**5. Other accesses for insertion of central venous catheter**

If the jugular veins are not accessible for long-term placement, the subclavian vein opposite the dominating side can be used. The nephrologist must realize the risk of subclavian stenosis (Feldman et al 1996, Can 2008). The subclavian vein should never be catheterized on the side of the unhealed arteriovenous fistula.

Fig. 4. Transhepatic placement of a Retrocath (45 cm long, 16Fr) into the portal vein. Contrast was injected to confirm the successful cannulation of the portal venous system.

Other alternative sites have been used for CVC placement when none of the typical central accesses is available. Such procedures must be conducted by an experienced interventional radiologist in a fully equipped facility. Alternative methods may be used: catheterization of the inferior vena cava, or hepatic, translumbar, renal, intercostal and mediastinal veins.

The translumbar approach to cannulation of the inferior vena cava, first described in 1971, has gained renewed attention as an alternative method for CVC access. High adequacy dialysis with low rates of catheter-related infection has recently reported from a single center study (Power et al 2009). The catheter care protocols, a policy of clinically appropriate catheter salvage with empirical broad-spectrum antibiotics and prior experience with translumbar catheter may also have the influenced outcome.

Transhepatic placement of hemodialysis catheter first described in 1994 can be associated with infrequent complications such as line sepsis, catheter migration, thrombosis and bleeding (Smith et al 204). These complications can be minimized when the procedure is performed by an interventional radiologist who is familiar with portal venogram (Figure 4)

Acute and Chronic Catheter in Hemodialysis 119

Hemmelgarn BR, Moist LM, Lock CE, Tonelli M, Manns BJ, Holden RM, LeBlanc M, Faris P,

James MT, Manns BJ, Hemmelgarn BR, Ravani P: What's next after fistula first: Is an

Kim SH, Song KI, Chang JW, Kim SB, Sung SA, Jo SK, Cho WY, Kim HK: Prevention of

Lacson E, Lazarus JM, Himmelgarb J, Ikizler TA, Hakim RM: Balancing fistula first with

Leblanc M, Bosc JY, Paganini EP, Canaud B: Central venous dialysis catheter dysfunction.

Lin BS, Kong CW, Tarng DC, Huang TP, Tang GJ: Anatomical variation of the internal jugular

Mathur MN, Storey DW, White GH, Ramsey-Stewart G: Percutaneous insertion of long-term venous access catheters via the external iliac vein. *Aust NZ J Surg* 1993; 63: 858-863. Maya ID, Aldon M: Outcomes of tunnelled femoral hemodialysis catheter: Comparison with

McDowell DE, Moss AH, Vasilakis C, Bell R, Pillai L: Percutaneously placed dual lumen silicone catheters for long-term hemodialysis. *Am Surg* 1993; 59: 569-573. McIntyre CW, Hulme LJ, Taal M, Fluck RJ: Locking of tunnelled hemodialysis catheters with

Moist LM, Chang SH, Polkinghorne KR, McDonald SP, Australia and New Zealand Dialysis

Moran JE, Ash SR for the ASDIN Clinical Practice Committee: Locking solutions for

Murthy R, Arbabzadeh M, Lund G, Richard H, Levitin A, Stainken B: Percutaneous transrenal hemodialysis catheter insertion. *J Vasc Interv Radiol* 2002; 13: 1043-1046. National Kidney Foundation: Clinical practice guidelines for vascular access: 2006 updated,

NKF-DOQI Clinical practice guidelines for vascular access: Updated 2000, *Am J Kidney Dis*

Nori US. Manoharan A, Yee J, Besarab A: Comparison of a low-dose gentamicin with

Passerini L, Lam K, Costerton JW, King EG: Biofilms on indwelling vascular catheters. *Crit* 

minocycline as catheter lock solutions in the prevention of catheter-related

and Transplant Registry (ANZDATA): Trends in hemodialysis vascular access from the Australia and New Zealand Dialysis and Transplant Registry 2000-2005. *Am J* 

hemodialysis catheters: heparin and citrate: A position paper by ASDIN. *Semin Dial*

internal jugular vein catheters. *Kidney Int* 2005; 68: 2886-2889.

Morgan JE: Subcutaneous vascular access devices. *Semin Dial* 2001; 14: 452-457.

gentamicin and heparin. *Kidney Int* 2004;66:801-805.

*Am J Kidney Dis* 2006; 48 (suppl 1): S176-S285.

bacteraemia. *Am J Kidney Dis* 2006;48:596-605.

*Engl J Med* 2011; 364: 303-312.

fistula is not possible? *Semin Dial* 2009; 22: 539-544.

catheters last. *Am J Kidney Dis* 2007; 50: 379-395.

*Adv Ren Replace Ther* 1997; 4: 377-389.

*Kidney Dis* 2007: 50: 612-621.

2001; 37 (suppl 1): S137-S181.

*Care Med* 1992; 20: 665-673.

2008; 21: 490-492.

Keenan SP: Use of ultrasound to place central lines. *J Crit Care* 2002; 17: 126-137.

Barre P, Zhang J, Scott-Douglas N for the Prevention of Dialysis Catheter Lumen Occlusion with rt-PA versus Heparin (PreCLOT) Study Group: Prevention of dialysis catheter malfunction with recombinant tissue plasminogen activator. *New* 

arteriovenous graft or central venous catheter preferable when an arteriovenous

uncuffed hemodialysis catheter-related bacteremia using an antibiotic lock technique: a prospective, randomized clinical trial. *Kidney Int* 2006;69:161-164. Kovalik EC, Newman GE, Suhocki P, Knelson M, Schwab SJ: Correction of central venous

stenosis: use of angioplasty and vascular wall stents*. Kidney Int* 1994; 45: 1177-1181.

vein and its impact on temporary haemodialysis vascular access: An ultrasonographic survey in uraemic patients. *Nephrol Dial Transplant* 1998; 13: 134-138.

(Yap et al 2010). In exceptional lack of options, transrenal access into the renal vein with consequent insertion of a tunneled catheter has been attempted (Murthy et al 2002).
