Withoon Ungkitphaiboon

Assistant Professor, Department of Surgery,

Maha Chakri Sirindhorn Medical Center

Srinakharinwirot University

Present in “ One-day in Vascular Disease #11

4 Feb 2560

Troubleshooting Technique forHemodialysis Catheter Insertion

Troubleshooting

Finder Needle 1.5 ’’ length

Difficulty feeding the Guidewire

Poor Arterial Channel Blood Flow

Partial: Tenting

Partial

Failure to insert Guidewire into Venous lumen

Free blood aspiration

Partial

Failure to insert Guidewire into Venous lumen

Free blood aspiration

Complete Bevel of Needle

Complete

90 degree rotation of Needle :

Bevel direction to the Heart

Heart

Insert Guidewire to GUIDEWIRE

Poor Arterial BFR DLC : Kinking ,Intraluminal Clot and Sucking Wall SUCKING WALL : Turn the Catheter 180 º

Position: Medial Venous ch.

A V

SVC

180º

Lateral approach : Maxid Permcath insertion

How to get best result with Catheter insertion ?

Withoon Ungkitphaiboon

Assistant Professor, Department of Surgery,

Maha Chakri Sirindhorn Medical Center

Srinakharinwirot University

Present in “ One-day in Vascular Disease #11

4 Feb 2560

Best Function, Lowest Complication

: due to

1. Tip : Good Position

: Good design : No sucking wall

2. Curve

: Anti-kinking : Material

: High or Low insertion

: Lateral or Anterior approach

3. Diameter Large or Small

4. Length of Catheter selection

Curve

Tip

Size

–Internal jugular vein.(Rt) first

–External jugular vein.

–Subclavian vein.(Supraclav.)

–Femoral vein.

–Subclavian vein (Infraclav.)

Sites of Cannulation:

very important

Preop. Assessment

Short NeckShort Neck

Thyroid Enlargement

Previous puncture

Dilatation of superficial vein

Central Vein stenosis

• Previous Central line or DLC insertion

Failure cannulation before

Preop. Imaging: CTV & MRV

Brachiocephalic vein occlusion

MRV Central Vein of chest

Permcath(TCC)insertion technique and instrument

Anatomical landmark

Position

Modified Seldinger technique

Selection of appropriate size and length

Ultrasound with vascular probe

Fluoroscopy

Set of Mahurkar temporary double lumen HD cath.

Instrument

Doppler US(Vascular)&

Fluoroscopy

Fluoroscopy

Doppler Ultrasound

improve success

Short and long axis

Short Axis

Short Axis

SCM

Long Axis : Needle

SHORT AXIS

Ultrasound view

SHORT AXIS

Ultrasound view

Short Axis

Vertical out-of-Plane technique

Annals Surgical Treatment

and Research 2015;88(2):114-117

Cutting Edge Vascular Access Masters Course |

Wednesday, February 15, 2017 40

Cutting Edge Vascular Access Masters Course |

Wednesday, February 15, 2017 41

- Traditional Out-of-plane/Short axis

- Lateral in-plane/Short axis

(Lateral short axis in-plane)

Cutting Edge Vascular Access Masters Course |

Wednesday, February 15, 2017 42

Long axis in-plane

Short axis lateral in-plane

Short axis, Out-of-Plane

Vertical(Anterior) approach

Short Axis,

Lateral in Plane technique

Internal jugular vein(Right)

Sedillot’s triangle

Sedillot triangle

Internal jugular vein insertion(Left)

High insertion

Middle insertion

Low insertion

Cross section of internal jugular vein

Approach to int.jugular vein

Ultrasound view

SCM

Lateral

Anterior

Anterior approach

Lateral approach

High Insertion

External jugular vein

Curve into Medial

External jugular vein

Femoral Vein

Common Site of Puncture

1.(Anterior) IJV.

2.(Infraclavicular)

Subclavian V.

1

2

Subclavian Route No need to position in Trendelenberg Place small towel roll between scapulas(Infraclavicular) Abduct arm to flatten deltoid bulge(Infraclavicular) Abduct arm and pull toward down to foot(Supraclavicular)

Infraclavicular subclavian V

Mid clavicular

Supraclavicular subclavian V.

CCA

Subclavian V

- Int Jugular V

Junction

Approach to supraclav. subclavian

Advantages of Supraclavicular subclavian approach

No need for Trendelenberg No need for Head turn Lower incidence of Central

vein stenosis than Infraclavicular approach

Most successful Can use U/S to find vein