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Direct visualization of the guidewire into the inferior vena cava and catheter tip positioning by fluoroscopy is considered the gold standard for tunneled hemodialysis catheter placement (tHC). Kächele et al. describe their experience of ultrasound (USG) guided tHC placement without fluoroscopy in more than 130 patients during COVID-19 pandemic.
Our objective was to describe the safety and effectiveness of tHC placement under real-time ultrasound without fluoroscopy.
Cross sectional cohort study data from 2018-2023 in Interventional Nephrology Service of the National Institute of Cardiology “Dr. Ignacio Chávez. tHC was performed by expert interventional nephrologist. The procedure was performed just under local anesthesia with continuous cardiac monitoring. We performed a real time USG-guided vein cannulation, then introduce the guidewire and performed a four-chamber cardiac (4chC)- USG to observe the guidewire into the right atrium. An anterograde tunneled insertion was performed using the pull apart device, introduced catheter and then we performed again a 4chC-USG to visualize the catheter tip and an agitated saline infusion was additionally used for the assessment of correct tip position. The procedure success was defined as a correct tip catheter position and optimum function in hemodialysis therapy. Complications were classified as immediately (during procedure), early (48 hours) and late follow up (30 days): bleeding, hematoma, malposition, tip catheter migration, catheter blood stream infection and death.
306 procedures were performed. Most frequent insertion sites: in 67%% right side internal jugular vein, 17.9% left side jugular vein. 86% had history of previous vascular access. We had a successful procedure in 94.4% by tip catheter position and 99% of success achieved by function with a mean of 383 mL/min during hemodialysis therapy. Early complications were bleeding insertion site 4.57% and hematoma in 3.59%,without any transfusion requirements. Death in 0.32% secondary to cardiac arrhythmia. Late complications: No blood stream infections were reported during the follow-up 30 days of placement.
Table 1.
Reports from experienced centers and guidelines support that the use of fluoroscopy is not mandatory for the placement of tunneled vascular access. Direct visualization of the catheter tip with real-time ultrasound with four-chamber technique allows safe and precise placement of tunneled catheters.
The main limitation for fluoroscopic technique was the difficult access in several regions of the world, although it is considered the gold standard the successful rate is 60% in the historical cohort, and we demonstrated a major successful procedure rate. The immediate complications were less, without any significant impact, and early and late complications were not present.