If sedation is planned during the procedure, the patient should be evaluated for sedation based on the institution’s sedation guidelines (e.g., body mass index, American Society of Anesthesiologists (ASA) score). Anesthesia guidelines typically recommend that a patient be NPO 6 h prior to the planned procedure to minimize the risk of aspiration. Laboratory values, including a recent platelet count and coagulation screen should be obtained. Transfusion may be necessary to minimize bleeding risks. If the patient’s laboratory values cannot be corrected or emergent dialysis is needed, non-tunneled line placement should be considered. Non-tunneled line placement can be performed expeditiously, at the patient’s bedside, and does not require the creation of a subcutaneous tunnel—an additional potential site of bleeding in an uncorrected patient.

Antibiotic prophylaxis is not routinely recommended prior to central venous catheter placement per recommendations from the Centers for Disease Control based on a recent study in oncology patients [15]. However, intravenous (IV) antibiotics are advisable during tunneled dialysis catheter exchanges for catheter dysfunction [16].

Non-tunneled dialysis catheters are typically placed at the patient’s bedside. Local anesthesia with 1 % lidocaine is often adequate for anesthesia and patient comfort. Additional sedative medications to enhance patient cooperation and comfort are left to the operator and nurse’s discretion. Given that live fluoroscopy is not readily available when line placement is performed at the bedside, a portable chest radiograph is required post-placement to verify catheter position (Fig. 13.2) and to assess for complications such as pneumothorax [5].

Placement of tunneled dialysis catheters should be performed in an interventional radiology (IR) or surgical suite (OR) with live fluoroscopy readily available. Since a tunneled catheter is intended for long-term use, every attempt should be made to avoid kinking of the catheter at the vein entry site and to position the catheter tip in the right atrium. Live fluoroscopy allows for real-time, minor adjustments in line position and allows for optimal, safe placement that is intended to be durable. Although it is possible to perform tunneled line placement at the patient’s bedside, the authors do not recommend placement of a tunneled line without the use of fluoroscopy. Similar to a non-tunneled hemodialysis catheter placement, the patient is positioned supine on the procedural table. Most of these procedures can be performed with minimal or moderate sedation for patient comfort and cooperation. Occasionally, monitored sedation (or even general anesthesia) delivered by the anesthesiology service is necessary for severely ill or uncooperative patients.

Strict adherence to sterile technique is mandatory to minimize the risk of short-term infectious complications [4, 17]. Required measures include wide skin preparation with 2 % chlorhexidine gluconate with alcohol, draping the entire procedural site and patient, and appropriate sterile equipment worn by the operators, including a mask, hat, gown, and gloves. Povidone-iodine with 70 % alcohol is an acceptable alternative antiseptic solution [18].

Ultrasound-guided venous access is standard of care per K/DOQI and the American Society of Diagnostic and Interventional Nephrology (ASDIN) guidelines [5, 19]. Ultrasound allows for continuous needle visualization during vessel entry, essentially eliminating the risk of arterial puncture or pneumothorax [20]. In the hands of an experienced operator, ultrasound assistance will minimize the number of skin punctures required to successfully enter the vein [5]. Multiple punctures into the target vessel and resulting hematoma formation have both been associated with an increased risk of venous stenosis and/or thrombosis [4, 5]. It is desirable to confirm vein patency prior to draping the patient. Many of these patients have undergone multiple venous access procedures and are thus at some risk for venous thrombosis.

The internal jugular veins are typically superficial and slightly lateral to the common carotid artery. The femoral vein is medial to the common femoral artery and identified by its large size. Unlike the artery, a patent vein should be completely compressible with the ultrasound transducer. Color Doppler can also provide assistance in distinguishing the vein from artery and confirming vein patency (Fig. 13.3).

Once the patency and location of the vein are verified, a skin site is chosen for access. In the case of a non-tunneled line, access into the vein can be from a lateral or superior approach, given that a tunnel does not need to be created and there is much less risk of the catheter kinking at the venotomy site. For non-tunneled catheters, the ideal skin entry site is within a few centimeters of the clavicle. This location will minimize patient discomfort from the external portion of the device. For tunneled catheters, a skin entry site is chosen as close to the clavicle as possible to minimize catheter kinking within the tunnel.

The skin and subcutaneous tissues are anesthetized with 1 % lidocaine. A small skin nick is made with a #11 scalpel, followed by blunt dissection of the subcutaneous tissues with a small curved clamp to accommodate future passage of the dilators and the catheter. With constant direct sonographic visualization, a 21-gauge micropuncture needle is advanced into the IJ vein. A lateral approach to the vein allows for constant visualization of the entire needle. With a superior approach, only portions of the needle will be visualized. Entry into the vein may only be noted by release of tenting of the anterior vein wall. Blood may or may not drip out of the needle once the vein is entered. If no blood appears at the needle tip, aspiration with a saline syringe can be attempted to verify venous entry. Under fluoroscopic guidance, a 0.018” wire is then advanced through the needle toward the right atrium. The needle is then exchanged for a micropuncture sheath. The wire tip is positioned in the middle of the right atrium (for tunneled hemodialysis catheters) or cavoatrial junction (for non-tunneled hemodialysis catheters, if fluoroscopy is used). The microwire is clamped at the catheter hub, the wire is withdrawn at the length of the hub system, and the wire is re-clamped and removed. The measured length from tip to clamp represents the intravascular length. This measurement is also used to select the appropriate “tip to cuff” catheter length (see below). Once the wire and inner dilator of the micropuncture sheath are removed, a 0.035” wire is advanced centrally. Ideally, the wire is directed into the IVC. The patient’s cardiac rhythm should be observed to assess for ectopy. If the guidewire does not follow the expected course of the venous system, the wire should be withdrawn and contrast injected through the microcatheter to exclude vascular anomaly, venous occlusion, or inadvertent arterial entry (when fluoroscopy is used).

For non-tunneled hemodialysis catheter placement, a variety of catheters are commercially available (e.g., 13.5 Fr Mahurkar temporary dialysis catheter, Covidien, Dublin, Ireland). The functional catheter length (e.g., 15 cm, 20 cm) must be no longer than the measured or estimated (when fluoroscopy is not available) intravascular distance. Once a catheter length is chosen, the subcutaneous tissues are serially dilated, and the catheter is advanced over the wire until the hub is flush with the skin. The catheter is secured in place with sutures and both lumens are flushed with heparin solution (1000 units/mL). A portable radiograph is obtained to document the position of the catheter tip and to assess for potential complication, such as pneumothorax. The ideal catheter tip location for non-tunneled catheters is the inferior aspect of the SVC [5], just central to the cavoatrial junction (Fig. 13.2).

For tunneled dialysis catheters, a variety of catheters are commercially available. No particular catheter has been consistently shown to be superior to any other device. All catheters have a dual lumen, have high flow configuration, and are composed of kink-resistant material. Typical catheter diameters range from 13 to 14.5 Fr and have variable lengths, typically 19 cm, 23 cm, or 28 cm. The endholes can be symmetric or asymmetric, with lumens that are staggered, non-staggered, or split. A synthetic fabric (Dacron) cuff embedded on the catheter shaft will, over time, cause a fibrous reaction that secures the catheter to the tissues and provides a mechanical barrier to spread of infection from the exit site (Fig. 13.4). The labeled catheter length “tip to cuff” must be greater than the measured intravascular distance. This is due to the Dacron cuff being located at least a few centimeters away from the vascular entry point. After venous access has been obtained, the operator then forms the subcutaneous tunnel, which is typically about 7 cm in length from the venous access site to skin exit site.

After application of 1 % lidocaine for local anesthesia at the chosen skin site, a stab incision followed by blunt dissection is made. Blunt dissection of the subcutaneous tissue in the tunnel facilitates subsequent passing of the tunneler and prevents kinking of the catheter. With the catheter attached to the tunneling device (metal or plastic), the tunneler is advanced through the subcutaneous tissues to the venous access site. The entire catheter is then pulled through the tunnel until the Dacron retention cuff is within the tunnel.

Dilators are then advanced under fluoroscopic guidance over the wire at the venous access site to accommodate the peel-away sheath. The peel-away sheath is then advanced over the wire under fluoroscopic guidance into the right atrium. These steps should be performed under fluoroscopy to assess adequate wire length and position before dilator or sheath advancement. Failure to advance these devices properly and safely can result in central vein or mediastinal injury (Fig. 13.5). With the patient suspending respiration (to avoid air embolism), the inner dilator and wire are removed from the peel-away sheath and the catheter is rapidly advanced into the sheath. The sheath is then peeled away from the catheter, leaving only the catheter behind. Using fluoroscopy, the catheter tip is adjusted so that it ideally terminates in the middle of the right atrium (Fig. 13.1). This is the standard location of the catheter tip recommended by K/DOQI [5]. Because the catheter tip will typically migrate about 3 cm cephalad with the patient upright, the ultimate catheter position (just inferior to the cavoatrial junction) will allow unimpeded blood flow during dialysis and extend the functional life of the catheter.

The catheter is then secured to the skin at the exit site using sutures, and the small skin incision overlying the venotomy site is closed with a single absorbable suture or skin glue (e.g., Indermil, Covidien). Both catheter lumens are then flushed with heparin solution (1000 units/mL).

Similar steps are followed for placement of external jugular (Fig. 13.6), subclavian, and femoral vein catheters. Ultrasound can be used and is recommended for venous access at any of these locations [5]. For tunneled femoral catheters, long devices (e.g., 55 cm tip to cuff) allow for tip positioning in the right atrium (Fig. 13.7). In the case of a tunneled line, the tunnel pathway will depend on the location of vein entry and surrounding soft tissues. The tunnel exit site should be several centimeters away from the venous access site and in a location which is easily accessible to the dialysis staff. In the case of a tunneled femoral line, the tunnel is frequently created several centimeters inferior or lateral to the venous access site.

Patients who have been on chronic hemodialysis for many years are prone to central venous obstructions due to the occasional or frequent need for indwelling catheters. In rare cases, all potential thoracic and femoral venous sites for subsequent catheter placement are exhausted. In this situation, consideration can be given to translumbar or transhepatic IVC access [21–24]. These two procedures require advanced imaging techniques for placement and are typically performed in interventional radiology.