**2. Vascular access variant**

## **2.1 Upper hemithorax**

Several blood vessels can be punctured in this area for the implantation of central venous catheters (Figure 1).

Fig. 1. 1- Innominate Vein, 2- Internal Jugular Vein, 3- Supraclavicular Vein, 4- Infraclavicular Vein, 5- Axillary Vein.

The **internal jugular** access is the most commonly used by nephrologists, but surgeons and intensive care units prefer **Infraclavicular (subclavian)** access. Subclavian access has a disadvantage; it produces subclavian vein stenosis that leads to arm edema when AV fistula is later practiced on the same side (Figure 2).

routes is necessary. Routine practice of procedures through these routes can make them much more available; the purpose of this article is to familiarize physicians with these routes

Several blood vessels can be punctured in this area for the implantation of central venous

and the correct techniques for accomplishing safe alternative vascular accesses.

Fig. 1. 1- Innominate Vein, 2- Internal Jugular Vein, 3- Supraclavicular Vein,

The **internal jugular** access is the most commonly used by nephrologists, but surgeons and intensive care units prefer **Infraclavicular (subclavian)** access. Subclavian access has a disadvantage; it produces subclavian vein stenosis that leads to arm edema when AV fistula

4- Infraclavicular Vein, 5- Axillary Vein.

is later practiced on the same side (Figure 2).

**2. Vascular access variant** 

**2.1 Upper hemithorax** 

catheters (Figure 1).

Fig. 2. Edema in left arm by subclavian vein stenosis and brachiocephalic fistula.

Catheters in the internal jugular vein kept for prolonged periods can also cause stenosis, in this case the superior vena cava (Figure 3).

Fig. 3. Cava superior syndrome.

For patients in which the implantation of catheters in the internal jugular vein is not possible, and those in which puncturing this vein or the subclavian vein would not be convenient (for example patients with tracheostomy), an alternative not commonly used is the implantation of catheters in the **axillary vein**. (3)

This vein extends from the clavicle to the axilla (figure 4). The segment in the axillary fossa has been used for decades by pediatric surgeons especially in children with extended burns in whom this is the only preserved area. Unfortunately there are severe infectious complications due to the bacterial flora that lives in this area. (4)

Unusual Vascular Access for Hemodialysis Therapies 319

In our experience and with patience it is possible to palpate the axillary artery and immediately under it puncture the axillary vein for catheter implantation. It is important to remember that in order to get to the axillary vein both pectoralis major and minor must be

In our experience also this catheter have utility in patients in intensive care unit in which is

Fig. 6. Pectoralis Minor Muscle. Fig. 7. Patient with tracheostomy and

Fig. 8. Ultrasound guidance for axillary catheter implantation.

The use of ultrasound guidance is a very good alternative, since it allows for an easy and clear view of the vessels of the axillary region, reducing the number of punctures (Figure 8).

axillary catheter.

penetrated and hence this vessel is located in deep layers (Figure 6).

common the presence of tracheostomy (Figure 7).

Fig. 4. Axillary Vein and muscle of anatomic area.

Other segments of the axillary vein, from the axillary fold to the clavicle have minimal risk of infection. Classically it is recommended puncturing two finger widths below the site where the coracoid process is found. (5) (Figure 5).

Fig. 5. Recommended place to insert axillary catheter.

Other segments of the axillary vein, from the axillary fold to the clavicle have minimal risk of infection. Classically it is recommended puncturing two finger widths below the site

Fig. 4. Axillary Vein and muscle of anatomic area.

where the coracoid process is found. (5) (Figure 5).

Fig. 5. Recommended place to insert axillary catheter.

In our experience and with patience it is possible to palpate the axillary artery and immediately under it puncture the axillary vein for catheter implantation. It is important to remember that in order to get to the axillary vein both pectoralis major and minor must be penetrated and hence this vessel is located in deep layers (Figure 6).

In our experience also this catheter have utility in patients in intensive care unit in which is common the presence of tracheostomy (Figure 7).

Fig. 6. Pectoralis Minor Muscle. Fig. 7. Patient with tracheostomy and axillary catheter.

The use of ultrasound guidance is a very good alternative, since it allows for an easy and clear view of the vessels of the axillary region, reducing the number of punctures (Figure 8).

Fig. 8. Ultrasound guidance for axillary catheter implantation.

days.

**2.2 Lower hemithorax** 

different approaches.

Unusual Vascular Access for Hemodialysis Therapies 321

There are two final vascular accesses in the upper hemithorax for the implantation of central catheters: intracardiac and superior vena cava access. For the first, anterior thoracotomy is performed in the fifth intercostal space and the catheter is inserted into the right atrium (7). For the second, proceed with anterior right mediastonomy, incision through the third intercostal space and resecting the condrosternal union. Under direct vision puncture the superior vena cava and introduce the catheter. (8) (Figure 11) The appearance of hemothorax, pneumothorax and pneumopericardium is common in these patients, so a routine chest tube implantation is recommended during the procedure and kept for several

Fig. 11. Patient with catheter in superior vena cava and pneumopericardium.

when the patient received a renal transplant. (Figure 12)

After exhausting the vessels of the upper hemithorax is necessary to use the lower hemithorax to continue chronic hemodialysis therapy. An alternative is to divert patients to peritoneal dialysis, but when this is not possible for various reasons it is essential to use

In our renal unit, the first access we use is the **femoral vein** option. They are classically canalized and then tunneled either to the anterior abdominal wall or into the thigh on the same side. In our experience, this access produces complications such as frequent infections in the exiting orifice for the catheter and also thrombosis (comment pending publication). In one of our patients we managed to keep this catheter for one year only to be withdrawn

The **innominate vein** is another blood vessel rarely used for the implantation of central catheters. It is a resource most commonly used by anesthesiologists and its use has not been spread due to fear of puncturing the pleural dome. To access this vessel percutaneously an aspiration needle is introduced holding it immediately above the clavicle between the sternal and clavicular bundles of the sternocleidomastoid muscle. It is directed to the mediastinum and parallel to the anterior chest wall to obtain an abundant blood return. The vein is easily punctured and only 2 to 4 centimeters from the skin. (6) Radiologically the catheters implanted in this blood vessel can be seen riding on top of the clavicle. (Figure 9).

Fig. 9. Catheter inserted into the innominate vein, riding on top of the clavicle.

Innominate vein thrombosis is a rare event, but it can be seen as a complication of the extended use of catheters in this blood vessel. (Figure 10).

Fig. 10. Innominate vein thrombosis.

The **innominate vein** is another blood vessel rarely used for the implantation of central catheters. It is a resource most commonly used by anesthesiologists and its use has not been spread due to fear of puncturing the pleural dome. To access this vessel percutaneously an aspiration needle is introduced holding it immediately above the clavicle between the sternal and clavicular bundles of the sternocleidomastoid muscle. It is directed to the mediastinum and parallel to the anterior chest wall to obtain an abundant blood return. The vein is easily punctured and only 2 to 4 centimeters from the skin. (6) Radiologically the catheters implanted in this blood vessel can be seen riding on top of the clavicle. (Figure 9).

Fig. 9. Catheter inserted into the innominate vein, riding on top of the clavicle.

extended use of catheters in this blood vessel. (Figure 10).

Fig. 10. Innominate vein thrombosis.

Innominate vein thrombosis is a rare event, but it can be seen as a complication of the

There are two final vascular accesses in the upper hemithorax for the implantation of central catheters: intracardiac and superior vena cava access. For the first, anterior thoracotomy is performed in the fifth intercostal space and the catheter is inserted into the right atrium (7). For the second, proceed with anterior right mediastonomy, incision through the third intercostal space and resecting the condrosternal union. Under direct vision puncture the superior vena cava and introduce the catheter. (8) (Figure 11) The appearance of hemothorax, pneumothorax and pneumopericardium is common in these patients, so a routine chest tube implantation is recommended during the procedure and kept for several days.

Fig. 11. Patient with catheter in superior vena cava and pneumopericardium.

### **2.2 Lower hemithorax**

After exhausting the vessels of the upper hemithorax is necessary to use the lower hemithorax to continue chronic hemodialysis therapy. An alternative is to divert patients to peritoneal dialysis, but when this is not possible for various reasons it is essential to use different approaches.

In our renal unit, the first access we use is the **femoral vein** option. They are classically canalized and then tunneled either to the anterior abdominal wall or into the thigh on the same side. In our experience, this access produces complications such as frequent infections in the exiting orifice for the catheter and also thrombosis (comment pending publication). In one of our patients we managed to keep this catheter for one year only to be withdrawn when the patient received a renal transplant. (Figure 12)

Unusual Vascular Access for Hemodialysis Therapies 323

Fig. 14. Position of patient for implantation ideal of catheter in inferior vena cava, and

Fig. 15. Angiography guide, and needle with a minimum length of 18 cm. Procedure

It is necessary to use a needle with a minimum length of 18 cm. The infusion of contrast medium allows the inferior vena cava location, then directing the needle toward her, and once punctured proceed to catheter implantation in technique like any tunneled catheter.

angiography guide.

(Figure 15 and 16).

performed by the author of the chapter.

Fig. 12. Tunneled femoral catheter to anterior abdominal wall or into the thigh.

The **iliac vein** can also be used, but requires the participation of a vascular surgeon to achieve safe punctures once the ilioinguinal region has been dissected and the blood vessel exposed (Figure 13).

Fig. 13. Tunneled iliac catheter and radiological control.

We then proceed to channel the **inferior vena cava**; we perform this procedure using fluoroscopy or angiography. First we implant a transient catheter in femoral vein, then place the patient in left lateral position with knees flexed and produce a lumbar puncture at the level of the iliac crest, 10 cm from the midline in an upward direction, close to the vertebral body to avoid puncturing the ureter (Figure 14).

Fig. 12. Tunneled femoral catheter to anterior abdominal wall or into the thigh.

Fig. 13. Tunneled iliac catheter and radiological control.

body to avoid puncturing the ureter (Figure 14).

exposed (Figure 13).

The **iliac vein** can also be used, but requires the participation of a vascular surgeon to achieve safe punctures once the ilioinguinal region has been dissected and the blood vessel

We then proceed to channel the **inferior vena cava**; we perform this procedure using fluoroscopy or angiography. First we implant a transient catheter in femoral vein, then place the patient in left lateral position with knees flexed and produce a lumbar puncture at the level of the iliac crest, 10 cm from the midline in an upward direction, close to the vertebral

Fig. 14. Position of patient for implantation ideal of catheter in inferior vena cava, and angiography guide.

It is necessary to use a needle with a minimum length of 18 cm. The infusion of contrast medium allows the inferior vena cava location, then directing the needle toward her, and once punctured proceed to catheter implantation in technique like any tunneled catheter. (Figure 15 and 16).

Fig. 15. Angiography guide, and needle with a minimum length of 18 cm. Procedure performed by the author of the chapter.

Unusual Vascular Access for Hemodialysis Therapies 325

Fig. 17. No benefit with antibiotic prophylaxis for prevention of central venous catheters

It has been suggested that every patient with a central venous catheter implanted on his or her superior hemithorax, must have PA chest radiography before actually using the catheter to confirm a correct placement. In occasions it is necessary to take the patient to hemodialysis therapy immediately after implanting the catheter and the radiological control can delay this process. In the year 2008 we published our experience with 245 jugular catheters implanted in the past years, all of them had PA chest radiography performed after the implantation. Only 4 cases (1,6%) had a significant complication (10). Based on this and if the implantation of the catheter was easy, we avoid soliciting the radiography and

**4. Radiological control after the implantation of jugular catheters** 

immediately proceed to the hemodialysis practice. (Figure 18).

infections.

Fig. 16. Tunneled inferior vena cava catheter in use.

Other vascular access used by other groups, and with which we have not experience is transhepatic access.
