the right atrium and subsequently into the inferior vena cava. The Glidewire was then exchanged for a 0.035-inch Amplatz Super Stiff guide wire (Boston Scientific/ Medi-tech). A tunneled 19-cm 14-F Circle C hemodialysis catheter (Neostar Medical Worldwide) was thereafter placed with the use of standard tunnel-
ing technique, creating an exit site over the left anterior chest (Fig 2d). The catheter was used that same day and subsequently three times weekly, yielding flow rates of 400 mL/ min. The catheter worked well until the patient’s death 18 days later. A post-mortem examination was performed. The cause of death was ascribed to septicemia secondary to in-
fective endocarditis, which was believed to be caused by the hemodialysis graft infection.
DISCUSSION Central venous occlusions resulting from multiple catheters or long-term catheterization is a common but diffi-
644
•
Direct US-guided Puncture of the Innominate Veins
cult problem. It is a complication associated with both internal jugular and subclavian venous approaches, although its incidence is much higher with the use of large-bore catheters and the subclavian approach (14). Through a conscious effort to avoid the subclavian veins in catheter hemodialysis (15,16), we have been able to diminish, but not eliminate, the problem. Central venous stenosis not only leads to the loss of access for catheter hemodialysis, it also precludes the use of the upper extremities for arteriovenous grafts and fistulas. When encountering central venous stenosis in patients who require longterm hemodialysis, efforts have focused on recanalization of the central veins or location of alternative sites for catheter hemodialysis. Recanalization of the central veins involves successfully manipulating a guide wire and catheter across the lesion, thereby enabling balloon angioplasty and placement of a catheter (9,10). More aggressive operators have attempted puncture through occluded veins with use of snares, occlusion balloons, or catheters introduced from below as targets (11–13). Alternative sites for catheter placement outside the traditional internal jugular and subclavian approaches include the femoral vein (3), inferior vena cava (4 – 6), and hepatic vein via a transhepatic route (7,8). Our technique differs from previous descriptions of recanalization of occluded central veins in several aspects. First, we employ US guidance for our puncture. This allows us to visualize all structures along the intended path of puncture and therefore avoid injury to interposing arteries or lungs. These structures might not be demonstrated on fluoroscopy, the imaging modality used thus far. Second, there is no need for a target to be introduced from the groin and manipulated into the patent portion of central vein. US demonstration of the central vein provides the target for puncture. Freehand US technique is used for the puncture. The advantages of this technique therefore translate into savings in costs and time. More importantly, it obviates the need for an additional puncture of the femoral vein, a potential site of future venous access. This technique of direct puncture of the central veins is not without risks.
The main risks of the procedure are pneumothorax and hemorrhage. Attempts should be made to avoid a twowall venous puncture because this may result in uncontrolled mediastinal hemorrhage. The concern for inadvertent arterial puncture arises from the difficulty in applying pressure to the artery to secure hemostasis, caused by its inaccessibility behind the sternum. However, with the current level of expertise with US-guided procedures and the use of a micropuncture needle, the risk of arterial hemorrhage can be minimized. We recommend the use of color and pulsed-wave Doppler US during the preliminary survey of the mediastinum to confirm that the intended target is a vein. In addition, it is always helpful to negotiate a guide wire into the inferior vena cava before dilation of the venotomy to remove any remaining doubts that the cannulated vessel is not a vein. It might also be prudent to avoid this technique in patients with vascular abnormalities, such as ascending aortic aneurysm, or pulmonary emphysema, in which case the lung or aorta may crowd out the central veins. As a rule of thumb, this technique should be performed only in patients in whom US demonstrates a clear trajectory from the suprasternal region to the patent reconstituted portion of the central vein. Our apprehension of significant mediastinal hemorrhage on removal of a large-bore hemodialysis catheter seems to be unfounded. The elective removal of the catheter in one patient was uneventful. The catheter was removed in the usual fashion with use of a combination of blunt and sharp dissection to mobilize the cuff from its subcutaneous tunnel. This was followed by the application of digital pressure to the exit site and suprasternal region. As a precaution, we observed the patient for an hour before discharging her home. She was reported to be well when she returned for hemodialysis 2 days later. In our second patient, the catheter was still patent and functional at death (non– catheter-related cause of death). The removal of such catheters is analogous to removal of translumbar inferior vena cava hemodialysis catheters, in which it is also impossible to exert direct manual pressure directly over the venous puncture site. The true risk of bleeding from removal of hemodi-
May 2001
JVIR
alysis catheters in the innominate veins is not known. We recognize that this procedure may not be possible in all patients. Of note is that both our patients were relatively thin. This might have facilitated imaging of the superior mediastinal vessels and subsequent puncture of the central veins. A review of any available imaging studies will help identify suitable candidates. Venograms, computed tomographic scans and magnetic resonance venograms of the chest are particularly useful. However, the “acid test” is to use the US probe and directly evaluate accessibility of the central veins. Direct puncture of the central veins under US guidance may seem drastic to some. However, drastic measures are sometimes required to preserve life. This method can prolong the use of an access site that might otherwise be abandoned. In addition, it does not preclude the use of alternative techniques and provides another valuable option in dealing with the difficult problem of maintaining central venous access. There are possible complications, but we believe that the potential benefits outweigh the risks. We have demonstrated that it is feasible and additional cases will hopefully demonstrate the safety of this approach. References 1. Sunrrat RS, Picus D, Hicks ME, Darcy MD, Kleinhoffor M, Jendrisak M. The importance of preoperative evaluation of the subclavian vein in dialysis access planning. AJR Am J Roentgenol 1991; 156:623– 625. 2. Barrett N, Spencer S, Mclver J, Brown EA. Subclavian stenosis: a major complication of subclavian dialysis catheters. Nephrol Dial Transplant 1988; 3:423– 425. 3. Copley JB, Bartram LS, Smith BJ, Sandoval J, James MK, Hickman RO. Transabdominal angio-access catheter for long-term hemodialysis. Ann Intern Med 1984; 100:236 –237. 4. Lund GB, Trerotola SO, Scheel PJ Jr. Percutaneous translumbar inferior vena cava cannulation for hemodialysis. Am J Kidney Dis 1995; 25:732–737. 5. Gupta A, Karak PK, Saddekni S. Translumbar inferior vena cava catheter for long-term hemodialysis. J Am Soc Nephrol 1995; 5:2094 –2097. 6. Rajan DK, Croteau DL, Sturza SG, Harvill ML, Mehall CJ. Translumbar placement of inferior vena caval catheters: a solution for challenging hemodialysis access. Radiographics 1998; 18: 1155–1167.
Volume 12
Number 5
7. Bergey EA, Kaye RD, Reyes J, Towbin RB. Transhepatic insertion of vascular dialysis catheters in children: a safe, life-prolonging procedure. Pediatr Radiol 1999; 29:42– 45. 8. Po CL, Koolpe HA, Allen S, Alvez LD, Raja RB. Transhepatic PermCath for hemodialysis. Am J Kidney Dis 1994; 24:590 –591. 9. Horton MG, Mewissen MW, Rilllng WS, Crain MR, Bair D. Hemodialysis catheter placement directly into occluded central vein segments: a technical note. J Vasc Interv Radiol 1999; 10: 1059 –1062. 10. Moriniere P, Rodary-Vautier R, Fillioux-Morfaux V, et al. Percutaneous
Lau et al
recanalization of occlusion of central and proximal veins in chronic hemodialysis: technical note. Kidney Int 1997; 52:1406 –1411. 11. Funaki B, Zaleski GX, Leef JA, Rosenblum JD. Radiologic placement of long-term hemodialysis catheters in occluded jugular or subclavian veins or through patent thyrocervical collateral veins. AJR Am J Roentgenol 1998; 170: 1194 –1196. 12. Gupta H, Murphy TP, Soares GM. Use of a puncture needle for recanalization of an occluded right subclavian vein. Cardiovasc Intervent Radiol 1998; 21:508 –511. 13. Ferral H, Bjarnason H, Wholey M, Lopera
•
645
J, Maynar M, Castaneda-Zuniga WR. Recanalization of occluded veins to provide access for central catheter placement. J Vasc Interv Radiol 1996; 7:681–685. 14. Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterization vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant 1991; 6:722–724. 15. Konner K. Subclavian haemodialysis access: is it still justified in 1995? Nephrol Dial Transplant 1995; 10:1988 –1991. 16. Uldall PR. Subclavian cannulation is no longer necessary or justified in patients with end-stage renal failure. Semin Dial 1994; 7:161–164.
Innominate vein
•
Central venous access
•
Veins, stenosis or obstruction
J Vasc Interv Radiol 2001; 12:641– 645
A continually growing population of patients with end-stage renal disease, coupled with the chronic lack of kidneys available for transplantation, has swelled the ranks of patients requiring hemodialysis. Although long-term access via an arteriovenous fistula or polytetrafluoroethylene grafts is preferred, most patients are temporarily, and in some chronically, reliant on double-lumen catheters for hemodialysis. The traditional access sites are the internal jugular and subclavian veins. However, these may be complicated by stenosis or occlusions. The incidence of catheter-related stenosis in the subclavian veins has been reported to be as high as 40% (1,2). Alternative means of central venous access that have developed include the femoral vein (3), inferior vena cava (4 – 6), and intercostal and hepatic veins (7,8). Attempts have also been made to recanalize occluded venous segments in an effort to extend the usefulness of an access (9 –13). However, each of these approaches has its attendant risks and difficulties. Venograms obtained in patients with occluded subclavian and jugular From the Department of Radiology, University of California San Diego Medical Center, 200 W. Arbor Dr., San Diego, CA 92013-8756. Received September 15, 2000; revision requested November 2; revision received November 20; accepted November 21. Address correspondence to T.B.K.; E-mail: tbkinney @ucsd.edu © SCVIR, 2001
veins often show reconstitution of the more central veins (innominate vein and superior vena cava) beyond the level of obstruction. In two such patients, we explored the feasibility of direct puncture and placement of a large-bore hemodialysis catheter via the innominate veins. The purpose of this article is to indicate that direct ultrasound (US)-guided puncture of the innominate vein can be performed in patients with limited access sites.
CASE REPORTS Case 1.—A 24-year-old woman with end-stage renal disease of unknown etiology was referred to our department for placement of a tunneled hemodialysis catheter. She had been undergoing dialysis for 11 years with multiple catheter placements. Multiple upper extremity arteriovenous grafts had also failed. Just before a third request for another catheter placement, she was undergoing dialysis through a left thigh arteriovenous graft that had clotted. Despite valiant attempts at declotting and surgically revising the graft twice, the graft remained nonfunctional. Doppler US had demonstrated stenosis of the subclavian and internal jugular veins. Venography performed via a vein in the right neck confirmed occlusion of the distal right internal jugular vein with reconstitution of the more central right and left innominate veins. Through a suprasternal acoustic
window, we were able to visualize with US the patent central veins (Fig 1a). The confluence of the right and left innominate veins was accessed with freehand technique with use of a 21-gauge micropuncture needle (Cook, Bloomington, IN) and a venogram was obtained (Fig 1b). With use of a 5-F Cobra catheter (Cook) and a 0.035-inch Glidewire (Boston Scientific/Meditech, Watertown, MA), the wire and catheter were successfully manipulated into the right atrium and then into the inferior vena cava. The wire was then exchanged for an Amplatz Super Stiff guide wire (Boston Scientific/Meditech). When the Amplatz guide wire was in place, the rest of the procedure continues as a routine tunneled hemodialysis catheter placement. An exit site in the infraclavicular region was chosen so the subcutaneous tunnel would form a gentle curve over the anterior chest wall. A tunneled 19-cm 14-F Circle C hemodialysis catheter (Neostar Medical Worldwide, Manchester, GA) was placed, with the tip of the catheter positioned in the mid right atrium (Fig 1c). The catheter was used effectively the next day, providing flow rates of 354 mL/sec. It continued to function well for dialysis three times a week without complications until it was removed electively 76 days later because of a working left thigh arteriovenous graft. Removal of the catheter was similar to that of any other tunneled he-
641
642
•
Direct US-guided Puncture of the Innominate Veins
May 2001
JVIR
Figure 1. Coronal US image (a) obtained with a 7.5-MHz transducer positioned in the suprasternal notch. A widely patent left innominate vein is seen coursing across the superior mediastinum. The thoracic aorta (AO) lies deep to it. (b) Contrast venogram obtained after direct puncture of the confluence of the right and left innominate veins demonstrating the patency of the left innominate vein. However, there is a mild stenosis at its junction with the superior vena cava. Filling of the superior vena cava and right atrium were better demonstrated on subsequent images. Note the enlarged collaterals of the azygos system. (c) Chest radiograph after catheter placement showing tip of the catheter in the middle of the right atrium. The catheter is tunneled across the right anterior chest and exits below the clavicle.
modialysis catheter, with use of a combination of blunt and sharp dissection to free the cuff of the catheter from its subcutaneous tunnel. Firm digital pressure was held over the suprasternal region as the catheter was pulled out and for the ensuing 10 minutes to ensure hemostasis. The only departure from our normal practice was to observe the patient for an additional 30 minutes after catheter removal. Case 2.—The patient was a 24year-old man with prune belly syndrome and end-stage renal disease secondary to obstructive uropathy and renal dysplasia. He had been un-
dergoing dialysis since infancy. At one stage, he was undergoing peritoneal dialysis, but it had been complicated by peritonitis. Renal transplantation had failed twice. After the failed transplantations, he underwent hemodialysis through multiple access sites in both arms and groins. As a consequence, both internal jugular and subclavian veins, as well as his left common femoral vein, were occluded (Fig 2a). On two occasions, we had also placed a hemodialysis catheter in his inferior vena cava through a translumbar approach. A request for yet another hemodialysis
catheter placement arose because his right groin arteriovenous graft had become infected. A CT scan of his chest previously obtained to evaluate for sepsis had demonstrated patent innominate veins arising from collaterals in the neck and chest. This was visualized and confirmed on a subsequent US examination (Fig 2b). With a suprasternal approach, the left innominate vein was punctured under US guidance with a 21-gauge micropuncture needle (Cook). Venogram was performed to confirm position of the needle in the left innominate vein (Fig 2c). A 5-F Kumpe catheter (Cook) and a 0.035-
Volume 12
Number 5
Lau et al
•
643
Figure 2. Right internal jugular venogram (a) shows distal occlusion with reconstitution of the central veins via collaterals. (b) Coronal US image of the superior mediastinum showing a patent left innominate vein (arrowhead) as well as several collateral vessels. The aortic arch (arrow) is seen in transverse cross section as it courses anteroposteriorly. (c) Venogram obtained after obtaining access to the distal left innominate vein which demonstrates its patency and free flow of contrast material into the superior vena cava. (d) Chest radiograph after successful placement of a tunneled hemodialysis catheter directly into the left innominate vein.
inch Glidewire (Boston Scientific/Meditech) were negotiated into the right atrium and subsequently into the inferior vena cava. The Glidewire was then exchanged for a 0.035-inch Amplatz Super Stiff guide wire (Boston Scientific/ Medi-tech). A tunneled 19-cm 14-F Circle C hemodialysis catheter (Neostar Medical Worldwide) was thereafter placed with the use of standard tunnel-
ing technique, creating an exit site over the left anterior chest (Fig 2d). The catheter was used that same day and subsequently three times weekly, yielding flow rates of 400 mL/ min. The catheter worked well until the patient’s death 18 days later. A post-mortem examination was performed. The cause of death was ascribed to septicemia secondary to in-
fective endocarditis, which was believed to be caused by the hemodialysis graft infection.
DISCUSSION Central venous occlusions resulting from multiple catheters or long-term catheterization is a common but diffi-
644
•
Direct US-guided Puncture of the Innominate Veins
cult problem. It is a complication associated with both internal jugular and subclavian venous approaches, although its incidence is much higher with the use of large-bore catheters and the subclavian approach (14). Through a conscious effort to avoid the subclavian veins in catheter hemodialysis (15,16), we have been able to diminish, but not eliminate, the problem. Central venous stenosis not only leads to the loss of access for catheter hemodialysis, it also precludes the use of the upper extremities for arteriovenous grafts and fistulas. When encountering central venous stenosis in patients who require longterm hemodialysis, efforts have focused on recanalization of the central veins or location of alternative sites for catheter hemodialysis. Recanalization of the central veins involves successfully manipulating a guide wire and catheter across the lesion, thereby enabling balloon angioplasty and placement of a catheter (9,10). More aggressive operators have attempted puncture through occluded veins with use of snares, occlusion balloons, or catheters introduced from below as targets (11–13). Alternative sites for catheter placement outside the traditional internal jugular and subclavian approaches include the femoral vein (3), inferior vena cava (4 – 6), and hepatic vein via a transhepatic route (7,8). Our technique differs from previous descriptions of recanalization of occluded central veins in several aspects. First, we employ US guidance for our puncture. This allows us to visualize all structures along the intended path of puncture and therefore avoid injury to interposing arteries or lungs. These structures might not be demonstrated on fluoroscopy, the imaging modality used thus far. Second, there is no need for a target to be introduced from the groin and manipulated into the patent portion of central vein. US demonstration of the central vein provides the target for puncture. Freehand US technique is used for the puncture. The advantages of this technique therefore translate into savings in costs and time. More importantly, it obviates the need for an additional puncture of the femoral vein, a potential site of future venous access. This technique of direct puncture of the central veins is not without risks.
The main risks of the procedure are pneumothorax and hemorrhage. Attempts should be made to avoid a twowall venous puncture because this may result in uncontrolled mediastinal hemorrhage. The concern for inadvertent arterial puncture arises from the difficulty in applying pressure to the artery to secure hemostasis, caused by its inaccessibility behind the sternum. However, with the current level of expertise with US-guided procedures and the use of a micropuncture needle, the risk of arterial hemorrhage can be minimized. We recommend the use of color and pulsed-wave Doppler US during the preliminary survey of the mediastinum to confirm that the intended target is a vein. In addition, it is always helpful to negotiate a guide wire into the inferior vena cava before dilation of the venotomy to remove any remaining doubts that the cannulated vessel is not a vein. It might also be prudent to avoid this technique in patients with vascular abnormalities, such as ascending aortic aneurysm, or pulmonary emphysema, in which case the lung or aorta may crowd out the central veins. As a rule of thumb, this technique should be performed only in patients in whom US demonstrates a clear trajectory from the suprasternal region to the patent reconstituted portion of the central vein. Our apprehension of significant mediastinal hemorrhage on removal of a large-bore hemodialysis catheter seems to be unfounded. The elective removal of the catheter in one patient was uneventful. The catheter was removed in the usual fashion with use of a combination of blunt and sharp dissection to mobilize the cuff from its subcutaneous tunnel. This was followed by the application of digital pressure to the exit site and suprasternal region. As a precaution, we observed the patient for an hour before discharging her home. She was reported to be well when she returned for hemodialysis 2 days later. In our second patient, the catheter was still patent and functional at death (non– catheter-related cause of death). The removal of such catheters is analogous to removal of translumbar inferior vena cava hemodialysis catheters, in which it is also impossible to exert direct manual pressure directly over the venous puncture site. The true risk of bleeding from removal of hemodi-
May 2001
JVIR
alysis catheters in the innominate veins is not known. We recognize that this procedure may not be possible in all patients. Of note is that both our patients were relatively thin. This might have facilitated imaging of the superior mediastinal vessels and subsequent puncture of the central veins. A review of any available imaging studies will help identify suitable candidates. Venograms, computed tomographic scans and magnetic resonance venograms of the chest are particularly useful. However, the “acid test” is to use the US probe and directly evaluate accessibility of the central veins. Direct puncture of the central veins under US guidance may seem drastic to some. However, drastic measures are sometimes required to preserve life. This method can prolong the use of an access site that might otherwise be abandoned. In addition, it does not preclude the use of alternative techniques and provides another valuable option in dealing with the difficult problem of maintaining central venous access. There are possible complications, but we believe that the potential benefits outweigh the risks. We have demonstrated that it is feasible and additional cases will hopefully demonstrate the safety of this approach. References 1. Sunrrat RS, Picus D, Hicks ME, Darcy MD, Kleinhoffor M, Jendrisak M. The importance of preoperative evaluation of the subclavian vein in dialysis access planning. AJR Am J Roentgenol 1991; 156:623– 625. 2. Barrett N, Spencer S, Mclver J, Brown EA. Subclavian stenosis: a major complication of subclavian dialysis catheters. Nephrol Dial Transplant 1988; 3:423– 425. 3. Copley JB, Bartram LS, Smith BJ, Sandoval J, James MK, Hickman RO. Transabdominal angio-access catheter for long-term hemodialysis. Ann Intern Med 1984; 100:236 –237. 4. Lund GB, Trerotola SO, Scheel PJ Jr. Percutaneous translumbar inferior vena cava cannulation for hemodialysis. Am J Kidney Dis 1995; 25:732–737. 5. Gupta A, Karak PK, Saddekni S. Translumbar inferior vena cava catheter for long-term hemodialysis. J Am Soc Nephrol 1995; 5:2094 –2097. 6. Rajan DK, Croteau DL, Sturza SG, Harvill ML, Mehall CJ. Translumbar placement of inferior vena caval catheters: a solution for challenging hemodialysis access. Radiographics 1998; 18: 1155–1167.
Volume 12
Number 5
7. Bergey EA, Kaye RD, Reyes J, Towbin RB. Transhepatic insertion of vascular dialysis catheters in children: a safe, life-prolonging procedure. Pediatr Radiol 1999; 29:42– 45. 8. Po CL, Koolpe HA, Allen S, Alvez LD, Raja RB. Transhepatic PermCath for hemodialysis. Am J Kidney Dis 1994; 24:590 –591. 9. Horton MG, Mewissen MW, Rilllng WS, Crain MR, Bair D. Hemodialysis catheter placement directly into occluded central vein segments: a technical note. J Vasc Interv Radiol 1999; 10: 1059 –1062. 10. Moriniere P, Rodary-Vautier R, Fillioux-Morfaux V, et al. Percutaneous
Lau et al
recanalization of occlusion of central and proximal veins in chronic hemodialysis: technical note. Kidney Int 1997; 52:1406 –1411. 11. Funaki B, Zaleski GX, Leef JA, Rosenblum JD. Radiologic placement of long-term hemodialysis catheters in occluded jugular or subclavian veins or through patent thyrocervical collateral veins. AJR Am J Roentgenol 1998; 170: 1194 –1196. 12. Gupta H, Murphy TP, Soares GM. Use of a puncture needle for recanalization of an occluded right subclavian vein. Cardiovasc Intervent Radiol 1998; 21:508 –511. 13. Ferral H, Bjarnason H, Wholey M, Lopera
•
645
J, Maynar M, Castaneda-Zuniga WR. Recanalization of occluded veins to provide access for central catheter placement. J Vasc Interv Radiol 1996; 7:681–685. 14. Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterization vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant 1991; 6:722–724. 15. Konner K. Subclavian haemodialysis access: is it still justified in 1995? Nephrol Dial Transplant 1995; 10:1988 –1991. 16. Uldall PR. Subclavian cannulation is no longer necessary or justified in patients with end-stage renal failure. Semin Dial 1994; 7:161–164.