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Arteriovenous fistula (AVF) considered the best access for haemodialysis due to the longevity and less complications in comparison to other dialysis access.
However the primary failure of AVF may reached up to 60% .and in some patients because of their anatomical vasculature abnormality , creating AV fistulae sometimes is not possible, or while waiting the maturation of the AV fistula, there's patient s who landed acutely in emergency situation where they will need acute initiation of haemodialysis. In these conditions Placement of long-term haemodialysis catheter, cuffed tunnelled dialysis access (permcath) will be an acceptable alternative option
The preferred site for haemodialysis catheters is right internal jugular vein as per Dialysis Outcomes Quality Initiative guidelines and that because of direct anatomy between right internal jugular ( IJ )and superior Vena Cava in comparison to the left IJ , this will decrease the risk of complications which may associated with such invasive vascular procedure .
We reported her a case of dextrocardia who required IJ perm cath insertion for initiation of haemodialysis. We used a 14 F × 24 cm cuffed catheters Placement of the Perm cath done under local anaesthesia. The Optima position of the catheter's tip was confirmed and adjusted under fluoroscopy
in majority of cases placement of tunnelled perm cath dialysis access is straight forward procedure. Particularly when the vascular anatomy is normal. However rarely complications can be occurred. The complications can be divided either acute at time of insertion (usually are mechanical complications) or late complication for example formation of thrombosis and sheath this will lead to poor blood flow, on long term catheter can cause stenosis and this may complicated with superior vena cava syndrome, and more serious complication include infection and septicemia.
the rate of mechanical complications range from 3.3% to 19% .theses complications included failure of catheter placement, arterial puncture, improper position, pneumothorax, bleeding with formation of hematoma , and hemothorax. This in general it depends on experience of the person performing the procedure, patients characteristic, and site of insertion left versus right IJ with more complications reported at left IJ .
Patient’s characteristic with higher risk of mechanical complication includes high and low BMI, prior CVCs and surgeries, prior radiotherapy, advanced age, number of percutaneous punctures, insertion site right versus left IJ cannulation.
In our case in view of dextrocardia we performed the tunnel dialysis access insertion from the left side at left IJ and the procedure was similar to the placement of the catheter in normal anatomy from right IJ In normal person.
The technique is similar to normal individual.
A ultrasound was used for the visualization and identification of the left IJ vein . Then micro puncture needle used a single puncture into the left IJ vein under ultrasound guidance. Then micro guide wire was inserted thru micro system after that a J guide wire inserted into the right atrium and IVC under fluoroscopic guidance. Then 10 and 12 F dilator successfully attempts by using the Seldinger’s technique. Tunnel under the skin created and perm cath was pulled. Subsequently pell away sheath inserted then perm cath inserted in pellaway sheath , after that pell way sheath removed and the perm cath secured position.
Prior information and examination about the anatomy of internal jugular vain before insertion tunnelled dialysis access is important to avoid any complication. In dextrocardia patient with different anatomy insertion of intrrnal jugular dialysis access can be safely inserted at the left side in similar manoeuvre and technique of patient with normal anatomy.