Anaesthesiology Intensive Therapy, 2010,XLII,4; 184-186

Translumbar inferior vena cava cannulation

*Grzegorz Kade1, Jarosław Leś2, Joanna Grzesiak2, Antoni Sokalski3, Jolanta Buczyńska-Chyl3, Zbigniew Rybicki2, Zofia Wańkowicz1


1Department of Internal Diseases, Nephrology and Dialysis Therapy, Military Medical Institute in Warsaw


2Department of Anaesthesiology of Intensive Therapy, Military Medical Institute in Warsaw


3Unit of Dialysis with Subunit of Nephrology, Radom Specialist Hospital

  • Table 1. Characteristics of haemodialysis procedures using translumbar inferior vena cava cannulation
  • Fig. 1. X-ray of the right subcostal region visualizing the shadow of a catheter placed into the inferior vena cava from translumbar access

Background. The aim of the study was to review our three year experience with translumbar insertion of dialysis catheters.

Methods. In five adult patients (4 males and one female, mean age 45 yr), requiring dialysis due to  end-stage chronic renal failure, the inferior vena cava was cannulated because of the impossibility of using any other approach. All procedures were performed under fluoroscopy. After visualisation of the inferior vena cava by injection of contrast medium into a peripheral vein,  the vena cava was punctured with a 20 cm long needle, at the L3 level. The position of the needle was confirmed by injection of contrast medium, and the vein was then cannulated with a peel-away cannula, using a standard Seldinger technique. Subsequently, a pre-tunneled silastic catheter was introduced and secured.

Results. The catheters were used for from 3 to 10 months. No case of permanent catheter dysfunction was noted. Three episodes of temporary thrombosis, in two patients, were successfully treated with heparin and urokinase. Three catheters became contaminated, but they were treated without the necessity for catheter removal.

Conclusion. The described method is a safe and effective way of securing haemodialysis access in patients where a standard approach is not possible.

Haemodialysis (HD) is the basic form of renal replacement therapy in patients with end-stage renal failure (ESRF). The dynamically increasing number of patients qualified for the HD programme observed recently is associated with wider availability of this method of treatment as well as longer survival and higher quality of life of patients on chronic dialysis. The prerequisite of effective HD is adequate vascular access. The Dialysis Outcomes and Practice Patterns study has revealed that 48% of American patients and 74% of those in Europe start the HD programme with central venous access obtained using a non-tunnelled dialysis catheter until the arteriovenous fistula has been created. Such catheters are generally used for over 3 weeks - in accordance with the manufacturer’s instructions [1, 2, 3].

This alarming tendency to use only central venous accesses instead of arteriovenous fistulas is favoured by the population of HD patients, i.e. the elderly, with vascular complications of diabetes or late referral for renal replacement therapy. Due to repeated central venous cannulation, the standard vascular access cannot be provided. In such cases, translumbar inferior vena cava cannulation is the last chance. In Poland, this method was used for the first time in our hospital in 2007 [4, 5].

The aim of the present study was to assess the efficacy of translumbar inferior vena cava cannulation for haemodialysis.

METHODS

The study involved patients with ESRF in whom the classical access to the superior and inferior vena cava was not available, which was demonstrated on vascular examinations. In all patients, catheter implantation was urgent. The inferior vena cava was cannulated under X-ray guidance. To visualise the inferior vena cava, the patient was injected with 10 mL of contrast medium (johexol − 350 mg mL-1 in 10 mL 0.9% NaCl) to the lower extremity peripheral vein.

The 20-cm needle was inserted about 10 cm to the right from the body posterior midline and 1.5 cm above the iliac crest medially and cephally (about 45° in the frontal and sagittal plane) to reach the inferior vena cava at the L3 level. The needle was advanced in such a way that its distal end was placed near the midline without exceeding it. After insertion of the needle, contract medium was administered under fluoroscopy to confirm the identification of the vessel. During the next stage, the long-term haemodialysis catheter was inserted using the Seldinger technique, pre-tunnelled subcutaneously in the right subcostal region (Fig. 1). Haemodialysis was performed on the following day. 

RESULTS

In the years 2007-2010, translumbar inferior vena cava cannulation was performed in 5 patients (4 males and 1 female, mean age 45 years). The procedures lasted 60-90 min.

The only complications were small subcutaneous and intradermal haematomas in the area of catheter tunnelization not requiring surgical interventions.

Table 1 presents remote outcomes of translumbar inferior vena cava cannulation by the end of observation.

The longest lasting catheter (40 weeks) is still in use in one patient (M. L.) with systemic lupus and antiphospholipid syndrome who has been under nephrologic care for 6 years. The patient consciously chose the central vascular access as the optimal method enabling HD therapy, rejecting the programme of peritoneal dialysis and creation of an arteriovenous fistula. Despite continuous immunosuppressive treatment, the patient had only one episode of bacteraemia efficiently managed with standard therapy. In another patient (B. L.) with longstanding diabetes, no episodes of infection were observed for 36 weeks of access use. The highest number of infections related to catheters was noted in another female patient (B. A.). They were successfully treated with standard antibiotic therapy without the necessity of catheter removal.

Partial thrombosis of vascular access was observed in 2 patients (3 episodes); in each case it subsided after increased doses of heparin or a single dose of urokinase.

During the observation period, the mean time of translumbar catheter functioning was about 8.4 months and no cases of their permanent dysfunction were observed. After 6 months, all catheters were in good working order.

DISCUSSION

The first inferior vena cava cannulation was performed 25 years ago [6]. Over this period, the technique has been used for parenteral feeding, collection of stem cells for bone marrow transplantation, systemic chemotherapy, haemodialysis or photophoresis. In 1995, the first translumbar catheter for haemodialysis was inserted [7].

The authors performed translumbar inferior vena cava accesses to insert haemodialysis catheters when standard approaches were not possible. During the observation period, no specific complications described in literature were found, e.g. catheter displacement to the femoral veins or retroperitoneal space. Moreover, there were no complications during catheter implantation, e.g. damage to renal vessels, renal pelvis or ureters [4, 5]. The commonest complications included infections successfully treated without the necessity to remove the catheter. Temporary partial thrombosis of vascular access in two patients was effectively managed with fibrinolytic treatment.

Our experiences confirm the reports that the mean time of translumbar dialysis  catheter functioning is about 8 months. Inferior vena cava catheters may be in place for 6 months after implantation in 55% of patients, and for 12 months − in 29% [8]. According to other sources, the percentages are 52% and 17%, respectively [9]. The mean functioning time of a translumbar dialysis catheter is 121 days (14 − 536 days) [10, 11].

The incidence of catheter dysfunction related to thrombosis is 0.33/100 days, related to infection – 0.28/100 days of their use [9]. In our patients, thrombosis was rarer (0.21/100 days) despite the catheter use for photophoresis, which was associated with low blood flows. The incidence of catheter-related infections was higher (0.43/100 days), which may be explained by hospitalization of patients from different centres of varied epidemiological surveillance.

CONCLUSIONS

1. Proper percutaneous inferior vena cava cannulation is a useful and safe method of securing permanent haemodialysis access when standard approaches are not possible.

2. Percutaneous inferior vena cava cannulation should be included in the arsenal of alternative ways of performing central vascular accesses.  

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REFERENCES

1.     National Kidney Foundation: Kidney Disease Outcomes Quality Initiative (K/DOQI), Clinical Guidelines for Vascular Access, update 2000.

2.     Saad TF: Central venous dialysis catheters: catheter-associated infection. Semin Dial 2001; 14: 446-445.

3.     Allon M: Dialysis catheter-related bacteremia: treatment and prophylaxis. Am J Kidney Dis 2004; 44: 779-791.

4.     Leś J, Grzesiak J, Łabuś M, Kade G, Żelichowski G, Brzozowski K, Żukowski P, Wańkowicz Z, Rybicki Z: Przezlędźwiowa kaniulacja żyły głównej dolnej jako alternatywny dostęp naczyniowy do hemodializ. Pol Merk Lek 2008; 142, 331-334.

5.     Leś J, Grzesiak J, Rybicki Z, Brzozowski K, Żukowski P, Kade G, Żelichowski G, Wańkowicz Z: Percutaneus translumbar placement of long-term hemodialysis catheter in the inferior vena cava – case report. 5th International Congress of the Vascular Access Society 2007, Poster Presentation.

6.     Kenney PR, Dorfman GS, Denny DF: Percutaneus inferior vena cava cannulation for long-term parenteral nutrition. Surgery 1985; 97: 602-605.

7.     Gupta A, Karak PK, Saddekni S: Translumbar inferior vena cava catheter for long-term hemodialysis. J Am Soc Nephrol 1995; 5: 2094-2097.

8.     Biswal R, Nosher JL, Siegel RL, Bodner LJ: Translumbar placement of paired hemodialysis catheters (Tesio catheters) and follow-up in 10 patients. Cardiovas Intern Radiol 2000; 23: 75-78.

9.     Lund GB, Trerotola SO, Scheel PJ jr: Percutaneous translumbar inferior vena cava cannulation for hemodialysis. Am J Kidney Dis 1995; 25: 732-737.

10.    Bennett JD, Papadouris D, Rankin RN, McGloughlin RF, Kribs S, Kozak RI, Garvin G, Elliott J: Percutaneous inferior vena caval approach for long-term central venous access. J Vasc Interv Radiol 1997; 8: 851-855.

11.    Elduayen B, Martinez-Cuesta A, Vivas I, Delgado C, Pueyo JC, Bilbao JL: Central venous catheter placement in the inferior vena cava via the direct translumbar approach. Eur Radiol 2000; 10: 450-454.

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address:

*Grzegorz Kade
ul. Umińskiego 18 m.63, 03-984 Warszawa
tel.:+48 692 417 783
e-mail: gkade5@wp.pl

received: 09.08.2010
accepted: 20.10.2010