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European Journal of Radiology 81 (2012) 22702272

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European Journal of Radiology
j our nal homepage: www. el sevi er . com/ l ocat e/ ej r ad
Insertion of central venous catheters for hemodialysis using angiographic
techniques in patients with previous multiple catheterizations
Kotsikoris Ioannis
a,1
, Zygomalas Apollon
b,
, Papas Theofanis
a,2
, Maras Dimitris
a,3
,
Pavlidis Polyvios
a,4
, Andrikopoulou Maria
a,6
, Tsanis Antonis
c,5
, Alivizatos Vasileios
d,7
,
Bessias Nikolaos
a,8
a
Department of Vascular Surgery, Erythros Stauros General Hospital, Greece
b
Department of General Surgery, University Hospital of Patras, Greece
c
Department of Interventional Radiology, Erythros Stauros General Hospital, Greece
d
Department of General Surgery and Articial Nutrition Unit, Agios Andreas General Hospital of Patras, Greece
a r t i c l e i n f o
Article history:
Received 14 March 2011
Received in revised form 4 June 2011
Accepted 7 June 2011
Keywords:
Central venous catheter
Angiographic technique
Venography
Hemodialysis
Multiple catheterizations
a b s t r a c t
Introduction: Central venous catheter placement is an effective alternative vascular access for dialysis
in patients with chronic renal failure. The purpose of this study was to evaluate the insertion of central
venous catheters for hemodialysis using angiographic techniques in patients with previous multiple
catheterizations in terms of efcacy of the procedure and early complications.
Materials and methods: Between 2008 and 2010, the vascular access team of our hospital placed 409
central venous catheters in patients with chronic renal failure. The procedure was performed using the
Seldinger blind technique. In 18 (4.4%) cases it was impossible to advance the guidewire, and so the
patients were transported to the angiography suite.
Results: Using the angiographic technique, the guidewire was advanced in order to position the central
venous catheter. The latter was inserted into the subclavian vein in 12 (66.6%) cases, into the internal
jugular vein in 4 (22.2%) and into the femoral vein in 2 (11.1%) cases. There was only one complicated
case with severe arrhythmia in 1 (5.5%) patient.
Conclusion: Our results suggest that insertion of central venous catheters using angiographic techniques
in hemodialysis patients with previous multiple catheterizations is a safe and effective procedure with
few complications and high success rates.
2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Adequate treatment for uremic patients on hemodialysis
requires valid and lasting access to their vessels. Arteriovenous
stulas (AVF) represent the main access option used for chronic
stable patients, while central venous catheters (CVCs) are an

Corresponding author at: University Hospital of Patras, 26504, Rio, Patras,


Greece. Tel.: +30 6979326000.
E-mail addresses: gkotsikoris@gmail.com(I. Kotsikoris), azygomalas@upatras.gr
(A. Zygomalas), pfanis@otenet.gr (T. Papas), dimmaras@gmail.com (D. Maras),
polpavlidis@yahoo.gr (P. Pavlidis), madric@gmail.com (M. Andrikopoulou),
atsanis@gmail.com (A. Tsanis), valiviz@hol.gr (V. Alivizatos), bessias@otenet.gr
(N. Bessias).
1
Red Cross Hospital, Athens, Greece. Tel.: +30 6932344686.
2
Red Cross Hospital, Athens, Greece. Tel.: +30 6945269717.
3
Red Cross Hospital, Athens, Greece. Tel.: +30 6977200553.
4
Red Cross Hospital, Athens, Greece. Tel.: +30 6973023916.
5
Red Cross Hospital, Athens, Greece. Tel.: +30 6979000005.
6
Red Cross Hospital, Athens, Greece. Tel.: +30 6934563456.
7
Agios Andreas General Hospital, Patras, Greece. Tel: +30 2613603888.
8
Red Cross Hospital Athens, Greece. Tel.: +30 6932375692.
effective alternative for dialysis [1]. Importantly, CVCs should be
placed when AVFs cannot be used (due to poor vascular status with
previous AVF failure and/or while waiting for a newAVF to develop
vessels that can be punctured), and the insertion should be carried
out by experienced surgical teams in order to avoid complications
[2,3].
Central vein stenosis is commonly associated with chronic CVC
use. Placement of multiple catheters, longer duration, location in
subclavian vein, and placement on the left-hand side of neck seem
to predispose to the development of central vein stenosis [4].
The purpose of this study was toevaluate the insertionof central
venous catheters for hemodialysis using angiographic techniques
in patients with previous multiple catheterizations in terms of ef-
cacy of the procedure and early complications.
2. Materials and methods
FromJanuary 2008 to December 2010, the vascular access team
of our hospital placed 409 central venous catheters for hemodial-
ysis. CVCs were inserted at the bedside using the Seldinger blind
technique. In 18 (4.4%) cases, it was impossible to advance the
0720-048X/$ see front matter 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejrad.2011.06.025
I. Kotsikoris et al. / European Journal of Radiology 81 (2012) 22702272 2271
Fig. 1. (A) Venipuncture of the right subclavian vein, the arrow shows the needle. (B) The contrast is injected and a stenosis (arrow) in the right subclavian vein is revealed.
(C) The guidewire (arrow) has been properly advanced. (D) Positioning of the central vein catheter (arrow) where the catheter tip should be adjusted to the level of the caval
atrial junction or into the right atrium to ensure optimal blood ow.
guidewire after at least 3 consecutive efforts and therefore these
patients were transported to the angiography suite. There was no
difference between patients with successful guidewire placement
and those in whom the guidewire could not be safely advanced in
terms of age, presence of diabetes, hyperlipidaemia, hypertension,
and number of previous AVFs/CVCs. The present study included the
18 patients in whom the guidewire could not be advanced. Patient
median age was 59.3 years (range 3978). Patients had multiple
previous CVC with a median total indwelling time of 36 months.
Each patient had a CVC (permanent or temporary) placement at
least 6 times in the last 5 years. In all cases, written informed con-
sent was obtained by the patient before the procedure.
Using the angiographic technique, the contrast substance was
injected into the central vein and the guidewire was appropriately
advanced in order to position the CVC (Fig. 1). The placement of the
CVC was in the subclavian vein in 12 (66.6%) cases, internal jugular
in4 (22.2%) andinthe femoral veinin2 (11.1%) cases. We evaluated
the efcacy of the procedure and the early complications.
3. Results
In all patients in whom the bedside procedure failed, a steno-
sis in the central vein (subclavian in 15 cases or internal jugular in
3 cases) developed. Dilatation of the stenotic vein was avoided to
minimize risk of trauma and because of our teams poor experience
in dilatation. Thus, the CVC was successfully inserted by the angio-
graphic technique in 5 (27.7%) cases, while an alternative central
vein was used in all other cases. However, in 2 (11.1%) patients,
both the subclavian and the internal jugular vein developed steno-
sis, and so the CVC had to be inserted into the femoral vein. In all
cases, positioning of the CVCwas completedusing the angiographic
technique.
There was only one complication with atrial brillation in one
(5.5%) patient. This was due to close contact between the heart and
theCVCandoccurredduringtheprocedure. Thepatient was treated
with amiodarone by the cardiologists and the arrhythmia resolved
after 1h.
2272 I. Kotsikoris et al. / European Journal of Radiology 81 (2012) 22702272
4. Discussion
Central vein stenosis is associated with placement of CVC and
multiple catheters, longer duration, locationinsubclavianvein, and
placement on the left-hand side of neck seem to predispose to the
development of central vein stenosis [2]. In our study, we observed
central vein stenosis in all the patients in whom the bedside pro-
cedure failed.
The National Kidney Foundation Kidney Disease Outcomes
QualityInitiative (NKF KDOQI) guidelines for vascular access clearly
determine the indications and the type of CVC that should be used
inhemodialysis patients. The use of angiographic techniques is pro-
posed for the insertion of both permanent and temporary CVCs
[5]. Venography, color Doppler sonography and digital subtrac-
tion angiography have been used to display the anatomy of the
vascular region involved [5,6]. More recently, however, magnetic
resonance venography (MRV) is being established as the most reli-
able modality [7]. The latter was not used in our centre, as it was
not available.
Importantly, radiologic CVC insertion is generally safe, with
complication rates lower than 5% [810]. This is conrmed in the
present study, although the small number of patients prevents
drawing rm conclusions. The radiologic technique allowed the
identication of veins suitable for access in all the patients and the
safe CVC positioning.
5. Conclusion
Our results suggest that insertion of central venous catheters
using angiographic techniques in hemodialysis patients with
previous multiple catheterizations appears to be safe and effec-
tive with few complications and high success rate. However,
it must be borne in mind that our series is rather small,
and so further conrmation in a larger patient population is
needed.
Conict of interest
The authors and authors institutions have no conicts of inter-
est.
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