**3.6 Sixth step**

The dilator is inserted with the sheath that corresponds to each catheter. Depending on the case, a double lumen catheter or two catheters are used.

**Figure 11.** *Photo without doppler shows the needle inside the thrombosed jugular.*

*Exhaustion of Vascular Accesses for Haemodialysis: Access by Thrombosed Vein DOI: http://dx.doi.org/10.5772/intechopen.101198*

#### **Figure 12.**

*Looking at the guidewire by doppler ultrasound and fluoroscopy at the same time.*

**Figure 13.** *The guidewire inside superior cava, arrows.*

**Figure 14.** *Guidewire advances through the thrombosed iliac vein.*

It can happen that the catheters do not progress through the sheaths, because the strictures are very rigid.

In that case I used thinner catheters inside the haemodialysis catheter. This step can be very cumbersome; so you also have to take it easy and use all your resources and skills to get the catheter where it needs to go (**Figures 16** and **17**).

Some brands of catheter brings thinner semi-rigid catheters for these cases, and they are inserted with 2 guide wires and 2 semi-rigid catheters, one for each lumen (**Figure 18**).

#### **Figure 15.**

*A Once the guidewire is in the inferior vena cava, in this case, progressively thicker dilators are advanced B Sheath where 2 guide wires were passed.*

**Figure 16.** *Double lumen catheter in inferior cava.*

**Figure 17.** *Double lumen catheter in right atrium by superior cava.*

*Exhaustion of Vascular Accesses for Haemodialysis: Access by Thrombosed Vein DOI: http://dx.doi.org/10.5772/intechopen.101198*

#### **Figure 18.**

*Catheter model with 2 semi-rigid catheters, which guide wires are passed inside, all this inside the 14 French double lumen catheter.*

**Figure 19.** *Tunnelling a double lumen catheter.*

**Figure 20.** *Tunnelling a double lumen catheter.*

## **3.7 Seventh step**

The catheter is positioned and the corresponding tests are performed to obtain adequate flow; tunnelling is performed (**Figures 19**–**21**).

**Figure 21.** *In this case, we passed the kit of two catheters through the right jugular.*

More adequate tunnelling, either with a tunneller that comes with the kit, or with an incision of the necessary size, since some catheters must first be tunnelled and then inserted; this is not possible in these cases because you have to push directly and not through a tunnel.
