THE STEP-TIP TYPE DIALYSIS CATHETERS ARE BEST SUITED FOR PLACEMENT THROUGH THE LEFT INTERNAL JUGULAR VEIN.

THE STEP-TIP TYPE DIALYSIS CATHETERS ARE BEST SUITED FOR PLACEMENT THROUGH THE LEFT INTERNAL JUGULAR VEIN.

Hemodialysis patients often require non-cuffed or cuffed catheters at times. The rate of infection is higher when catheters are placed from superficial femoral vein. In cases of obstruction of the right jugular vein, Safe placement of dialysis catheters through the left internal jugular vein is a technique we must master. The route of placement via the right internal jugular vein is straight, but via the left internal jugular vein, the catheters requires passing through two bends. Thus, safety is reduced and difficulty is increased(Fig.1).

In the possible cases, we have preceded the guidewires till under the diaphragm before catheter placements finally(Fig.2). We used 271 dialysis catheters of 13 different tip-types over a recent 5-year period. Of these, 34 catheters (non-cuffed: 26 cases and cuffed: 8 cases) were placed via the left internal jugular vein route. In addition, 23 step-tip type catheters (19 non-cuffed and 4 cuffed) were used into via the left internal jugular vein. At the time of placement, we used an ultrasound echo device and an x-ray device in all cases. In addition, we performed contrast studies in cases where possible, during the placement procedure or later(Fig.3ab). In about half of the left internal jugular vein route cases, we used the guidewires into the catheters in middle course of the placement procedures, and they guided to good positions, due to difficulty passing through the left brachiocephalic vein, superior vena cava, and near the right atrial appendage. The safety of the indwelling procedures and post-placement courses were compared with those of the same period using catheters with different tip type catheters.

As long as the guidewires were preceded from the left neck to the deeper than the diaphragm, in every cases with an effective length of 22 cm or longer, the catheters were smoothly placed in the target positions. All patients with 12.0Fr. or 12.5Fr. Step-Tip types were safely implanted. The catheter dysfunction rates were lower in cases in which the catheter was placed in the proper apical position. On the other hand in 14 of the 34 cases of left internal jugular vein pathway placement, the tip positions were not adequate. In 13 cases, the reason were that the catheter kits for the right neck had to be used from the left neck(Fig.4abc), which were short. In the remaining one case, by venous atypia, resulted in catheter non-function(Fig.5ab).

1)Step-Tip type dialysis catheter; 2）the right atrial auricle; 3）the left internal jugular vein; 4）the right atrium; 5）（RAA pocket ） apical doom.

Via the left internal jugular vein route, if the catheters were placed along the J metal guide wires those preceded the catheter under the diaphragm, we could place the catheters easier and safer to pass through the two bends. The Step-Tip type dialysis catheters are by far safer than other tip shapes when placed from the left cervical region. In Japan, with an effective length of 22 cm, it was possible to place the tip in a good position, even for large size men. Tapered step-tip catheters are ideal for safe and smooth placement into the right atrium via the left internal jugular vein. In the last decade, selective contrast of the right atrial appendage, part of the right atrium, has proposed that there are two types of dome-like structures in the right atrial auricle. Catheter placement from the left neck requires safe passage through this twin doon structure (RAA apical doom and RAA pocket).