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Please prepare and upload your E-Poster no later than March 14, 2026 11.59PM CET. After this date, you will no longer be able to prepare and upload your E-poster and it will not be displayed and accessible on the congress website.
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The problem of poor vascular access is not uncommon in patients maintained on hemodialysis especially in low-income countries. This may be attributed to many factors, mainly: prolonged use of hemodialysis catheters, shortage of trained vascular surgeons for early creation of arteriovenous accesses and for early intervention when indicated, and recurrent hemodialysis catheter infections.
As a tertiary referral center operated mainly by nephrologists, we are frequently consulted for patients who are referred due to exhausted central veins after long period of missed sessions due to the lack of vascular access.
For those patients, we invented the method of ultrasound guided insertion of transhepatic hemodialysis catheter after exclusion of other accessible commonly used veins bilaterally. It was inserted as an emergency when the c-arm is not readily available, and the patient is indicated for urgent hemodialysis.
We used AMECATH(R) cuffed hemodialysis catheters 19 – 27 cm tip to cuff length, 14 and 16 Fr, with step tip and split tip designs. The following steps were done:
Step 1: Scanning for hepatic veins to choose the best vein for cannulation regarding diameter, depth from skin, and accessibility by ultrasound. Figure 1
Step 2: After injection of 1% xylocaine subcutaneously as local anesthetic, we cannulate either left or right hepatic veins using a standard 18 gauge, 7 cm needle using the long or the short axis veiws. We have used longer (20 cm) needle in one obese patient whose his left hepatic vein was about 13 cm deep from the skin. Figure 2
Step 3: We insert guidewire after successful cannulation. We use the standard j-tip Nitinol guidewire 0.035 inch in the cannulated vein to the inferior vena cava (IVC) and the right atrium. We use ultrasound to trace the guidewire after insertion to confirm location in the right atrium. Figure 3
Step 4: We measure the deep portion of the catheter while confirming guidewire in place using the ultrasound. Figure 4
Step 5: We use the standard tunneller tool inside the kit to make the subcutaneous tunnel of the catheter.
Step 6: Gradual, gentle and rotatory dilatation of the deep track is ensured after injecting local anesthesia deep till the wall of the liver.
Step 7: We insert the catheter over the peelable sheath, or over the wire or both simultaneously. We ensure adequate blood flow though the catheter and a make the final fixation suture and dressing.
Step 8: Tip location of the catheter in the right atrium or the atriocaval junction is ensured using ultrasound machine. A final x-ray is obtained to confirm tip location and kink free insertion. Figure 5
Seven out of 8 attempts were inserted successfully with tip in position and demonstrated excellent blood flow rates during hemodialysis sessions. Duration of catheter use ranged from 60 – 1230 days. Two catheters were exchanged over a guidewire. The first one was exchanged due to presence of blood stream infection with a fungal organism after 115 days, and the other due to tip migration after 60 days.
Ultrasound guided insertion of transhepatic hemodialysis catheter with post-insertion x-ray is a safe, affective and lifesaving technique with favorable outcomes if done by well-trained nephrologists. It should be done if there is a lack of c-arm facilities as an emergency for certain patients.
