Mediastinal approach to the placement of tunneled hemodialysis catheters in patients with central vein occlusion in an outpatient access center.

OBJECTIVES: Endovascular therapy for hemodialysis (HD) access is now performed in outpatient centers in a growing number of cities in the US. As patients live longer, we are facing a growing number of patients with central venous occlusion. We report our first three cases of mediastinal tunneled dialysis catheter placement in a clinic setting.

METHODS: Between 15 November 2009 and 1 April 2010, three patients with central vein occlusion required tunneled HD catheter placement. Case #1 was a 60-year-old male with left subclavian and innominate vein occlusion from a defibrillator pacemaker and two previous right internal jugular tunneled dialysis catheters with occlusion of the right internal jugular vein. He lost right arm access after two failed arteriovenous fistulas (AVF) and an occluded upper arm AV graft. His last right external jugular catheter was removed for infection. Case #2 was a 72-year-old female with a thrombosed left upper arm and a right basilic vein AV access. She had a history of left leg deep vein thrombosis (DVT) and a vena cava filter. The left and right internal jugular veins were occluded as well as the left subclavian vein after stent placement. She required a tunneled HD catheter after a failed attempt at endovascular salvage of her right basilic AVF. Case #3 was a 78-year-old female who had been on HD for 4 yr. She refused AVF surgery and had four tunneled HD catheters removed for infection. She presented with bilateral internal jugular vein thrombosis and the removal of an infected right subclavian tunneled HD catheter. THE TECHNIQUE: The dialysis catheters were placed using standard C-arm fluoroscopy. We accessed the right femoral vein to pass a Berenstein catheter (Cordis, Inc, Warren, NJ) into the right innominate-subclavian vein junction. Using the catheter as a fluoroscopic target, a micropuncture needle was guided into the right innominate vein and a standard J-guidewire was used to dilate the mediastinal tract and place a new tunneled dialysis catheter.

RESULTS: In all three cases, the tunneled dialysis catheters were placed under local anesthesia with no intravenous sedation. No pneumothorax occurred and all three catheters were used for HD within 24 hr. Two catheters were removed at 3 and 4 months for infection. One catheter continues to function well.

CONCLUSIONS: As the lifespan of our dialysis patient population continues to improve, we will see an increasing need to perform complicated access procedures to maintain HD support. These three cases emphasize the value of the transmediastinal technique using basic C-arm fluoroscopy and a limited stock of basic catheters and guidewires.