**4. Preservation of central veins**

Since CVS precludes to a creation of successful VA for long-term HD, it is essential to spread the awareness about preservation of central veins. It is a common practice to preserve peripheral veins (especially in nondominant hand) in a patient with chronic kidney disease (CKD, G III or higher). This is known to residents, fellows, nursing staff, etc. However, the concept of preservation of central veins in CKD is not widespread. CKD patients do get repeated central catheters at pre-HD stage due to medical problems, or PICC line, or the cardiologists requiring to put cardiac rhythm devices. There needs to be a dialog with cardiology colleagues to try and avoid insertion of SCV leads in CKD patients who are going to need HD in future. They can be requested to go for epicardial lead pacemakers (**Figure 2**) (author's personal work). Also, stiff non-cuffed HD catheters should not be kept in situ in jugular veins for more than 15 days. Even if patient has acute kidney injury and likely to need prolonged HD beyond 15 days, it is essential to change them to TCC, which has lesser chances of CVS than non-cuffed catheters. SCV catheterization should not be performed in CKD patients, although it still occurs frequently. Many intensivists prefer SCVs for central line insertion, and they should be convinced to avoid it in CKD patients.

#### **Figure 2.**

*(A) Pacemaker lead, with TCC. Pull back angiograph shows SVC occlusion and filling of azygous vein. (B) Pacemaker with epicardial leads in a patient with CKD GIIIb due to DKD.*
