PROCEDURE:
- Tunneled hemodialysis catheter exchange under fluoroscopy
- Central venogram through existing catheter
- Central venoplasty
- Post venoplasty central venogram
DATE:
CLINICAL INDICATION:
OPERATING PHYSICIANS: , MD (Attending)/ , MD (Fellow)
MEDICATIONS: Ancef 1 gram IV, Versed mg IV, fentanyl mcg IV
ACCESS: Existing approach tunneled hemodialysis catheter
CONTRAST:
FLUOROSCOPY TIME: minutes
COMPLICATIONS: None
IMPLANTABLE DEVICE: 15.5 French x cm tip-to-cuff hemodialysis catheter
PROCEDURE: After written and informed consent was obtained, the patient was placed supine on the procedure table. The existing catheter and chest/neck were prepped and draped in standard sterile fashion. A scout image was obtained. The indwelling heparin was withdrawn from the catheter lumens. The skin and subcutaneous tissue surrounding the catheter were anesthetized with 2% lidocaine. The catheter cuff was loosened with blunt dissection. The catheter was pulled back and a central venogram was then obtained through the catheter.
A 0.035″ stiff Glidewire was advanced through each catheter lumen and into the IVC. The catheter was removed over the guidewires and a French sheath was placed over one of the guidewires. Through the sheath a mm x 4 cm balloon was advanced over the guidewire and positioned over the fibrin sheath. The balloon was inflated and advanced centrally to disrupt the sheath. A repeat central venogram was then obtained through the sheath. The balloon and sheath were removed and a new 15.5 French x cm tip-to-cuff hemodialysis catheter was advanced centrally over the guidewires using fluoroscopy. The guidewires were removed and the catheter was tested, flushed, and charged with appropriate volumes of heparin. The catheter was secured to the skin with 2-0 Ethilon and a biodisc and sterile dressing were applied. The patient tolerated the procedure well and there were no immediate complications.
FINDINGS:
- Scout image demonstrates a approach tunneled hemodialysis catheter.
- Venogram through the existing catheter demonstrates .
- Following balloon disruption there is markedly improved flow through with no evidence of residual fibrin sheath.
- The new catheter tip terminates in the right atrium.
- Satisfactory function with 20 ml syringe test.
IMPRESSION: Successful image-guided exchange of a tunneled hemodialysis catheter and disruption of fibrin sheath as above.
Frequently Asked Questions
What is a permacath exchange procedure?
A permacath exchange is a medical procedure where an existing tunneled hemodialysis catheter is replaced with a new one. This is typically done to maintain proper function and reduce infection risk. It involves removing the old catheter, often under fluoroscopic guidance, and inserting a new catheter through the same pathway.
How is a fibrin sheath around a catheter disrupted?
A fibrin sheath can form around a catheter, hindering its function. To disrupt it, a balloon venoplasty technique is used. A small balloon is inflated within the vein to mechanically break down the sheath, restoring proper blood flow and catheter function.
A central venogram is an imaging test that uses contrast dye and X-rays to visualize the veins. It's performed during procedures like a permacath exchange to assess the venous anatomy and check for blockages or sheath formations that need correction.
What is the role of guidewires in catheter exchange procedures?
Guidewires are thin, flexible wires inserted into the body to guide the placement of catheters or other medical devices. In a catheter exchange, guidewires help ensure the new catheter is accurately positioned in the vein, minimizing complications.
Are there any complications associated with permacath exchange procedures?
Permacath exchange procedures are generally safe, but like any medical procedure, they carry risks. Potential complications include infection, bleeding, or damage to the vein. However, with proper technique and sterile conditions, these risks are minimized.
Why is fluoroscopy used during catheter exchanges?
Fluoroscopy provides real-time X-ray imaging that helps guide the catheter exchange process. It allows physicians to visualize the catheter's position within the body, ensuring accurate placement and reducing the risk of complications.
What medications are commonly used during a permacath exchange?
During a permacath exchange, antibiotics like Ancef may be administered to prevent infection. Sedatives such as Versed and pain relievers like fentanyl are also used to ensure patient comfort throughout the procedure.
How is the new catheter secured after a permacath exchange?
After placing the new catheter, it is secured to the skin using sutures like 2-0 Ethilon. A biodisc and sterile dressing are applied to protect the insertion site and reduce infection risk, ensuring the catheter remains in place.