Implantation of a tunneled, double-lumen atrial catheter in the right internal jugular vein for hemodialysis

After skin disinfection and sterile draping, duplex sonography is performed for the purpose of localizing the internal jugular vein. Not shown in the clip is the local anesthesia, which covers the selected side of the neck, the entire subcutaneous tunnel, and the later percutaneous exit site of the catheter infraclavicularly. Typically, 10-15 ml of local anesthetic is required (e.g., Xylonest® 1%).

Under ultrasound guidance, the puncture of the internal jugular vein is performed with the Seldinger cannula. Insertion of the guidewire.

Tips:

1. In dehydrated patients, it is recommended to use the head-down position before the puncture maneuver, as the vein is then easier to puncture due to increased blood filling.

2. The ultrasound probe should only be placed lightly transverse to the vessel course, as the vein collapses under stronger pressure and the puncture is more difficult.

 3. A venesection, i.e., exposure of the internal jugular vein, is not indicated due to the significantly greater access trauma. However, it may be necessary in rare cases after major local interventions (carotid TEA, thyroid, parathyroid). This involves accessing the vein behind the muscle via an approximately 3 cm long incision at the anterior border of the sternocleidomastoid muscle, where it runs parallel to the common carotid artery.  Before the puncture and the placement of a peel-away sheath, it is recommended to place a purse-string suture.

After advancing the Seldinger wire, position control is performed by brief fluoroscopy. After dilating the puncture site with a small skin incision, the puncture cannula is removed. Insert the peel-away sheath over the lying wire under image converter control. Removal of the wire.

Tips:

1. The insertion of the sheath must be done carefully and slowly without forceful maneuvers. Caution in case of resistance, then possibly phlebography.

2. For catheter implantation via the right jugular vein, catheters 23 to 28 cm long are often required, on the left up to 33 cm. Ultimately, the required length depends on the patient's body size.  In case of difficulties, the required length can be determined using a measuring pigtail catheter.