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

The German dialysis access recommendations state the indication for permanent dialysis via a tunneled catheter "as a last resort, if no other permanent access or peritoneal dialysis is possible."

(Source: Hollenbeck M, Mickley V, Brunkwall J et al (2009) Interdisciplinary recommendation of German specialist societies on vascular access for hemodialysis. Nephrologie 4:158–176)

Clear indications:

• "Bridging", i.e. need for catheter dialysis for more than 3 weeks during shunt maturation
• Patients with steal syndrome if the AV shunt had to be ligated
• Severe heart failure with an ejection fraction significantly below 30%
• Low life expectancy, e.g., in metastatic tumor
• Predictably very short dialysis time in case of planned living donor transplantation in the next weeks

Possible indications:

• Poor venous conditions
• Motor restlessness of the patient
• Patient's wish

Absolute Contraindications:

• local infections such as e.g. eczema or fungal infections
• systemic infection
• previous local radiation therapy
• thrombosis of the subclavian vein, the superior vena cava or occlusion of the internal jugular vein on both sides

Relative Contraindications:

• Multiple previous punctures or a previous port implantation and explantation (implantation possibly significantly complicated)
• Unclear pathological laboratory chemical inflammation parameters such as an increase in leukocytes and/or CRP*
• severe coagulation disorder with highly pathological plasmatic coagulation and a platelet count of less than 30G/l*
• most severe cachexia with missing subcutaneous adipose tissue prepectoral

(*Postpone procedure, clarification, optimize coagulation)

History

• venous accesses in the surgical area in the past?

Clinical Examination

• Skin conditions in the implantation area (infections?)
• Arm swelling as well as subcutaneously increased venous markings as a sign of upper inflow obstruction e.g. due to thrombosis of the subclavian vein
• positive Stemmer sign: non-liftable skin fold on the fingers → lymphedema

Instrumental Examination

• Duplex Sonography → patency of the external and internal jugular veins, subclavian vein or the great saphenous vein and the femoral vein (in bedridden patients, saphenous or femoral veins may alternatively be considered for catheter placement)

Laboratory

• inflammation and coagulation parameters

• if necessary, shaving
• for ITN, keep fasting for 4-6 hours
• perioperative antibiotic prophylaxis e.g. with a first-generation cephalosporin

• upon insertion of the catheter, injury to a blood vessel, extremely rare heart wall, heart valve or adjacent organs; pericardial effusion, hemothorax, pneumothorax, air embolism
• Injury to larger lymphatic vessels → lymph fistula, chylothorax
• Nerve injury in neck/shoulder area → N. phrenicus/respiratory disorder; N. recurrens/hoarseness, rarely shortness of breath; brachial plexus/disorders of sensitivity and motor function in arm, also pareses
• Arrhythmias when advancing the catheter, mostly harmless, transient, rarely requiring medication or defibrillation
• stronger bleedings, rebleedings; possibly surgical hemostasis, blood transfusions
• Allogeneic blood transfusion with risk of hepatitis or HIV infection
• Mis-puncture: unintended puncture of adjacent arteries (A. carotis, A. subclavia); correspondingly strong bleeding, also thromboembolisms-> stroke (paralysis, speech, hearing, vision disorders); temporary, possibly also permanent
• after longer indwelling time of the catheter, thrombus formation at the catheter tip or in the catheter-carrying vein possible → swellings neck/arm, occlusion of the V. cava superior; pulmonary embolism, thrombectomy
• Infection → immediately postoperative, also in the further course; sepsis, endocarditis, possibly removal of the catheter system
• Malfunction of the catheter: dislocation, kinking, catheter breakage → intervention for position correction or new insertion
• Allergy/intolerance (e.g. latex, medications, contrast agents)
• if intraoperative angiography required → hyperthyroidism, deterioration of any remaining renal function
• Keloids

• depending on compliance and the patient's wish: local anesthesia or laryngeal mask anesthesia

• Supine position with slightly elevated upper body
• Head slightly hyperextended and turned to the opposite side (headrest)
• on the surgical side arm adducted, if necessary opposite side abducted

The surgeon and OR specialist stand on the operating side. The image intensifier and ultrasound device are positioned contralaterally.

• small vessel sieve
• Scalpel, skin suture
• Atrial catheter set (usually contains insertion kit and tunneler)
• Local anesthesia: 10 ml syringe, cannula, local anesthetic (e.g. Scandicain or Mepivacaine 1 %)
• Heparin saline solution
• mobile DSA unit
• Ultrasound device

Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current guideline Treatment of acute perioperative and posttraumatic pain.

Medical Follow-up Care

• no special follow-up care required
• in principle, chest X-ray
• Catheter system can be put into operation immediately

Thrombosis Prophylaxis

• not applicable

Mobilization

• immediately after surgery under local anesthesia

Physiotherapy

• not applicable

Diet Build-up

• immediately after surgery under local anesthesia

Stool Regulation

• not applicable

Incapacity for Work

• due to the underlying disease, there is usually already occupational disability, otherwise approx. 14 days