Tunnelled Dialysis Catheters

and Christopher Isles²

(1)

Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK

(2)

Dumfries and Galloway Royal Infirmary, Dumfries, UK

Q1 Describe the different types of vascular access for haemodialysis

There are four, summarised in Box 41.1. Fistulas are the preferred form of vascular access as discussed in Chap. 37.

Box 41.1 Different Types of Vascular Access

Arterio-Venous Fistula (usually known as a fistula)

Arterio-Venous Graft (usually known as a graft)

Tunnelled Central Venous Catheter (usually known as a tunnelled line)

Non-Tunnelled Central Venous Catheter (usually known as a temporary line)

Q2 Why do some patients dialyse with a tunnelled line?

Tunnelled lines are an effective and very quick method of achieving vascular access but are more likely to become infected than fistulas. Other complications of tunnelled lines include central venous stenosis and poor flow due to kinking or formation of a fibrin sheath on the outside of the catheter. Despite these limitations some patients dialyse quite successfully with a tunnelled line rather than a fistula. Indications for a tunnelled line are shown in the box:

Box 41.2 Common Reasons for Long-Term Central Venous Catheter Use

Late presenters in whom there has not been time to create a fistula.
Patients with poor peripheral vessels in whom a fistula is not technically possible.
Patients with chronic heart failure whose cardiac output might be further compromised by a fistula, because so much of it goes through the fistula.
Patients with hypotension whose blood pressure might be further lowered by a fistula.
Very elderly patients (>80 years) who may have poor peripheral vessels, chronic heart failure, hypotension and poor life expectancy in whom a fistula might not be of any real benefit.
Rarely, patients with a true needle phobia will refuse a fistula or a graft

Q3 What is the best vein for a tunnelled line and why?

The right internal jugular vein is preferred for catheter placement due to its direct continuity with the superior vena cava and the right atrium. Alternative sites are the left internal jugular vein (more difficult to place and 50 % risk of venous stenosis), subclavian vein (should be avoided because of higher incidence of central venous stenosis) and femoral vein (higher risk of infection).

Q4 What is the correct position for a tunnelled line?
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