Alec R. Hovagim, Paul J. Poppers (Auth.), Vittorio E. Andreucci MD (Eds.) Vascular and Peritoneal Access For Dialysis 1989 PDF

VASCULAR AND PERITONEAL ACCESS FOR DIALYSIS
TOPICS IN RENAL MEDICINE

Vittorio E. Andreucci. Series Editor
1.
2.
3.
4.
VE Andreucci, The Kidney In Pregnancy. ISBN 0-89838-741-8

AR Clarkson, IgA Nephropathy. ISBN 0-89838-839-2
V Cambi, Short Dialysis. ISBN 0-89838-858-9
RN Fine, Chronic Ambulatory Peritoneal Dialysis (CAPD) and Chronic
Cycling Peritoneal Dialysis (CCPD) in Children. ISBN 0-89838-859-7
5. CYC Pak, Renal Stone Disease. ISBN 0-89838-886-4
6. CE Mogensen, The Kidney and Hypertension in Diabetes Mellitus. ISBN
0-89838-958-5
7. S Giovannetti, The Nutritional Treatment of Chronic Renal Failure. ISBN
0-7923-0086-6
VASCULAR AND PERITONEAL ACCESS

FOR DIALYSIS
edited by
VITTORIO E. ANDREUCCI
University of Naples
Naples, Italy
"
~.
KLUWER ACADEMIC PUBLISHERS

BOSTON /DORDRECHT (LONDON
Distributors for North America:

Kluwer Academic Publishers
101 Philip Drive
Assinippi Park
Norwell, Massachusetts 02061 USA
Distributors for all other countries:
Kluwer Academic Publishers Group
Distribution Centre
Post Office Box 322
3300 AH Dordrecht, THE NETHERLANDS
Library of Congress Cataloging-in-Publication Data

Vascular and peritoneal access for dialysis.
(Topics in renal medicine)
Includes bibliographies and index.
1. Arteriovenous shunts, Surgical. 2. Peritoneal
access. 3. Hemodialysis. 4. Peritoneal dialysis.
I. Andreucci, Vittorio E. II. Series. [DNLM: 1. Hemodialysis. 2. Peritoneal Dialysis.
WJ 378 V331!
RD598.5. V343 1989
617'.46059
88-37747
ISBN-l3: 978-1-4612-8880-0
e-ISBN-13: 978-1-4613-1589-6
DOl: 10.1007/978-1-4613-1589-6
Copyright
1989 by Kluwer Academic Publishers
Softcoverreprint of the hardcover I st edition 1989
All rights reserved. No part of this publication may be reproduced, stored in a retrieval saystem or
transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise,
without the prior written permission of the publisher, Kluwer Academic Publishers, 101 Philip
Drive, Assinippi Park, Norwell, Massachusetts 02061.
To my wife Gabriella and to my children Michele and Maria Vittoria
CONTENTS
Contributing Authors
Prcfacc
IX
xv
1. Anesthcsia for vascular and pcritoncal access for dialysis

ALEC R. HOVAGIM, PAUL J. POPPERS
I. VASCULAR ACCESS FOR HEMODIALYSIS
2. External arteriovenous shunt: The first permanent vascular access device

for hemodialysis 15
WAYNE E. QUINTON
3. Thc arteriovenous fistula
23
ENRICO DI SALVO, STEFANO FEDERICO, VITTORIO E. ANDREUCCI
4. Autogenous saphenous vein grafts as vascular access for hemodialysis
45
JOHN P. HARRIS, JAMES MAY
5. Bovine heterograft and umbilical cord graft for arteriovenous fistulas
55
JOHN L. HUSSEY
6. Prosthetic graft fistulas: The expanded PTFE graft
73
L. RICHARD ROEDERSHEIMER
7. Blood access without needles: The Hemasitc titanium vascular access device
91
WILLIAM P. REED
8. Angiography for studying hemodialysis vascular access
111
ENRIQUE M. BURSZTYN
vii
viii
Contents
9. Percutaneous femoral vessel cannulation for hemodialysis

RAYMOND
c.
129
VANHOLDER, SEVERIN M. RINGOIR
10. Subclavian vein cannulation for hemodialysis
153
JEAN-LOVIS VANHERWEGHEM
11. Internaljugular vein cannulation for hemodialysis
169
BERNARD JEAN-MARIE CANAUD
12. Vascular access for hemodialysis in children
195
WOLF D. BRITTINGER, WOLF D. TWITTENHOFF, GOTTFRIED WALKER
II. PERITONEAL ACCESS FOR PERITONEAL DIALYSIS

13. The use of the disposable, stylet catheter
217
STEFANO FEDERICO, GIORGIO FUIANO, VITTORIO E. ANDREUCCI
14. The permanent Tenckhoff catheters
225
ALAIN SLINGENEYER
15. The permanent Toronto Western Hospital catheters
257
RAMESH KHANNA, DIMITRIOS G. OREOPOULOS
16. Swan Neck peritoneal dialysis catheters
271
ZBYLUT J. TWARDOWSKI, RAMESH KHANNA
17. The choice of access for long:-term peritoneal dialysis
291
MICHAEL J. FLANIGAN
18. Dermaport peritoneal dialysis catheter
307
BENEDICT D. T. DALY, KURT A. DASSE
19. Peritoneal access for dialysis in infants and children
315
KLAUS-EUGEN BONZEL, HELGA ROTH, KARL SCHARER
20. Prevention of peritonitis during CAPO: Special precautions and use of

connection systems 333
ROSARIO MAIORCA, GIOVANNI C. CANCARINI, CORRADO CAMERINI
List of Manufacturers
Index
369
357
CONTRIBUTING AUTHORS
Vittorio E. Andreucci, MD
Professor of Nephrology and Chairman
Department of Nephrology
Second Faculty of Medicine
80131 Naples, Italy
Klaus-Eugen Bonzel, MD
Department of Pediatric Nephrology
University Children's Hospital
Hufclandstrasse 55
D-4300 Essen, Fed. Rep. Germany
WolfD. Brittinger, MD
Associate Professor of Medicine
University of Heidelberg
Chief, Department ofInternal Medicine
Rehabilitationsklinik
Neckargemund/Heidelberg, Fed. Rep. Germany
Enrique M. Bursztyn, MD
Chief Radiologist
Greater Westchester Diagnostic Imaging Services
955 Yonkers A venue
Yonkers, New York 10704, USA
ix
Corrado Camerini, MD
Institute of Nephrology, University of Brescia
Division of Nephrology, Spedali Civili
25100 Brescia, Italy
Bernard Jean-Marie Canaud, MD
Assistant des H6pitaux
Assistant a la Faculte
Nephrology Department
Lapeyronie University Hospital
34059 Montpellier, France
Giovanni C. Can carini, MD
Division of Nephrology, Sped ali Civili
Benedict D. T. Daly, MD
Professor of Cardiothoracic Surgery
Tufts University School of Medicine
Boston, Massachusetts 02111, USA
Kurt A. Dasse, PhD
Assistant Professor of Physiology
Boston University School of Medicine
Boston, Massachusetts 02111, USA
Enrico Di Salvo, MD
Associate Professor of Surgery
Division of Surgery and Organ Transplantation
University ofNaplcs
80131 Naples, Italy
Stefano Federico, MD
Associate Professor of Nephrology
80131 Naples, Italy
Michael J. Flanigan, MD
Associate in Medicine
Department ofInternal Medicine
University ofIowa Hospitals and Clinics
Iowa City, Iowa 52242, USA
Giorgio Fuiano, MD
80131 Naples, Italy
John P. Harris, MS, FRACS, FRCS, FACS,
Senior Lecturer in Surgery
Royal Prince Alfred Hospital
Missenden Road
Camperdown N.S.W. 2050, Australia
Alec R. Hovagim, M.D.
Assistant Professor
Department of Anesthesiology
Health Sciences Center
State University of New York at Stony Brook
Stony Brook, New York 11794-8480, USA
John L. Hussey, MD
Section Head, Division of Transplantation
Department of Surgery
Ochsner Clinic and Alton Ochsner Medical Foundation
New Orleans, Louisiana 70121, USA
Ramesh Khanna, MD, FACP
Associate Professor of Medicine
Division of Nephrology
Department of Medicine
MA 436 Health Sciences Center
University of Missouri
Columbia, Missouri 65212, USA
Rosario Maiorca, MD
Professor of Nephrology and Chairman
Division of Nephrology, Spedali Civili
James May, MS, FRACS, FACS
Professor of Surgery
Royal Prince Alfred Hospital
Missenden Road
Camperdown N.S.W. 2050, Australia
xi
xii
Dimitrios G. Oreopoulos, MD, PhD, FRCP, FACP

Professor of Medicine
Toronto Western Hospital
Toronto, Ontario, Canada
Paul]. Poppers, M.D.
Professor and Chairman
Department of Anesthesiology
Health Sciences Center
State University of New York at Stony Brook
Stony Brook, New York 11794-8480, USA
Wayne E. Quinton
Chairman of the Board
Quinton Instrument Company
2121 Terry Avenue
Seattle, Washington 98121, USA
William P. Reed, MD
Associate Professor of Surgery
Tufts University School of Medicine
Baystate Medical Center
Springfield, Massachusetts 01199, USA
Severin M. Ringoir, MD
University Hospital
De Pintelaan 185
B-9000 Ghent, Belgium
L. Richard Roedersheimer, MD, FACS
Clinical Instructor
Department of Surgery
University of Cincinnati Medical Center
Good Samaritan Hospital
St. Francis-St. George Hospital
311 Howell Avenue
Cincinnati, Ohio 45220, USA
Helga Roth, MD
Dapartment of Pediatric Surgery
University of Heidelberg
1m N euenheimer Feld 150
D-6900 Heidelberg, Fed. Rep. Germany
Karl Scharer, MD
Professor of Pediatrics
Division of Pediatric Nephrology
University Children's Hospital
1m N euenheimer Fcld 150
D-6900 Heidelberg, Fed. Rep. Germany
Alain Slingeneyer, MD
Head, Division of Peritoneal Dialysis
A.I.D.E.R., Rue de la Croix de Lavit
Consultant Physician
Lapeyronie University Hospital
34059 Montpellier Cedex, France
ZbylutJ. Twardowski, MD, PhD, FACP
Professor of Medicine
Division of Nephrology
Department of Medicine
MA 436 Health Sciences Center
University of Missouri
Columbia, Missouri 65212, USA
WolfD. Twittenhoff, MD
Jean-Louis Vanherweghem, MD, PhD
Department of Nephrology , Dialysis, Transplantation
Cliniques Universitaires de Bruxelles
H6pital Erasme
Universite Libre de Bruxelles
808, Route de Lennik
1070 Brussels, Belgium
Raymond C. Vanholder, MD
University Hospital
De Pintclaan 185
B-9000 Ghent, Belgium
Gottfried Walker, MD
xiii
PREFACE
When the external Quinton-Scribner arteriovenous shunt was developed in

1960, and, a little later, the internal Brescia-Cimino arteriovenous fistula was
developed as a vascular access for hemodialysis, thereby making possible
regular dialysis therapy of chronic uremic patients, many nephrologists
became surgeons, having learned the type of vascular surgery related to
hemodialysis quite well. The same series of events occurred with regards to
peritoneal dialysis with the introduction of the Tenckhoff catheter and the
need for gaining a permanent access to the peritoneum for chronic ambulatory
peritoneal dialysis (CAPD) therapy.
With time, however, problems relating to vascular and peritoneal access
have forced many nephrologists to give up their surgery; meanwhile, many
surgeons have become quite expert in some sophisticated techniques relating
to dial ysis (e. g., vessel grafting, prosthesis implantation, etc.).
Today, whether or not involved in this type of surgery, both nephrologists
and surgeons remain interested in knowing all available access devices for
dialysis as well as the surgical techniques involved. However, all nephrologists
involved in dialysis must know how to prevent or treat complications related
to dialysis access. Thus, it appeared to me to be quite advisable to have a book
in my series, Topics in Renal Medicine, dealing with vascular and peritoneal
access for dialysis.
The aim of this book was not only to describe in detail the surgical
techniques of dialysis access, but also to suggest care of the access, and
xv
xvi
Preface
prevention and treatment of any complications occurring in relation to access

devices. In doing this, some items may be repetitive in different chapters; this
repetition, however, was intentionally allowed in order to provide completeness in every chapter.
In addition to the more common procedures for permanent or transitory
access to the bloodstream or to the peritoneum, new devices have been
described, such as the Hemasite (the only blood access without a needle
available today, since DiaT AP, mentioned in Chapter 12, is no longer on the
market) and the Dermaport peritoneal dialysis catheter.
Because of the peculiar problems of pediatric patients, vascular access and
peritoneal access in children have been dealt with in separate chapters by
pediatric nephrologists.
The main problem of peritoneal dialysis remains infection. All nephrologists
must be updated in prevention devices (connection systems) and measures;
thus, even though it is not strictly related to peritoneal access, this topic has
been included, for the sake of completeness in this book.
It is, in my opinion, useful for the reader to have a list of the manufacturers
(with their addresses) of all items mentioned in the book. This was therefore
provided.
Special thanks are due to Kluwer Academic Publishers for the publication of
this volume despite its great length, mainly due to the number of (undoubtedly
necessary) figures.
Vittorio E. Andreucci
VASCULAR AND PERITONEAL ACCESS FOR DIALYSIS
1. ANESTHESIA FOR VASCULAR AND

PERITONEAL ACCESS FOR DIALYSIS
ALEC R. HOVAGIM and PAUL]. POPPERS
Anesthesia for access surgery ranges from local to general anesthesia. Once
the patient has been carefully evaluated, then the appropriate premedication,
monitoring, and form of anesthesia can be selected. The anesthesiologist
must also take certain precautions in managing the uremic patient and must be
vigilant in looking for potential perioperative complications.
1. PREOPERATIVE EVALUATION OF THE UREMIC PATIENT
The uremic patient who requires access surgery presents the anesthesiologist
with a multiplicity of problems secondary to the multisystemic nature of
chronic renal failure. Preoperative evaluation must include the changes uremia
produces in the cardiovascular, pulmonary, hematologic, neuromuscular, endocrine, and gastrointestinal systems. Furthermore, the patient's state of hydration and electrolyte and acid/base balance are very important.
Cardiovascular disease in the uremic patient can present as hypertension,
ischemic heart disease, congestive heart failure, and pericarditis. Hypertension, usually the result of fluid overload, is very common in the uremic
patient. Treatment is either dialysis by temporary access or medical therapy
with antihypertensives. Accelerated atherosclerosis in the chronic hemodialysis
population leads to coronary artery disease and peripheral vascular disease.
Numerous other factors contributing to cardiac failure include glucose intolerance, diabetes mellitus, hypercalcemia (resulting from hyperparathyroidism),
hyperlipidemia, altered volume states, and anemia, which increase myocardial
work.
Andreucci. V.E. (ed.), VASCULAR AND PERITONEAL ACCESS FOR DIALYSIS.
Copyright 1989 by Kluwer Academic Publishers. All rights reserved.
Clinical manifestations of ischemic heart disease in uremic patients include

angina and myocardial infarction. Frequently, these patients are taking nitrates, beta blockers and/or calcium channel blockers, all of which should be
continued preoperatively.
Uremic pericarditis, an occasional occurrence, may cause chest pain or may
present as a pericardial rub. The recommended treatment is intensive dialysis.
Hemorrhagic cardiac tamponade secondary to uremic pericarditis, if present,
must be treated preoperatively.
The pulmonary abnormalities in the chronic renal failure patient, referred to
as the uremic lung, lead to pulmonary edema secondary to fluid overload or
congestive heart failure. Pulmonary edema presents radiologically as perihilar
vascular congestion and clinically as bibasilar rales, dyspnea, and hypoxia,
which may require dialysis, medications (e.g., digitalis), and supplemental
oxygen for treatment.
Hematologic changes of uremia are twofold: anemia and coagulopathy. The
anemia of uremia has multiple etiologies, including reduced production of
erythropoietin by the kidney as well as the effect of toxic metabolites of uremia
on bone marrow. Clinically, uremic patients are usually asymptomatic, presumably because the gradual progression of the disease allows for compensatory mechanisms to tolerate hematocrits as low as 15% -18%.
Occasionally, the anemia becomes so severe that the uremic patient becomes
symptomatic; blood transfusion may then become necessary. However, for
access surgery, no literature data exist that support blood transfusion if the
hematocrit is greater than 15%. The markedly reduced oxygen-carrying
capacity secondary to the severe anemia of uremic patients is usually compensated for by an increased cardiac output and, because of increased levels of
2,3-diphosphoglycerate, a right shift of the oxyhemoglobin dissociation
curve. Uremic coagulopathy consists of abnormal platelet adhesiveness and
aggregation, decreased factor III levels, and possibly capillary fragility. A
prolonged bleeding time is common and may thus be a contraindication to
regional anesthesia.
The neuromuscular abnormalities of uremia consist of peripheral neuropathy and changes in mental status that range from drowsiness to dementia.
Peripheral neuropathy is a common complication in the uremic patient. It
most often involves sensory, but also motor, fibers and affects the lower
extremities more frequently than the upper limbs. Uremic peripheral neuropathy may contraindicate the use of succinylcholine in light of the potential
for succinylcholine to produce hyperkalemia (vide infra) [1]. Mental status
changes as well as memory loss are early manifestations of uremia that resolve
with dialysis. Chronic dialysis itself may produce two neurological syndromes: dialysis dementia, possibly from aluminum intoxication, and the dialysis
disequilibrium syndrome, which presents with signs of increased intracranial
pressure.
Endocrine changes include insulin resistance, hyperparathyroidism, and car-
1. Anesthesia for dialysis
bohydrate intolerance. These changes, unless severe, should not alter anesthetic
management significantly.
The uremic patient is prone to aspiration of gastric contents because of
delayed gastric emptying time as well as hyperacidity and increased gastric
volume (vide infra).
The state of hydration may vary considerably in uremic patients depending
upon the time interval since dialysis. Prior to dialysis, the uremic patient is
hypervolemic, whereas postdialysis hypovolemia may be present. Regional
(spinal, epidural) and also general anesthesia may then produce hypotension in
the volume-depleted postdialysis patient because of sympathetic blockade.
Electrolyte disturbances include hyponatremia, hyperkalemia or hypokalemia, hypocalcemia, and hyperphosphatemia. Hyponatremia is usually mild
and rarely warrants treatment. Hyperkalemia, a hallmark of severe end-stage
renal failure, is usually well tolerated, most probably because of the slow,
chronic nature of the disease. Clearly, uremic patients on digitalis therapy
are at increased risk for arrhythmias in the setting of hyperkalemia or, after
dialysis, hypokalemia. Severe hyperkalemia may need to be emergently
treated by intravenous insulin and dextrose or by calcium. The ion-exchange
resin, sodium polystyrene sulforate (Kayexalate), may be used preoperatively
in the days prior to access surgery. Renal osteodystrophy, which produces
fragile bones, may result from hypocalcemia and hyperphosphatemia of
uremia and may be contributed to by secondary hyperparathyroidism and
abnormalities in vitamin D metabolism. Great care must be taken in positioning these patients for surgery in order to avoid fractures.
The acid/base balance in uremia patients is somewhat complex. Uremia
produces a build-up of toxic metabolites, which produce a chronic metabolic
acidosis. It may cause hyperventilation, which results in a compensatory
respiratory alkalosis and a normal pH. Severe metabolic acidosis may produce
cardiac depression, arrhythmias, and hyperkalemia.
2. PREMEDICATION
2.1. Routine medications
The routine medications taken by the uremic patient should be continued

preoperatively and postoperatively. In particular, cardiovascular drugs (e. g.,
antihypertensives, beta blockers) must be administered to avoid the hemodynamic instability that results from their sudden withdrawal. Drugs oflesser
importance, such as vitamins or iron supplementation, can be safely discontinued on a temporary basis.
2.2. Anesthetic premedications
The goal of successful anesthetic premedication is to make a patient free

from apprehension, cooperative, and comfortably sedated. This goal does not
routinely require pharmacologic support. A well-planned, informative pre-
operative visit by the anesthesiologist calms the patient and instills confidence
in the quality of care to be rendered [2]. Further, in a debilitated, severely ill
patient, administration of premedicant drugs might cause cardiopulmonary
depression.
The choice of pharmacologic premedication is widely variable, but it must
be appreciated that many drugs have a prolonged effect in the uremic patient.
Classical premedicants include barbiturates, narcotics, benzodiazepines, butyrophenones, antihistamines, and anticholinergics.
Decreased protein binding of barbiturates in uremic patients manifests
clinically as increased drug sensitivity and a prolonged duration of action [3].
For their analgesic and sedative effects, narcotics, in particular morphine
and meperidine, are commonly used. Aitkenhead et al. [4] found higher
than normal plasma concentrations in uremic patients secondary to a reduced
volume of distribution. Don et al. [5] report three cases of prolonged respiratory depression following morphine administration. Narcotics are extensively
metabolized in the liver to both active and inactive metabolites. Benson et al.
[6] theorize that active metabolites of morphine and meperidine possibly
contribute to prolonged effects in chronic renal failure patients. Despite these
few reports, morphine and meperidine have been safely administered as premedicants to uremic patients without complication.
Benzodiazepines as premedicants are given alone or in combination with
narcotics. They, too, undergo extensive hepatic metabolism, producing many
metabolites that are active and have long-lasting effects. Of all the benzodiazepines, midazolam is the drug of choice for the uremic patient. The elimination half-time, volume of distribution, and clearance are unaltered by renal
failure because of its almost total metabolism. Although Vinik et al. [7] report
that a greater proportion of midazolam is unbound in uremic patients, its
duration of action is only affected if it is given by continuous infusion. In
comparison to diazepam, midazolam provides greater amnesia and has a more
rapid onset. It is less irritating to the veins upon injection because of its water
solubility. The availability of ftumazenil, a specific benzodiazepine-receptor
antagonist, contributes to the safety of this class of drugs.
Droperidol is a butyrophenone that can be administered for premedication. Its long duration of action and potential to produce dysphoria limit its
usefulness.
Antihistamines are frequently given in combination with narcotics to produce antiemetic as well as additive sedative effects. Commonly used antihistamines, histamine 1 antagonists, include diphenhydramine, promethazine,
and hydroxyzine. These drugs undergo extensive hepatic metabolism. Since
little if any drug is excreted in unchanged form by the kidney, they can be
safely given to uremic patients.
The use of anticholinergics as part of preoperative medication is controversial. Atropine, scopolamine, and glycopyrrolate are employed in current
practice. The latter two drugs are more potent antisialogogues than atropine.
Scopolamine has, in addition, sedative and amnesic actions and can be combined with narcotics to produce heavy premedication. It is so extensively
metabolized that only 1 % is excreted unchanged by the kidney, whereas 50%
of all administered atropine can be found unchanged in the urine.
Another goal of anesthetic premedication is to prevent pulmonary aspiration
of gastric contents. Three classes of drugs are commonly used: histamine 2
(H 2 ) antagonists, antacids, and stimulants of gastric motility. Cimetidine and
ranitidine are H2 antagonists that inhibit gastric acid production. Both undergo
some hepatic metabolism, but at least 50% unchanged drug is found in urine.
Therefore, the duration of action of these drugs is markedly prolonged in
uremic patients. Antacids are divided into two groups, namely, particulate
(aluminum and magnesium hydroxide, calcium carbonate) and non particulate
(0.3 M sodium citrate). In uremic patients, all particulate antacids, except
aluminum compounds, can produce metabolic alkalosis. Sodium citrate, given
in doses of 15-30 ml orally, has a more rapid onset and poses less risk of
significant pulmonary dysfunction if aspirated in comparison to particulate
antacids [8]. Metoclopramide is a stimulant of gastric motility, but its duration
of action is markedly prolonged in uremic patients. Overall, whether the
anesthetic technique is regional or general, some form of aspiration prophylaxis should be used; as a minimum reguirement, all patients should receive
sodium citrate immediately before surgery.
3. MONITORING
Monitoring for access surgery should allow prompt recognition of potential

peri operative problems. Routine monitoring must include blood pressure
measurement by sphygmomanometry (on the opposite limb), evaluation of
respiration by precordial stethoscope, and evaluation of heart rate and rhythm
by electrocardiography. The recording of body temperature and the measurement of arterial hemoglobin oxygen saturation by pulse oximetry are very
strongly recommended. During general anesthesia, additional monitoring
might include estimation of neuromuscular blockade by a peripheral nerve
stimulator, evaluation of ventilation by end-tidal carbon dioxide measurement
or mass spectrometry, and invasive monitoring of arterial or central venous
blood pressures, as indicated by the patient's condition.
4. LOCAL AND REGIONAL ANESTHESIA
4.1. Local anesthesia/anesthetics
Local anesthesia is a popular choice of anesthesia for access surgery. Although

it minimally alters cardiopulmonary function, the stress response to needle
injections may prove adverse to the uremic patient with coronary artery
disease. Sedation and analgesia with a narcotic combined with local anesthesia
is clearly superior to local anesthesia alone in that it helps to blunt the stress
response to surgery. Note that the patient's requirement for physiological
monitoring must remam the same, irrespective of the mode of anesthesia

selected.
Based upon their chemical structure, the local anesthetics are divided into
two groups: amides and esters. Amide local anesthetics include lidocaine,
mepivacaine, prilocaine, bupivacaine, and etidocaine. They undergo extensive
hepatic metabolism, with little or no urinary excretion of unchanged drug. In
the presence of liver failure, their potential for systemic toxicity is somewhat
increased. Ester local anesthetics include procaine, chloroprocaine, and tetracaine. These drugs are hydrolyzed to inactive metabolites mostly by pseudocholinesterase in the plasma and, to a lesser extent, in the liver. Patients
with reduced levels of pseudocholinesterase or with atypical cholinesterase
metabolize ester local anesthetics more slowly, producing a prolonged duration of drug effect as well as an increased risk for systemic toxicity. Reidenberg
et al. [9] report a decreased rate of metabolism of procaine in proportion to
rising blood urea nitrogen levels.
Even so, local anesthetics can be safely employed in uremic patients because
the agents only minimally depend upon renal excretion.
4.2. Nerve blocks
For access surgery in the lower extremity, a lumbar plexus block can be
very satisfactory. It can be obtained either by a psoas compartment block or
by individual blockade of the lumbar plexus components, i. e., the sciatic,
femoral, obturator, and lateral femoral cutaneous nerves.
The upper extremity is much more commonly used for vascular accesss. A
brachial plexus block is considered by many to be the anesthetic of choice.
Although the supraclavicular and interscalene approaches are possible, the
axillary approach to the brachial plexus remains the most widely practiced
[10]. If the forearm is the site of surgery, individual blockade of the median,
radial, and ulnar nerves at the level of the distal arm may be considered.
Bromage and Gertel [11] reported a 38% reduction in the duration of brachial
plexus block in uremic patients; it appears that an increased cardiac output
produces a faster tissue washout of the local anesthetic.
4.3. Spinal and epidural anesthesia
For vascular access in the lower extremities or for peritoneal access, spinal or
epidural anesthesia is excellent. The sympathetic blockade that is a feature of
either of these techniques may produce significant hypotension in a patient
who is hypovolemic after hemodialysis via temporary vascular accesss. Orko
et al. (12] reported a more rapid onset of subarachnoid anesthesia with
bupivacaine, as well as a shorter duration of sensory and motor blockade in
chronic renal failure patients. A tendency to acidosis and a possibly re~uced
intrathecal space in uremic patients may account for the more rapid blockade.
Two conditions are considered to contraindicate the performance of a
regional anesthetic block: 1) an abnormal coagulation profile and bleeding
times which might cause a hematoma in a vascular shealth or within the

subarachnoid or epidural space and 2) uremic neuropathy.
5. GENERAL ANESTHESIA
5.1. General considerations
The decision whether to select general or regional anesthesia for access surgery
is based upon consideration of the patient's age, coexisting diseases, site
of surgery, risk of aspiration of gastric contents, and the patient's own preference. In the pediatric patient, most anesthesiologists would select general
anesthesia, citing inability of the conscious patient to cooperate with the
anesthesia team. Coexisting diseases very much influence the choice of anesthesia. In the case of severe pulmonary disease, regional anesthesia would
usually be preferable; whereas in the psychiatric patient, general anesthesia
would normally be chosen. Controversy exists about management of the patient with severe cardiovascular disease. Although local or regional anesthesia
usually alters hemodynamics less than general anesthesia, the stress of repeated
needle sticks and intraoperative anxiety may precipitate hypertension and
tachycardia, leading to myocardial ischemia. General anesthesia, in contrast,
renders the patient unconscious and allows for increased myocardial oxygen
delivery as well as reduced myocardial oxyge~ demand. Surgery performed on
the extremities readily lends itself to regional anesthesia, whereas peritoneal
access can be obtained under local anesthesia.
In light of the previously stated gastrointestinal changes, the uremic patient
is considered a potential "full stomach" and therefore at risk of aspiration
of gastric contents. Although most anesthesiologists would select regional
anesthesia in patients with a "full stomach," general anesthesia can be safely
administered, but only by using a rapid sequence induction. Lastly, the
patient's preference may help determine the choice of anesthesia. Clearly,
local, regional, or general anesthesia may be used for vascular and peritoneal
access surgery, but the anesthesiologist must consider which technique offers
the most benefit and the least risk.
5.2. Inhalation anesthetics
Inhalation anesthetics have one great advantage over most intravenous drugs
and that is their rapid excretion, independent of renal or hepatic function.
Although they be used as the sole anesthetic, they are commonly supplemented with intravenous agents. Inhalation anesthetics in current use include
the gas, nitrous oxide, and three volatile agents - halothane, enflurane, and
isoflurane.
Nitrous oxide, a weak anesthetic producing minimal hemodynamic alterations, is used in combination with volatile drugs, intravenous agents (e.g.,
narcotics, ketamine), or both. The technique that combines nitrous oxide and
narcotics, with or without concomitant administration of muscle relaxants,
has become very popular because a proper titration of drugs allows a smooth
and rapid emergence from anesthesia.
Halothane produces a dose-dependent decrease in blood pressure secondary
to myocardial depression; by doing so it reduces myocardial oxygen consumption, a great benefit for patients with ischemic heart disease. It also
causes bronchodilatation, desirable in asthmatic patients. However, halothane
renders the heart sensitive to catecholamine-induced ventricular arrhythmias.
Enflurane and isoflurane also lower the blood pressure by myocardial depression, and by decreasing systemic vascular resistance as well. High-dose enflurane anesthesia (greater than 3%) can produce electroencephalographic
changes consistent with seizure activity and therefore is relatively contraindicated in patients with convulsive disorders. Isoflurane can produce a doserelated tachycardia and, arguably, a coronary artery "steal" syndrome, which
is detrimental to patients with ischemic heart disease.
5.3. Intravenous agents
Sodium thiopental is the most commonly used drug for the induction of
general anesthesia. Since its duration of action is determined by redistribution
rather than by renal excretion, the concentration of free thiopental, unbound
to serum albumin, is important. Ghoneim and Pandya [3] reported that in
uremic patients 50% of thiopental is unbound to albumin as compared to 28%
in control patients. This implies that a given dose will produce a more
profound initial effect in uremic patients. Therefore, it is recommended that
half the normal dosage be used in anephric patients [13].
Ketamine undergoes extensive hepatic metabolism and subsequent renal
excretion. Chronic renal failure does not alter the duration of action of a single
dose [14]. Because of its sympathomimetic properties, it should be used with
caution in hypertensive patients. Etomidate also undergoes extensive hepatic
metabolism. Only 3% is excreted unchanged in urine and is therefore safe in
uremic patients. Although known as a hemodynamically stable induction
agent, its usefulness is limited by the frequency of thrombophlebitis and
possible adrenocortical suppression.
Fentanyl, sufentanil, and alfentanil are new short-acting narcotics frequently
used for general anesthesia or as a supplement to regional anesthesia. Like morphine and meperidine, these narcotics undergo extensive hepatic metabolism.
Although shorter acting narcotics afford greater control of their duration of
action, both sufentanil and alfentanil reportedly have a rather longer effect in
uremic patients. Wiggum et al. [15] reported a case of prolonged respiratory
depression secondary to markedly elevated sufentanil levels after surgery for
placement of a peritoneal dialysis catheter under general anesthesia. Chauvin et
al. [16] studied the pharmacokinetics of alfentanil and found elevated freefraction plasma concentrations in renal failure patients. Overall, the dose of
narcotics should be reduced and carefully titrated in uremic patients, the
shorter acting narcotics being preferable.
Neuroleptanalgesia, combining droperidol and fentanyl, is acceptable in

uremic patients, but the long duration of action of droperidol may produce
delayed awakening.
Benzodiazepines, previously discussed as pre medicant drugs, can also be combined with inhalation agents or with other intravenous agents (e.g., narcotics,
ketamine) for their amnesic properties. Again, midazolam emerges as the
preferred compound in the uremic patient.
5.4. Muscle relaxants
Succinylcholine is the only commonly used depolarizing muscle relaxant. It is

metabolized by plasma cholinesterase (pseudocholinesterase) and therefore
does not rely upon renal excretion for elimination. Quantitative or qualitative
reductions of plasma cholinesterase may cause a prolonged duration of action
of succinylcholine. Of great importance is its potential to produce hyperkalemia. ,An intubating dose increases serum potassium by 0.5 mEq/L. The usc
of succinylcholine in renal-failure patients has been shown to be safe if the
serum potassium concentration is less than 5.5 mEq/L. Walton and Farman
[17] suggests that in patients with advanced uremic neuropathy, succinylcholine
may produce an exaggerated hyperkalemic response, but clinical evidence supporting this view is weak. However, patients with extensive burns, trauma,
denervation that produces skeletal muscle atrophy, or upper motor neuron
lesions may suffer dangerous hyperkalemia in response to succinylcholine, the
serum potassium level rising by as much as 5 mEq/L.
Nondepolarizing muscle relaxants (in decreasing order of renal dependence
for excretion) include gallamine, metocurine, pancuronium, d-tubocurarine,
vecuronium, and atracurium. As gallamine is entirely eliminated by the
kidneys, it is contraindicated in uremic patients. Both metocurine and pancuronium largely depend upon renal elimination; therefore, their duration
of action can be expected to be prolonged. Although approximately 50%
of d-tubocurarine is found as unchanged drug in urine, it can also be excreted
by the liver. Prior to the availability of vecuronium and atracurium, d-tubocurarine was the preferred nondepolarizing muscle relaxant. However, its
disadvantages include ganglionic blockade and peripheral vasodilation secondary to histamine release, with resultant hypotension.
Vecuronium, an analog of pancuronium, is a new nondepolarizing muscle
relaxant without significant cardiovascular effects. Numerous studies have
shown its safety in uremic patients. Only 10% - 20% unchanged drug is found
in the urine, the remainder being eliminated with the bile. Uremia produces
little prolongation of neuromuscular blockade with vecuronium. Bevan et al.
[18] demonstrated that the duration of action after repeated small doses is
slightly longer, indicating that there is some accumulation in uremic patients.
Similarly, Bencini et al. [19] conclude that renal failure only slightly diminishes vecuronium clearance with consequent mild prolongation of effect and
recovery.
10
Atracurium, an analog of d-tubocurarine, is metabolized both by Hofmann

degradation and ester hydrolysis. The former is a nonenzymatic, spontaneous
breakdown of atracurium that occurs at normal body temperature and pH.
Neither metabolic pathway relies upon hepatic or renal function, making
atracurium the preferred neuromuscular blocking agent in the uremic patient.
Ward et al. [20] studied atracurium and found no significant differences in the
pharmacokinetics in patients with renal failure as compared to controls.
6. PRECAUTIONS IN MANAGEMENT OF THE UREMIC PATIENT
Susceptibility to viral diseases such as hepatitis B or non-A, non-B hepatitis is

well known in hemodialysis patients. Further, frequent blood transfusions
increase the risk for human T-cell lymphotropic virus type 3/lymphadenopathy associated virus (HTL V -3/LA V) infection, i.e., acquired immunodeficiency syndrome (AIDS). Peterman et al. [21] found a high incidence (4%) of
false-positive results of enzyme immunoassay tests (EIA) for HTLV-3/LA V
and a 0.8% incidence of positive results to both EIA and the Western blot tests.
Goldman et al. [22] found 5% of hemodialysis patients positive to both tests.
Both studies conclude that the source of infection was blood transfusion and
not hemodialysis. Until long-term studies are completed, the risk of AIDS in
uremic patients remains unclear. Recommendations for preventing transmission ofHTLV-3/LA V are the same as those for the hepatitis virus, namely, the
use of disposable gloves, gowns, and masks. In the operating room, anesthetic
precautions include the use of a disposable Bain breathing circuit, a disposable
laryngoscope, and goggles.
Strict aseptic techniques are required during placement of arterial or central
venous lines in immunosuppressed patients. Furthermore, placement of these
lines, as well as intramuscular injections of premedications, may be contraindicated if significant coagulopathy exists.
Prior to the use of atracurium and vecuronium, "recurarization" was
thought to be a concern in uremic patients [23]. An adequate alveolar ventilation must be assured intraoperatively as well as postoperatively.
Supplemental oxygen administration during regional anesthesia is important in the uremic patient because of a decreased oxygen-carrying capacity, as
previously discussed. Postoperatively, hypotension or malpositioning of the
patient's extremity may cause clotting of a newly created vascular access.
7. COMPLICATIONS
Complications related to anesthesia include pulmonary edema, hypoxia, and

hyperkalemia. Excess intravenous fluid administration in the uremic patient
may produce lung edema and hypoxia, requiring dialysis. Postoperative hypoxia may also be caused by a multiplicity of other factors, the most common
being the increase in right-to-Ieft intrapulmonary shunting secondary to
atelectasis. Supplemental oxygen should be routinely administered following
general anesthesia. Hyperkalemia may result from lactic acidosis secondary to
hypothermia, diabetes, or uremia.
11
The most common complications related to surgery are thrombosis of the

vascular access route and infection. Other complications are rare, yet serious.
They include arterial insufficiency of a distal extremity (steal syndrome),
hemorrhage, cardiac failure, pneumothorax, and air embolism [24, 25]. The
steal syndrome presents as a painful, cool distal extremity accompanied by a
decreased or absent digital pulse. Postoperative hemorrhage may be surgical or
secondary to the bleeding tendency of uremia. Cardiac failure can be produced
by the increased venous return of an arteriovenous access. Pneumothorax
often follows attempts of percutaneous cannulation of the subclavian vein. Air
embolism is a potential hazard whenever a major vein is cannulated, because
the negative intrathoracic presssure generated during inspiration may entrain
air into an open vessel.
REFERENCES
1. Walton JD, Farman JV: Suxamethonium hyperkalemia in uraemic neuropathy. Anaesthesia
28:666-668, 1973.
2. Leigh JM, Walker J, Janaganathan P: Effect of preoperative anaesthetic visit on anxiety. Br
MedJ 2:987, 1977.
3. Ghoneim MM, Pandya H: Plasma protein binding of thiopental in patients with impaired
renal or hepatic function. Anesthesiology 42:545-549, 1975.
4. Aitkenhead AR, Vater M, Achola K, Cooper CMS, Smith G: Pharmacokinetics of singledose I. V. morphine in normal volunteers and patientss with end-stage renal failure. Br J
Anaesth 56:813-817, 1984.
5. Don HF, Dieppa RA, Taylor P: Narcotic analgesics in anuric patients. Anesthesiology 42:
745-747, 1975.
6. Benson DW, Kaufman JJ, Koski WS: Theoretic significance of pH dependence of narcotics
and narcotic antagonists in clinical anesthesia. Anesth Analg 55:253-256, 1976.
7. Vinik HR, Reves JG, Greenblatt DJ, Abernethy DR, Smith LR: The pharmacokineticss of
midazolam in chronic renal failure patients. Anesthesiology, 59:390-394, 1983.
8. Gibbs CP, Hempling RE, WynneJW, Hood CI: Antacid pulmonary aspiration. Anesthesiology 51:S290, 1979.
9. Reidenberg MM, James M, Dring LG: The rate of procaine hydrolysis in serum of normal
subjects and diseased patients. Clin Pharm Ther 13:279-284, 1972.
10. Winnie AP Perivascular techniques of brachial plexus block, In: Hakansson L. (ed) Plexuss
Anesthesia. Perivascular Techniques of Brachial Plexus Block, Volume 2. Philadelphia: WB
Saunders, 1983, pp 122-131.
1]. Bromage PR, Gertel M: Brachial plexus anesthesia in chronic renal failure. Anesthesiology
36:488-493, ] 972.
12. Orko R, Pitkanen M, Rosenberg PH: Subarachnoid anaesthesia with 0.75% bupivacaine in
patients with chronic renal failure. Br J Anaesth 58:605-609, ] 986.
13. Morgan RNW: The patient with renal disease. In: Stevens J (ed) Clinics in Anaesthesiology,
Volume 4, Number 3. London: WB Saunders, 1986, pp 744-745.
14. Stoelting RK: Nonbarbiturate induction drugs. In: Stoelting RK (ed) The Pharmacology and
Physiology in Anesthetic Practice. Philadelphia: JB Lippincott, 1987, pp 135-144.
15. Wig gum DC, Cork RC, Weldon ST, Gandolfi AJ, Perry DS: Postoperative respiratory
depression and elevated sufentanillevels in a patient with chronic renal failure. Anesthesiology
63:708- 710, 1985.
16. Chauvin M, Lebrault C, LevronJC, Duvaldestin P: Pharmacokinetics of alfentanil in chronic
renal failure. Anesth Analg 66:53- 56, 1987.
17. Walton JD, Farman JV: Suxamethonium hyperkalemia in uraemic neuropathy. Anaesthesia
28:666-668, 1973.
18. Bevan DR, Donati F, Gyasi H, Williams A: Vecuronium in renal failure. Can Anaesth Soc J
31:491-496,1984.
19. Bencini AF, Scaf AH, Sohn YJ, Meistelman C, Lienhart A, Kersten VW, Schwarz S, Agoston
S: Disposition and urinary excretion of vecuronium bromide in anesthetized patients with
12
normal renal function or renal failure. Ancsth Analg 65:245-251, 1986.

20. Ward S, Boheimer N, Wcatherley BC, Simmonds RJ, Dopson TA: Pharmacokinetics of
atracurium and its metabolites in patients with normal renal function, and in patients in renal
failure. Br] Anaesth 59:697-706, 1987.
21. Peterman TA, Lang GR, Mikos NJ, Solomon SL, Schable CA, Feorino PM, Britz]A, Allen
]R: HTL V-III/LA V infection in hemodialysis patients. JAMA 255:2324-2326, 1986.
22. Goldman M, Liesnard C, VanherwcghemJL, Dolle N, Toussaint C, Sprecher S, Cogniaux],
Thiry L: Markers of HTL V-III in patients with end stage renal failure treated by haemodialysis. Br MedJ 293:161-162,1986.
23. Miller RD, Cullen DJ: Renal failure and postoperative respiratory failure: Recurarization? Br]
Anaesth 48:253-256, 1976.
24. Mattson WJ: Recognition and treatment of vascular stcal secondary to hemodialysis prostheses. Am] Sur 154:198-201,1987.
25. Tilney NL, Kirkman RL, Whittemore AD, Ostecn RT: Vascular access for dialysis and cancer
chemotherapy. In: MannickJ (ed) Advancess in Surgery, Volume 19. New York: Year Book
Medical Publishers, 1986, pp 221-270.
I. VASCULAR ACCESS FOR HEMODIALYSIS
2. EXTERNAL ARTERIOVENOUS SHUNT:

THE FIRST PERMANENT VASCULAR ACCESS
DEVICE FOR HEMODIALYSIS
WAYNE E. QUINTON
In 1961, the announcement of a relatively simple device, the Quinton-Scribner

shunt [1], changed forever the medical community's perception of the treatment methods for end-stage renal disease (ESRD). Now, 27 years later, more
than 300,000 ESRD patients undergo some form of dialysis treatment.
This chapter will recall the events leading up to the development of the first
external arteriovenous shunt, outline the knowledge and experience of the
participants, and discuss the materials that were available to work with at that
time. Hopefully, this will not only be interesting to the reader, but will also be
useful in furthering the development of blood access devices.
1. HISTORY OF THE ARTERIOVENOUS SHUNT
I came to the University of Washington in 1950 as department head of their

Medical Instrumentation Facility. However, it was not until 1959 that a crucial
event marked the beginning of my ongoing involvement in the artificial
kidney field. It began when a Montana deer hunter was severely wounded,
went into renal failure, and was brought to Seattle for dialysis treatment under
the direction of Dr. Belding Scribner at the University of Washington Hospital.
Dr. Scribner was faced with a patient who bled profusely during dialysis
because of the heparin required to make dialysis possible. He reasoned that
since blood clotting was temperature sensitive, if he kept the blood and dialysate cold while in the artificial kidney, it would provide functional dialysis
with a normal clotting time in the patient. In additional, cold dialysis would
15
16
I. Vascular access for hemodialysis
inhibit bacterial growth in the dialysis fluid. Dr. Scribner came to me for
technical assistance in creating a refrigerated tank for dialysis. Welcoming that
challenge, I began to work closely with Dr. Scribner on this and other design
projects that furthered his concepts of pumpless, continuous dialysis for acute
patients.
The deer hunter's treatment was frequently delayed while the surgeons
cannulated the blood vessels. As an engineer, I believed that the logical
solution to this problem was a quick-connect device that would provide ready
vascular access for repeated dialysis. Dr. Scribner responded favorably to the
suggestion and on February 23, 1960, at 3:30 pm, Dr. Dillard, Dr. Scribner,
and I met to discuss the possibilities and methods for creating such a device.
In less than a week's time, we designed an arteriovenous shunt system and
developed the techniques for its fabrication. The first all-Teflon shunt was
placed in a patient with acute renal failure on March 5, 1960. Twenty-four
hours after dialysis, the shunt had not clotted, so we decided to place a similar
shunt in Clyde Shields, a 39-year-old machinist suffering from severe terminal
uremia. On March 9, 1960, Mr. Shields was cannulated and a month later Dr.
Scribner, Mr. Shields, others, and I flew to an American Society of Artificial
Internal Organs meeting in Chicago to make the nephrology community
aware of this new method of treating end-stage renal disease.
2. FACTORS LEADING TO THE AV SHUNT'S DEVELOPMENT
The factors leading to any event are often perceived differently, depending
upon the observer. From my perspective, the major factors leading to the
development of the A V shunt were:
1. Dr. Scribner and the members of his team were dedicated to providing the
best possible care to both acute and chronic patients. Their outlook would
accept any concept that had a reasonable chance of success.
2. I had the necessary experience to give me the confidence to create a device
that would allow blood to flow through tubes that were external to the
skin.
3. New materials were available with greater biocompatibility than conventional materials.
Additionally, the years of 1950 to 1960 at the University of Washington
were very productive in research. The medical school was newly staffed with
individuals of great ability, energy, and vision.
My department was indicative of the attitudes that existed at that time. My
instructions from Dean Turner of the medical school were very succinct:
repair anything that needed repair, build anything that could not be purchased,
and do it all as economically as possible. I received requests for devices of all
kinds: ultramicrotomes for electron microscopy, electrophoresis devices for
biochemistry, oxygenators for open-heart surgery, prosthetic devices for
2. External arteriovenous shunt
17
blood-vessel replacement, diameter and pressure measuring devices for heart

research, and artificial heart valves - just to name a few.
Many of the projects I worked on were blood related, and observations
made during my work formed the basis of knowledge necessary to later
construct the arteriovenous shunt. For example, I had observed that blood
would clot when it came in contact with surface-active materials and that the
use of non-wettable plastics, such as Teflon or highly polished materials,
reduced the clotting. I had also noted that moving blood is less susceptible to
clotting than stagnant blood. This is seen in the fact that blood surrounded
by natural blood vessels will clot when blood flow is severely restricted or
stopped.
In addition to these factors, a detailed study of the fluid flow in a normal
cross section of the aortic valve had shown that each heart beat completely
purges or exchanges the blood in the outflow tract and that deviation in the
outflow tract's shape can cause localized clots to form. In corrugated prosthetic
vessel replacements, organized' clots form in the corrugations and eventually
heal, creating a straight, smooth interior. In veins with abnormalities or
reduced flow, clots form and sometimes proliferate into organized clots
extending for long distances along the vein. All these incidences of clotting
can be explained by the stagnant areas of flow that promote the formation of
clots.
Another important observation pertaining to clotting was that devices
implanted inside the heart rapidly developed a coating of organized clots until
they became streamlined and then developed a coating of pseudointimal cells
that prevented any further clot formation.
My work with Dr. Robert Rushmer, developing instrumentation to measure heart diameter and left ventricular pressure in a chronic dog preparation,
provided me with vital information about reducing infection. This instrumentation required wires to penetrate the skin for long periods of time. At
first, we tied the wires to a rib and excited the skin almost directly over the
rib. The resulting infection was rapid and often fatal to the experiment as well
as to the dog. When the wires were tunneled subcutaneously, for one to two
inches directly under the skin, we had no infection, nor did we bandage or
protect the exit site.
These dog-study results are not surprising when you consider that minor
skin abrasions, cuts, and punctures in humans that go no deeper than 2-3 mm
seldom become infected; however, deeper stab wounds often do become
infected. These observations, as well as discussions with several physicians, led
me to believe that the tissue close to the skin is more resistant to infection
than the deeper tissue. Therefore, implanted devices should exit through a
reasonably long path just under the skin. I have no quantitative data to support
this conclusion. However, this concept has been successfully applied to the
designs of both blood access cannulae and peritoneal catheters.
From these observations, I concluded that:
18
l. Vascular access for hemodialysis
Figure 2-1. Artist's drawing of the all-Teflon arteriovenous shunt system with the swage-lock
connectors mounted on an arm plate. This system was replaced by the silicone-Teflon cannula
and the arm plate was eliminated.
1. Plastic tubing made of a non wettable material would conduct blood without clotting, providing there was continuous flow in the tube.
2. It would also be necessary to ensure a steady flow with no stagnant areas in
the fluid path.
3. Placing the tube in a subcutaneous tunnel, just under the skin for a distance
of one to two inches, would reduce exit-site infection and hold it to
acceptable levels.
It was on the basis of these conclusions that the all-Teflon shunt or cannula
system was developed. It had a 180 bend near the vessel entry to anchor the
cannula in the tissue; a long, straight section to go under the skin to reduce
infection; a vertical rise through the skin; and an external connection of artery
and vein to keep the blood flowing. Figure 2-1 shows the all-Teflon A V shunt
system using an all-Teflon cannula (figure 2-2A), with the swage-lock connectors mounted on an arm plate. This system was then replaced by a siliconeTeflon cannula (figure 2-2B) and the arm plate was eliminated.
Originally we reduced the diameter of the external connecting tube to keep
the flow at a minimum when not dialyzing the patient. But this feature was
soon abandoned because of the difficulty of making the reduced section.
0
3. PROBLEMS WITH THE ALL-TEFLON SHUNTS
It was very fortuitous that we used a patient as our first test case. Subsequent
experience has demonstrated the difficulty in finding a suitable animal for
experimental work on cannula design. Cannulae in dogs invariably clot, and
other animals exhibit the same difficulties to a lesser degree.
We felt justified in using a patient, since the procedure was no more difficult
or traumatic than a routine cannulation for hemodialysis, and, if it succeeded,
the patient would be spared repeated cannulation. The fact that the uremic
patient's blood is more resistant to clotting than a normal patient is one of the
19
All Teflon
Silicone
& Teflon
Figure 2-2. A: Illustration of an all-Teflon cannula. These cannulae were usually fabricated on
site at the time of implantation. B: Illustration of a silicone-Teflon cannula showing the Teflon tips
and shunt connector. The tips are available in various sizes to fit the individual blood vessels. C:
Illustration showing the Ramirez modification, a straight tube with wing projections to anchor the
cannula in the patient.
reasons the cannula system worked. However, although we achieved some

degree of success with the all-Teflon shunts, there were problems.
Shortly after the first shunts were inserted, they began to fail due to
clotting, infection, erosion, and other problems. In searching for the causes
and possible solutions to these problems, I noted that the distance between the
exit site and the entrance of the cannula into the vessel varied greatly with the
motion of the arm. It was postulated that a material more flexible than Teflon
might reduce the mechanical trauma and reduce or alleviate cannula failures.
A relatively new material, silicone rubber (sample generously supplied by
Silas Brailey of Dow Corning), was tried as a replacement for Teflon. The new
cannula concept consisted of a Teflon tip inserted into the blood vessel, a
silicone rubber tube from the tip through the skin, and a Teflon connector to
join the two cannulae. This cannula or shunt design was commonly referred to
as the silicone-Teflon shunt (figure 2- 2).
There was a problem with the first silicone tubing. A fibrin-platelet clot
developed and lined the tube's slightly rough interior surface without adhering
to it. Eventually this lining broke loose and obstructed the Teflon tips used to
cannulate the blood vessels. I tried to extrude a silicone rubber tube with small
dovetail grooves, which would theoretically anchor the thin lining to the tube
in the hopes that the tube would become lined with pseudointimal cells similar
to larger diameter prostheses. In the process of trying to extrude the small
dovetail grooves, I learned how to produce a silicone tube with a very high
surface finish that resisted clotting.
The first silicone cannula made was put in Dr. Jim Albers in July of 1961.
This cannula remained functional for many years. Dr. Albers took very great
20
care of his cannula and restricted the movement of his cannulated arm.
As the use of cannulae became more widespread, several things became
apparent. The life expectancy of the silicon-Teflon shunt varied greatly. For
one of a group of patients, it was 3-5 months. For a second group, it was
6-12 months. For a third group, smaller in number, it was one or more years
with a reasonable expectancy of 1 year for a vein and 2 years for an artery.
No detailed analysis of these results exist, nor does it seem possible by
retrospective study to develop the data. Such things as erosion through the
skin and misalignment of the cannula with the blood vessel wass sometimes
due to the lack of experience or attention to detail when implanting the
cannula. Angular misalignment of the tip and vessel may have also been caused
by anatomical changes resulting from the healing process, which tend to
elevate or extrude the cannula. Weight loss tends to exacerbate this tendency.
As for infection, the skill of the nursing staff seemed to determine to a great
extent the longevity of the cannula.
Despite the best of surgical skill and subsequent nursing care, the junction
between the vein and the Teflon tip eventually failed. This failure occurred as a
result of deposits forming in the vein just distal to the Teflon tip and eventually
causing the vessel to clot. Some physicians would routinely replace the cannula
and extend the Teflon tip beyond the affected area. Although Dr. DePalma [2]
at Cedars-Sinai Medical Center made an angiographic study of these deposits,
no satisfactory method of prevention has been developed.
4. MODIFICATIONS TO SHUNTS AND OTHER DIALYSIS METHODS
Numerous innovators added variations to the cannula concept. In 1966, Dr.

Ramirez [3] made a straight shunt with small wings to stabilize the cannula by
fixing it to the tissue (figure 2-2C). In 1973, Dr. Buselmeier [4] devised a
short, compact silicone shunt, which increased the blood flow through the
shunt; blood access was achieved through two ports on the device. In 1969,
Dr. Thomas [5 J developed a shunt without Teflon tips by using a Dacron
applique on the femoral artery and vein.
5. CONCEPTS FOR FUTURE ACCESS DEVICE DEVELOPMENT
Today the need for simple and effective long-term access continues. As an
engineer, I have formed some concepts that could be useful in developing
better devices. Some of these concepts are somewhat general and others are
more specific.
5.1. General concepts
1. Although dialysis blood access is the major lifeline for uremic patients,
often too little skill and time is applied to its creation.
2. It is difficult to obtain an accurate comparative analysis of various devices.
3. The body's healing process usually tries to maintain the original status of
21
the body. Only by fully understanding the healing process, can we implant
a foreign body and have it function for a long time.
4. We must not interfere with the body's normal defenses against infection.
5.2. Specific observations
1. The devices that do not change the normal hemodynamic circulation are
most likely to succeed.
2. A method of bonding prosthetic devices to tissue over their entire area
could improve their performance.
3. Prosthetic devices should have the same flexibility ass the tissue into which
they are implanted.
4. Prosthetic devices should no more than minimally alter the blood supply to
the surrounding tissue, particularly on a macro and micro scale.
5. The use of smaller blood vessels to gain accesss to larger vessels with high
blood flow may prove to be the ideal solution to long-term access. An
example is the use of either the subclavian or jugular veins to gain access to
the superior vena cava with either a single- or double-lumen catheter.
6. The development of a painless, infection-free, and minimally inconvenient
access device will require commitment and cooperation between multiple
disciplines: materials engineering, medical science, patient, and those providing research funds.
(For the surgical procedure of insertion of an arteriovenous shunt see Chapter 3.)
ACKNOWLEDGMENTS
My thanks to Don Anzinger and Frank Gaffney for their excellent assistance in
editing and illustrations, respectively.
REFERENCES
I. Quinton WE, Dillard DH, Scribner BH: Cannulation of blood vessel for prolonged hemodialysis. Trans Am Soc Artif Intern Organ 6: 104-113, 1960.
') DePalma JR, et al: Evaluation of A-V cannula malfunction and clotting using shunt-angiography. Trans Am Soc Artif Intern Organs 15:278, 1968.
3. Ramirez 0, Swartz C, Onesti G, Maillous L, Brest: The winged in-line shunt. Trans Am Soc
Artif Intern Organs 12:220-221, 1966.
4. Busclmeier TJ, Kjellstrand CM, Simmons RL, NajarianJS: A new subcutaneous arteriovenous
shunt. Surgery 73:512-520, 1973.
5. Thomas GI: A large vessel applique A-V shunt for hemodialysis. Trans Am Soc Artif Intern
Organs 15:288, 1969.
3. THE ARTERIOVENOUS FISTULA
ENRICO DI SALVO, STEFANO FEDERICO, and VITTORIO E. ANDREUCCI
1. THE ARTERIOVENOUS FISTULA
The introduction of the radial artery-cephalic vein fistula in 1966 by Brescia

and Cimino [1] was a milestone for developing dialysis programs on a regular
long-term basis and still represents the most successful access to the circulation
for chronic hemodialysis.
The arterial-venous fistula (A VF) is a communication between an artery and
the nearest superficial vein by a surgical anastomosis so that a large amount of
blood (this is essential for dialysis treatment) runs in a venous network. The
resulting advantages are the following: 1) venipuncture is easier than arterial
puncture since the venous network is superficial and 2) the vein wall heals
more quickly and turns into aneurysms less easily than the arterial wall.
2. THE A VF IN THE UPPER ARM
One of the most important problems concerning patients on maintenance

hemodialysis is the progressive reduction in angioaccess for venipuncture. For
this reason, the general rule is that surgery for vascular access should be
performed as distal as possible in order to spare vessels. Consequently, in
deciding the site for performing an A VF in the upper arm, the anatomic
snuffbox must be the first choice; the wrist may be a second-choice site; a more
proximal site can be only a final choice.
2.1. The A VF at the anatomic snuffbox
The A VF at the anatomic snuffbox utilizes the dorsal branch of the radial
artery and the cephalic vein at its beginning. This fistula is possible when the
Andrcucci. V.E. (ed.), VASCULAR AND PERITONEAL ACCESS FOR DIALYSIS.
23
24
artery has a good pulse and the vein caliber is satisfactory. It is the most distal
fistula and can easily be created in young subjects or when the wrist exhibits
a bone hypertrophy (generally due to previous Colles' fracture), a hyperuricemic tophus, or any other local pathology. The major advantage resulting
from this surgical procedure is the possibility, in case of failure, of performing
a second more proximal A VF at the distal forearm. It is contraindicated in the
dominant hand, because the latter is more exposed to traumatism, and in
subjects with vascular pathology. Limits of this A VF are the frequent early
thrombosis, due to the anatomy of both the snuffbox and vessels, and the long
time necessary before full maturation and function occur to a degree that is
adequate for dialysis needs.
2.1.1. The technique
Under local anaesthesia of the snuffbox area, a longitudinal incision is made

parallel to tendons of the extensor pollicis muscles [2]. Caution must be
exercised to avoid lesions of the superficial radial nerve branch, which would
cause a permanent lateral-dorsal anaesthesia of pollex. After ligation and
interruption of three or four small branches of the artery and one or two
affluent branches of the vein, both vessels are mobilized for 1. 5-2 cm and the
anastomosis is made end-to-end or, less frequently, side (artery)-to-end (vein).
It is necessary to use atraumatic and small vascular clamps and to perform
a careful incision of vein adventitia. Vascular sutures are performed using
double-running or interrupted monofilament of 7 -0 size.
2.2. The A VF at the wrist
The A VF at the wrist is the most common vascular access for hemodialysis
treatment. The anastomosis can be performed between the radial artery and
the cephalic vein or between the ulnar artery and the basilic vein. Before
surgery, it is essential to verify the presence of a good artery pulse and to
visualize the vein patency with a tourniquet in place. Sometimes a Doppler
apparatus can help to evaluate the flow of vessels. Invasive procedures, such
as arteriography and venography, are unnecessary unless there are unusual
circumstances, such as suspicion of anomalous circulation, previous trauma,
or former vascular operation.
If vascular vessels of both forearms are satisfactory and alike, the nondomin ant extremity should be preferred for the operation, since it is less exposed
to trauma and any problem that may subsequently arise is less unfavorable for
the normal activities of the patient.
2.2.1. The radial-cephalic A VF
To create a radial-cephalic A VF at the wrist, a longitudinal skin incision (figure

3-1A) is usually performed, since it allows a further, more proximal isolation
of the vessels in case of immediate failure of the fistula. We prefer, however,
a transversal skin incision (figure 3-1B), since with this incision it is possible
3. Arteriovenous fistula
25
I,
I
c
L
Figure 3-1. Skin incisions at the wrist: a = longitudinal; b
trasverse; c = curvilinear.
to mobilize and approximate to each other even distant vessels. Should an

immediate A VF failure occur, in fact, we may continue the incison in a
curvilinear fashion (figure 3-1 C) for further isolation of vessels; such a curved
incision will heal without problems.
The vein is isolated and circumscribed with a strong tie for traction; lateral
tributary vessels are ligated using monofilament of 6-0 or 7 -0 size and then
are divided. The radial artery is then mobilized and circumscribed beneath the
flexor retinaculum; small and paired branches of the radial artery have to be
ligated and then divided (never divide without ligation because hemostasis
would require more time). For this purpose, a monofilament of 5-0 to 7-0
size is used depending on the size of the branches. To perform a comfortable
anastomosis, the artery must be mobilized for 2-3 em and the vein for 3-4 em
depending on the space necessary to apply vascular clamps. The anastomosis
can be performed end-to-end, side (artery)-to-end (vein), side-to-side, and,
exceptionally, end (artery)-to-side (vein).
2.2.1.1. THE END-TO-END RADIAL-CEPHALIC ANASTOMOSIS. Routinely we
perform the end-to-end anastomosis, provided that the pulse of the ulnar
artery at the wrist is present and valid; in this case, there will be no ischemia of
the hand. Using small vascular clamps, the artery and the vein are clamped
and then ligated distally. Both vessels are cut obliquely (like a whistle) and
inversely (AB and CD in figures 3-2A and 3-2B) by small angled scissors.
When the caliber of one vessel is smaller than that of the other, the following
procedure may help in widening the section of the small vessel: After the
26
'. YuJ
Figure 3-2. End-to-end anastomosis: a shows the direction of vein (A-B) and artery (C-D)
sections; b shows the vessels after their section; c shows the anastomosis at completion of the
surgical procedure (E and F are the distal ends of the two vessel).
oblique section of the vessel, for about 80% of its caliber (figure 3-3), one
branch of a Pott's scissors is inserted into its lumen to extend the section up the
caliber of the other vessel; then the oblique section can be completed.
The vein and the artery are knotted to each other at the proximal end of their
section (A and C in figure 3-4) using a double-armed monofilament (G-Gl in
figure 3-4), one needle (G in figure 3-4) being inserted through the wall of the
vein, the other one (G 1 in figure 3-4) through the wall of the artery. The same
procedure, with another double-armed monofilament (H-Hl in figure 3-4), is
then followed to knot the distal ends of the vein and artery sections (B and
D, respectively, in figure 3-4). A dilute, heparinized saline solution is then
injected, by a cannula, into the vein to verify its patency; afterwards, to check
the arterial blood flow, the arterial clamp is released for a while. At this
moment, if necessary, a Mosquito's klemmer may be used to dilate the vein;
this maneuver is contraindicated for the artery, especially when its wall is
calcified or atherosclerotic. Finally semicircle sutures (out-to-in of vein and
in-to-out of artery) are performed in a continuous fashion, first in the anterior
wall, starting from the proximal end (A-C in figure 3-4), then in the posterior
wall, after reversing the apical stitch to make it anterior to the posterior wall.
If a more physiological anastomotic angle is preferred, the following procedure has to be followed after having obliquely cut the vessels. One needle (G
27
Figure 3-3. Surgical procedure for widening the section of a low-caliber vessel.
Figure 3-4. End-to end anastomosis. The proximal ends of the vein (A) and artery (C) sections are knotted by the monofilament G-G1. The distal ends (B and D) are knotted by the
monofilament H-H1.
28
I. Vascul ar access for hemodialysis
J .fill
Figure 3-5. End-to-end anasto mosis with a physiological anastomotic angle. a shows the
particular disposition of the monofilam ents G-G 1 and H-H 1; b shows the anastomosis wh en
completed.
in figure 3-5A) of a double-armed monofilament (6-0 or 7 -0 size) is inserted

through the vein wall at the proximal end of its section (A in fi gure 3-5A) , and
the other needle (Gl in figure 3-5A) is inserted through the artery wall at the
distal end of its section (D in figure 3-5A). One needle (HI in figure 3-5A) of
another double-armed monofilament is then inserted through the artery wall
at the proximal end of its section (C in figure 3-5A), while the other needle
(H in figure 3-5A) is inserted through the vein wall at the distal end of its
section (B in figure 3-5A). Each monofilament is then ligated and a continuous
suture is performed, first in the anterior and then in the posterior wall of the
anastomosis (figure 3-5B).
Following is some useful technical advice:
1. The ideal clamp has to be atraumatic and has to possess a sufficient closing
pressure to prevent bleeding and accidental disruption.

2. Before the vascular suture, incision of the adventitia of the vein is not
necessary and should be avoided; such early incision, in fact, may cause
problems by reducing the thickness of the venous wall. At the end of the
anastomosis, however, when the clamps are open, a careful incision of
the adventitia can be performed, as far as possible from the sutures, using
two opposite Adson forceps. This maneuver is helpful in facilitating vein
dilation.
29
3. However, it is better to perform the incision of the arterial adventitia before

the anastOll1osis.
4. In the case of arterial calcification, it is preferable to leave the intimal plaque
and fix it to the anastomosis; the same procedure has to be done with a
valvular flap of the vein, should it be positioned close to the vein section.
After the removal of the vascular clamps, the anastomosis should have a
palpable thrill; a turbulence of blood within the vein may be seen.
An immediate failure of the A VF can be due to problems involving the
artery, the anastomosis, or the vein. The artery may exhibit the following
problems: 1) an arterial spasm, which can be resolved by irrigating the vessel
with papaverine or local anesthetic, 2) a reduction of blood flow to the anastomosis caused by a calcification situated proximal to the fistula that was
unrecognized before surgery, or 3) occlusion of the fistula by a calcified plaque
that has moved upon the release of the artery clamp. In these cases, a new A VF
needs to be made, without delay, at a more proximal site.
The anastomosis can be affected by early thrombosis or stenosis. In both
cases, by using a small Fogarty balloon catheter (which is introduced into the
vein through an incison 1 cm proximal to the anastomosis), the thrombus can
be removed and the stenosis dilated by gently inflating the terminal balloon.
The vein can be affected by a rotation, by an anomalous angulation at the
anastomotic site, or by a sclerosis or thrombosis at the level of the proximal
forearm. In the former case, the anastomosis has to be performed again using
the same vessels. In case of a venous thrombosis, usually the A VF is initially
functioning, but after a few hours the blood flow stops; in this condition, a
new A VF has to be made using other vessels.
When the skin has been sutured, the last essential procedure is to check the
thrill by a stethoscope. If the thrill is not present, the skin wound has to be
reopened to check the anastomosis. Sometimes, the thrill is absent and vein
filling occurs in a centripetal direction, as shown by the two-forceps test
(figure 3-6) while a good pulse in the vein is palpable. The reason for this
behavior may be excessive thickness of the venous wall or low arterial blood
pressure more frequently, however, no reason can be found. In many of these
cases, the thrill appears after several hours. Thus it is preferable to postpone
the decision to construct a new fistula. Under such circumstances, the use of
drugs inhibiting coagulation is helpful in preventing thrombosis.
2.2.1.2. THE SIDE-TO-END RADIAL-CEPHALIC ANASTOMOSIS. When the ulnar
artery is closed, a side (artery)-to-end (vein) anastomosis is indicated, because
with this type of A VF the hand is more protected from ischemia than after
a total interruption of blood flow through the radial artery. Ischemia of the
hand is actually exceptional with any A VF. The interossea artery, in fact, can
counterbalance the reduction of blood flow to the hand, even after ligation
of both the radial and ulnar arteries at the wrist, unless both ligations are
performed at the same time or with a few days' interval.
30
Figure 3-6. The two-forceps test to check the anastomosis patency when the thrill is absent and
the pulse is palpable. The two forceps are placed in the venous site, close to each other; then they
are moved away to empty the vein (a); in a well-functioning A VF, after the removal of the distal
forcep the blood fills the vein again (b). A = artery; V = vein
To perform this type of A VF, the vein has to be isolated for a longer
extension (4-5 cm) than for the end-to-end A VF; otherwise, after the anastomosis, when the artery recovers its deep position, the vein will be stretched,
thereby stopping the blood flow. The use of two tourniquets (rather than
clamps) around the artery allows space-saving and facilitates the surgical
procedure. The arteriotomy has to be slightly lateral, facing the vein. Using a
double-armed monofilament (G-G1 in figure 3-7), one needle (G1 in figure
3- 7) is inserted through the artery wall at the proximal end of the arteriotomy
(C in figure 3-7) and the other needle (G in figure 3-7) is inserted through the
vein wall at the proximal end of its section (A in figure 3-7). The same
procedure is performed with another double-armed monofilament (H-H1 in
figure 3- 7) for the distal end of both the arteriotomy and the vein section (D
and B, respectively, in figure 3-7). Each monofilament is then ligated and,
starting from the proximal stitch, a continuous suture (in-to-out of artery and
out-to-in of vein) is performed on the posterior wall by using one end of the
monofilament G-G 1. When the suture reaches the distal end of the anastomosis (E, D in figure 3-7), the stitch of this end (filament H-H1 in figure 3-7)
is removed and the anterior wall is sutured in a continuous everting fashion,
starting, again, from the proximal end of the anastomosis (A, C in figure 3- 7)
and utilizing the other needle (G1) of the proximal stitch. In the presence of
very small vessels, it is advantageous to utilize an interrupted suture for the
31
Figure 3-7. Side (artery)-to-end (vein) anastomosis. A-B is the vein section, C-D the artery
section. G-G 1 is the monofilament knotting the proximal ends (A and C) of the artery and vein
sections. H-Hl is the monofilament inserted in the distal ends of the two vessel sections.
anterior wall; in this case, the distal stitch is ligated with the monofilament
used for the posterior wall.
In order to increase an inadequate flow in the vein, some individuals ligate
the artery after the site of the anastomosis, thereby transforming a side-to-end
into an end-to-end anastomosis. This procedure must be avoided, since a
particular blood vortex may develop at the level ofligation and the A VF may
be occluded by a thrombosis.
2.2.1.3. THE SIDE-TO-SIDE RADIAL-CEPHALIC ANASTOMOSIS. The side-to-side
A VF, the classic Cimino-Brescia fistula, requires a large mobilization of the
artery and the vein to avoid both the anastomosis and the vein being stretched
at the end of the surgical procedure. The vessels are approximated side-to-side
and clamped together at both extremities of their isolated length with a vessel
loop or a small vascular clamp. The vein and artery are incised longitudinally
(figure 3-8), a double-armed stitch (G-Gl) is placed at the proximal end (A,
C), and another one is placed (H-Hl) at the distal end (B, D) of the incisions
(having used, as usual, one needle for the vein and the other one for the artery).
The proximal stitch (G-G 1) is then ligated, and one needle is used to suture the
posterior wall in a continuous fashion. To facilitate the surgical procedure,
only when this suture reaches the distal end of the incisions (B, D) is the distal
stitch (H-Hl) ligated. The monofilament (G) used for suturing the posterior
32
Figure 3-8. Side-to-side anastomosis. G is the needle of the monofilament G-G I used for
suturing the posterior wa ll of the anastomosis.
wall is then knotted with one end (H) of the distal stitch. A continuous or
interrupted suture is finally performed in the anterior wall of the vessels to
complete the anastomosis.
The essential advantage of this anastomosis is that it allows for the possibility of constructing a wide communication between the artery and vein,
thereby reducing the time necessary for vein maturation; thus, dialysis treatment can start within a few days . There are, however, some disadvantages: 1)
an aneurism can arise in the anastomosis when too wide a communication is
created between the vessels and 2) the arterial blood may flow into the distal
venous network of the hand, thereby causing edema of the hand. To correct
the latter complication, some individuals ligate the vein just distally to the
anastomosis (creating a side-to-end anastomosis). This procedure must be
avoided, since it may cause A VF thrombosis due to the blood vortex created at
the level of ligation.
2.2.1.4. THE END-TO-SIDE RADIAL-CEPHALIC ANASTOMOSIS. The end (artery)to-side (vein) anastomosis requires a technique that is similar to that used for
the side (artery)-to-end (vein) A VF. It is sufficient to change the role of the
artery and the vein during the procedure. There is no special surgical
indication to perform this type of anastomosis.
2.2.2. The uinar-basilic A VF
The ulnar-basilic A VF is a second possibility for performing an A VF at the

wrist. It may be preferred to radial-cephalic A VF when the following COI1-
3. Artcriovcnous fistula
33
ditions are present in both forearms: 1) a better pulse of the ulnar artery
compared with that of the radial artery and 2) lack of a good vein near the
radial artery when large veins are available near the ulnar artery. The radialcephalic A VF must be preferred instead for the following reasons: l)the ulnar
A VF forces the patient to dialyze in an uncomfortable position because the
forearm has to be extrarotated for venipuncture and 2) the wall of the basilic
vein is thinner than that of the cephalic vein.
Surgical techniques for ulnar-basilic A VF are not different from those described for radial-cephalic A VF.
2.3. The AVF at the distal part of the forearm
The A VF at the distal part of the forearm is usually created to convert an

external arteriovenous shunt (inserted straight, in line between the radial artery
and the cephalic vein) into an A VF. In children, and sometimes in adults with a
very small cephalic vein that is unsuitable for an A VF, it may be useful to first
insert an external A V shunt, which may then be successfully converted into
an A VF as soon as the vein becomes dilated and visible. Under such circumstances, the external A V shunt may be used for immediately starting hemodialysis treatment; furthermore, since the diameter of the vein, cannulated
with the shunt, increases considerably because of the high arterial blood flow,
the arterialized vein may be punctured for subsequent hemodialysis immediately after conversion of the external A V shunt into the internal A VF.
To create this A VF, a transverse or longitudinal incision of the skin is
performed 2-3 cm proximal to the shunt tips; the radial artery and the dilated
cephalic vein are mobilized; then an end-to-end A VF is constructed according
to the procedure described earlier in this chapter. Finally, the shunt is removed
by external traction through the original skin outlets, thereby avoiding contamination of the A VF wound.
2.4. The AVF at the middle part of the forearm
The possibility of an A VF at the middle part of the forearm may be considered

when a radial-cephalic A VF at the wrist has been occluded by a thrombosis but
the cephalic vein is still pervious. Usually this vein remains pervious at the
middle part of the forearm because of the venous blood flow coming from
more proximal venous branches. The A VF is created by an end-to-end or,
more rarely, by a side (artery)-to-end anastomosis, and the vein may be
im.mediately punctured for dialysis, since it is already dilated and arterialized.
2.5. The AVF at the proximal part of the forearm
The A VF at this level is indicated when a more distal A VF has failed and only
the median vein is suitable in the forearm, owing to thrombophlebitis of the
cephalic vein. Usually the median vein begins in the venous plexus of the palm
and forks in two branches in the cubital fossa, just below the crease of the
elbow. The two branches join the cephalic vein and the basilic vein respec-
34
tively, in the upper arm. The cubital fossa is a triangular space, one side of
which is defined by a line drawn between the two humeral epicondyles, while
the other two sides are made by the medial edge of the brachioradialis muscle
and the lateral edge of the pronator teres muscle, respectively.
To create this A VF, a transverse skin incision, 4-5 cm in length, is made
3-4 cm below the antecubital crease at the elbow. The median vein is isolated
until it forks in its two branches and is mobilized by ligating its deep branch at
the back. To isolate the radial artery, the following steps are performed in
order: 1) the vein is moved laterally by using two tourniquets, 2) the medial
side of the lacertus fibrosus of the biceps is transversely incised (2-3 cm in
length), and 3) by medially moving the pronator teres muscle and laterally
moving the brachioradiales muscle, the deep fascia of the forearm is incised
and the radial artery is exposed. The artery is isolated for 3-4 cm in length by
ligating three or four branches; care must be taken to spare the two venae
comitantes and the superficial branch of the radial nerve. The anastomosis may
be performed end-to-end or side (artery)-to-end depending on the different
anatomic positions of the vessels.
2.6. The A VF in the arm
The area 3-5 cm above the cubital fossa may be used to create an A VF by
utilizing the brachial artery and the cephalic or the basilic vein when peripheral
vessels are not available in both forearms. The distance of both veins from the
single artery of the arm requires mobilization of the vein.
2.6.1. The brachial-cephalic A VF
The cephalic vein is exposed by two transverse skin incisions, the first one
1 cm and the other one 4-5 cm above the crease of the elbow, along the venous
course, so that it can be mobilized medially to approach the brachial artery.
The adventitia of the vein should not be incised in order to avoid a subsequent
aneurism of the anastomosis due to the high flow and the high pressure that
will be created within the vein.
The brachial artery is exposed by medially extending the first incision
utilized for the vein. At this level, the artery is in the neurovascular bundle
with the radial nerve (in medial position with respect to the artery) and the two
venae comitantes. The veins and nerve must be carefully spared. Flushing the
nerve with a local anaesthetic will reduce the pain caused by the surgical
maneuver. The artery is isolated by ligating 3-4 lateral branches and is then
connected with the vein in side (artery)-to-end fashion. The arteriotomy has to
be small in order to avoid a large blood flow being shunted from the artery
to the vein, thereby causing cardiac failure or (more rarely) peripheral arm
ischemia. Before skin suture, the person performing the operation must verify
that forearm flexion does not stretch or compress the A VF.
35
2.6.2. The brachial-basilic A VF
This is the most frequent A VF in the upper arm. It requires mobilization of the
basilic vein, which lies deeply below the brachial aponeurosis just at the
beginning of the middle part of the arm. The basilic vein ha-s to be tunneled in
the subcutaneous tissue in order to have a vein easily puncturable for
hemodial ysis.
The vein is isolated through a longitudinal skin incision, beginning at the
upper end of the bicipital aponeurosis and extending 7-8 cm in length along
the course of the brachial artery. The vein is medial to the brachial artery and
has to be isolated by ligating one or two branches that drain the blood of the
dorsal forearm side. It is them mobilized until the point where it crosses the
medial cutaneous nerve. Since this nerve is more superficial than the vein, the
latter has to be distally dissected, washed with a heparin solution, and placed
above the nerve. The brachial artery is then prepared, as previously described,
and the vein is connected to the artery in a side (artery)-to end (vein) manner.
After the anastomosis, the skin incision is extended for the whole length of
the sulcus bicipitalis medialis up to the axilla and the vein is embedded into the
subcutaneous tissue while resuturing the fascia and then the skin.
2.6.3. The "reverse" A VF
This is a particular A VF proposed by Adar [3] and Geis [4] when the distal
veins in the forearm are unsuitable for an A VF and a superficial venous
network is present. Shapira et al. [5] have used the "reverse" A VF in children
weighing 12 kg or less.
The technique requires a skin incision just above and parallel to the antecubital crease of the elbow. The distal brachial artery and the basilic vein are
isolated and approximated; then a side-to-side anastomosis is performed. If a
thrill is palpable on the vein both proximally and distally to the anastomosis,
the basilic vein is ligated proximally and separated close to the anastomosis.
Thus the side-to-side A VF is converted into a side (artery)-to end (vein) A VF
with reverse pulsatile flow. The infrequent utilization of this A VF is due to the
following reasons: 1) the same unfavorable venous condition that has caused
the failure of the A VF at the wrist usually also endangers the "reverse" fistula,
and 2) massive retrograde arterialization may result in severe progressive
edema at the forearm and at the hand.
2.6.4. The "deep" AVFin the upper arm
This is an alternative technique to the use of biologic or prosthetic grafts. It

may be utilized for patients in whom no superficial veins are available in
superior limbs.
The A VF is created between the brachial artery and one of its venae comitantes; the vessels are exposed by a small incision just above the crease of the
elbow and a side (artery)-to-end anastomosis is performed.
36
The following precautions must be used: 1) the wall of the venae comitantes
is thinner than the wall of superficial veins; consequently, for the vascular
suture, more venous wall must be used in order to ensure a good seal at the
anastomosis; 2) the other vena comitans must absolutely be spared, since it
becomes the only vein supplying the deep venous circulation.
Two weeks after the anastomosis, the vein has to be carefully mobilized and
embedded into the subcutaneous tissue.
3. THE A VF IN THE LOWER EXTREMITY
Actually the creation of an A VF in the lower extremity is infrequent for the

following reasons: 1) in the lower extremity the superficial veins are poorly
developed since the blood preferentially flows in the deep veins, 2) infections
and thromboses are frequent and venipuncture is more painful and less tolerated, and 3) the veins are frequently varicose. Thus, in the case of failure of
the A VF in all available sites of the upper arm, nephrologists utilize biologic
or prosthetic grafts in the arms; alternatively, they switch the patients to
continuous ambulatory peritoneal dialysis (CAPD).
3.1. The AVF in the leg
Fistulas in the leg may be created between the saphenous vein and either the
posterior or the anterior tibial artery.
3.1.1. The A VF between the posterior tibial artery and the saphenous vein
A fistula utilizing the posterior tibial artery requires a longitudinal inCIsIOn

(5-6 cm in length) just above the malleolus medialis (figure 3-9). The artery
(A), which is posterior to the malleolus, is isolated for 4 cm, sparing the two
venae comitantes. The saphenous vein (B) is anterior to the malleolus and may
be isolated, through the same skin incision, for 5-6 cm by ligating 2-3
collateral branches. The anastomosis is performed side (artery)-to-end (vein)
using the technique previously described (figure 3-9). If the plantar arterious
plexus is intact, the anastomosis may be realized in an end-to-end fashion in
order to reduce the possibility of thrombosis.
3.1.2. The A VF between the anterior tibial artery and the saphenous vein
This A VF (figure 3-10) is rarely created since its anatomic position frequently
causes thrombosis because of foot movements. The skin incision is performed
2-3 cm above the articulation between the tibia and the tarsus. The anastomosis is performed in ent-to-end fashion.
3.2. The A VF in the thigh
In the thigh, the surgeon may attempt the creation of an A VF utilizing the
superficial femoral artery and the great saphenous vein either in the distal part
or in the proximal part of the thigh, by creating a loop.
37
Figure 3-9. Side (artery)-to-end anastomosis between the posterior tibial artery (A) and the
saphenous vein (B).
Figure 3-10. End-to-end anastomosis between the anterior tibial artery (A) and the saphenous
vein (V).
38
I
Figure 3-11. Side (artery)-to-end anastomosis between the superficial femoral artery (A) and
the saphenous vein (V) in the distal part of the thigh.
3.2.1. The A VF ill the distal part of the thigh
This A VF was proposed by Enderlin et al. [6] in 1971. It requires a cutaneous

incision (15-20 cm in length) from the medial femoral condyle to the middle
part of the thigh. The superficial femoral artery is isolated for 10 cm, sparing
the collateral branches; the saphenous vein is then isolated and distally sectioned; a side (artery)-to-end anastomosis is finally performed (figure 3-11).
Subcutaneous tissue is then placed between the artery and the vein in order to
avoid contact and the subsequent accidental puncture of the artery when the
vein is cannulated.
3 .2.2. The A VF ill the proximal part of the upper thigh
The technique for creating this A VF consists of making a loop by utilizing the
great saphenous vein, which is sutured to the superficial femoral artery at the
level of the Scarpa triangle (figure 3-12).
After a transversal or longitudinal skin incision performed at the Scarpa
triangle, the saphenous vein and the superficial femoral artery are carefully
isolated . Isolation of the vein is then carried out as distally as possible through
the same skin incision, meticulously tying off every branch found on the way
39
'
''''
',.
.,
"I,
.. :.
~: ~!
~0
~
Figure 3-12. Anastomosis between the superficial femoral artery (A) and the great saphenous
vein (V) at the level of the Scarpa triangle after mobilization of the vein and its conversion into
a loop.
with prolene. Two or three more skin incisions, 2.5-3 em long, are made in
the medial aspect of the thigh, down to the knee level, along the saphenous
vein. This vein is also bluntly isolated between the incisions ligating every
branch, and, at the level of the medial femoral condyle, it is ligated and
dissected. The vein is then exteriorized through the skin incision at the Scarpa
triangle and checked for leaks by filling it with heparin solution injected from
its distal end.
A large loop-shaped subcutaneous tunnel is then developed in the anterior
thigh; the vein is drawn through it by pulling its distal end, with the help of a
clamp, up to the superficial femoral artery in the incision at the Scarpa triangle
(figure 3-12). The saphenous vein is finally anastomized to the superficial
femoral artery in a side (artery)-to-end fashion. In making the loop, care must
be taken not to produce any rotation, kinking, or sharp angles in the vein.
However, thrombosis is a frequent complication of this fistula. Other problems of this A VF are: 1) congestive heart failure due to its high flow, 2)
difficult hemostasis after venipuncture, and 3) frequent infections related to its
position.
40
4. AVF COMPLICATIONS
4.1. Early coltlplications
Early complications are usually related to the surgical operation and include
hemorrhage, early thrombosis, and infection.
Hemorrhage may be caused by errors in suturing the anastomosis (particularly when an interrupted suture is used) or by incorrect ligation of a vein
branch. It is favored due to the high blood pressure that the fistula always
causes in the vein. This complication requires immediate reoperation; meanwhile, the hemorrhage has to be stopped immediately by inflating a pneumatic cuff above the values of the arterial blood pressure.
Early thrombosis usually occurs within the first 24-48 hours and may be
caused either by inadequate surgical technique or by erroneous choice of the
vessels. The most frequent conditions favoring early thrombosis are: 1) small
size of the anastomosis, 2) stretching of the vessels, 3) marked compression of
the A VF by the sutured skin, 4) presence of a residue of adventitia in the
anastomosis, 5) inadequate removal of vein adventitia, 6) outflow obstruction,
7) use of a calcified artery, 8) use of an artery distal to a severe stenosis and 9)
use of a vein with phlebitis.
The diagnosis is easy and is based on the absence of a thrill when using the
stethoscope or on the absence of flow with the Doppler apparatus. The therapy
is the reconstruction of the anastomosis in the same site or in a more proximal
site.
Infection is a possible but infrequent event. It may affect either the wound or
the anastomized vessels. In the former case, systemic antibiotic therapy and
local treatment may eradicate the infection. More severe is the infection of the
vessels, since it may cause disruption of the anastomosis with the consequent
sudden and severe hemorrhage or the creation of a false aneurysm. Under such
circumstances, an urgent vascular reoperation is necessary. In the case of a false
aneurysm, the artery must be isolated 5-6 cm above the anastomosis to
prevent and/or to dominate the hemorrhage that may arise as soon as the false
aneurysm is touched. No reconstruction is indicated near the infection site.
4.2. Late coltlplications
Late complications of the A VF may arise months or years after the surgical
procedure. They include: reduction of A VF outflow, A VF thrombosis, aneurysm formation, increase of cardiac output, ischemia of the extremity,
painful syndrome, and edema of the extremity.
4.2.1. ReductiOlI
of A VF outflow
Outflow reduction may develop progressively or occur suddenly and may be

caused by phlebitis or by stenosis arising in the artery, in the anastomosis, or in
the vein. Phlebitis may be cured by medical therapy. Stenosis requires a new
angioaccess when the blood flow becomes inadequate for an efficient dialysis.
41
4.2.2. A VF thromhosis
Thrombosis is the most frequent late complication. It is generally caused

by intimal hyperplasia of the venous segment adjacent to the anastomosis
because of blood turbulence across the artery-vein interface. It is a sterile
phlebothrombosis and is accompained by erythema and tenderness of the
tissue around the A VF. A new anastomosis has to be performed a few centimeters proximal to the original fistula. Some individuals prefer using a small
Fogarty catheter, which is introduced through a small phlebotomy near
the anastomosis, to remove the thrombus and enlarge the stenosis. This
maneuver, however, is frequently followed by a new thrombosis, since the
nature of the stenosis is an intimal hyperplasia.
4.2.3. Al1eurysmJormation
An aneurysm may develop at the level of the anastomosis or along the vein.
The venous wall may give rise to an aneurysm because it is subjected to a high
"arterial" blood pressure. Although these aneurysms may appear potentially
dangerous because of their size and anatomic position, only rarely do they
cause serious difficulties; these may be prevented by protecting the aneurism
with a band tightly wrapped at the wrist (as tennis players usually do). If a
surgical operation is indicated, banding of the aneurysm can be attempted;
otherwise, the fistula must be ligated. Aneurysms along the vein may also
occur at sites of repeated venipuncture [7]. In such circumstances, the aneurysm may be removed and substituted by a biologic or prosthetic graft.
Generally there is no reason to discontinue the use of an A VF when another
site of the vein may be utilized for puncturing.
4.2.4. Increase
of cardiac output
Cardiac output may increase with time because of dilatation of the vein and,
subsequently, of the artery. High output cardiac failure may arise. It is,
however, infrequently proven that the A VF is the cause of the patient's cardiac
problems [8]. Consequently, all other possible causes of cardiac failure (such as
primary cardiac disease, volume overload, hypertension, and anemia) should
be investigated prior to attempting manipulation of the fistula.
4.2.5. Ischemia oJthe extremity
Ischemia of the fingers is infrequent in the upper limb and may occur when
radial and ulnar arteries are simultaneously ligated. Distal ischemia may also
occur after the creation of a large anastomosis in a proximal fistula; in this
case, a large volume of arterial blood is shunted into the vein of the arm,
thereby causing peripheral ischemia. A banding of the anastomosis or a new
smaller anastomosis may solve the problem; otherwise the A VF must be
eliminated.
42
4.2.6. The painful syndrome
The painful sydrome is due either to the inclusion of a sensitive nervous branch
in the surgical wound or to the recovery of a hematoma that has followed a
venipuncture and has involved a nervous branch. The latter cause of the
painful syndrome is frequent in the A VF created between the brachial artery
and the basilic vein because of the proximity of the medial cutaneous nerve.
Another type of painful syndrome is the, carpal tunnel syndrome, which is
caused by progressive median and ulnar nerve compression at the wrist. In all
of these circumstances, a surgical operation is the only therapeutic possibility.
4.2.7. Edema of the extremity
Edema of the extremity is due to a venous hypertension. This may occur when
the valves of a lateral branch of the vein become incontinent so that the arterial
blood flows distally to the A VF; the ligation of the venous branch completely
resolves the problem. Severe edema may also occur when the A VF is created
between the brachial artery and one of the venae comitantes, since this type
of A VF is performed when all other vessels are no longer available; thus
the venous circulation becomes inadequate when a deep vein is utilized for
the A VF. This serious complication requires the immediate ligation of the
fistula in order to restore the deep venous circulation. This will solve even
a monstrous edema.
5. SUGGESTIONS FOR A LONG LIFESPAN OF THE AVF
In view of a long-term lifespan for a good A VF, a few rules for its correct use
ha ve to be followed. The main precautions include the disinfection of puncture
sites, the use of adequate needles, correct cannulation of the arterialized vein,
and, finally, general care of the A VF by the patient.
5.1. Disinfection of puncture sites
At the beginning of each hemodialysis, the forearm must be washed with soap
and disinfected with products adequate to prevent infections. At the end of
hemodialysis, the venipunture sites must be covered with a sterile medication.
The use of a bandage surrounding the forearm should be avoided, since
compression of the vein may cause thrombosis.
5.2. Use of adequate needles
Today high-quality needles are available for hemodialysis. In adult patients,

1S-gauge needles are usually recommended. Smaller needles (e.g., 16-gauge
needles) may be used when the vein is small or at the beginning of
cannulations.
5.3. Right cannulation of the arterialized vein
Cannulation of the arterialized vein is undoubtedly an important procedure,

both for the lifespan of the fistula and for adequacy of dialysis. The needles
43
have to be inserted into the vein in the correct direction and fixed in the correct
position. Needle direction differs depending on the vascular network. The
general rule, however, is to put the needles in opposite directions in order to
favor the blood flow coming from and returning to the patient, i.e., the needle
drawing the blood (the so-called arterial needle) has to face the anastomosis,
while the needle carrying the blood back to the patient's circulation (the socalled venous needle) has to face the proximal end of the limb.
The "arterial needle" has to be inserted more distally than, and as far as
possible from, the "venous needle," otherwise the same blood coming back
from the dialyzer is immediately drawn again to the dialyzer (recirculation).
Sometimes, for the nurse's convenience, both the "arterial needle" and the
"venous needle" in the arm are inserted toward the shoulder; particularly in
such cases, it is mandatory to leave an adequate distance between the two
needles, placing the "arterial needle" closer to the anastomosis in order to
avoid blood recirculation.
Generally, the patient prefers always being punctured in the same site of
previous venipuncture, since cicatritial tissue is less painful. This procedure,
however, in the long run, may cause aneurysms, since the vessel wall and the
superficial tissue, at the puncture site, will become thin and dystrophic. In our
opinion, therefore, puncturing different sites of the vein is mandatory.
5.4. General care of the AVF
The patient must protect the arm with the A VF by avoiding 1) tight clothes or
anything clamping the fistula, 2) low temperatures on the arm, and 3) use
of the arterialized vein for intravenous drug administration. Blood pressure
should never be measured in the fistula arm.
A common mechanism of early failure of the A VF is the premature use of
venous outflow. When the vein is "immature" for dialysis, needle punctures,
hematomas, and compression of the venipuncture sites at the end of hemodialysis may compromise the A VF by favoring thrombosis. This complication
is easily avoided by creating the A VF much in advance of the dialysis requirement in order to leave enough time for arterialization of the vein (i.e.,
wall thickening and luminal dilatation).
6. THE EXTERNAL ARTERIOVENOUS SHUNT
The external arteriovenous shunt was the first vascular access for regular
dialysis therapy (see Chapter 2). The main limits of this access are: local and
systemic infections, dislodgement of the cannulas, hemorrage, and frequent
clotting episodes. Although the A V shunt may be useful in obtaining an
immediate vascular access for hemodialysis, its use is no longer justified,
percutaneous femoral, subclavian, or internal jugular vein cannulation being
preferable for this purpose. In our opinion, the only clinical situation for which
it is worthwhile to use an external A V shunt in adult patients is when the
caliber of the cephalic vein is too small to create an A VF at the wrist. In this
44
case, the creation of an A V shunt between the radial artery and the cephalic
vein will allow arterial blood to flow into the vein; in 2-3 weeks, the cephalic
vein will be sufficiently dilated to allow the creation of an A VF proximal to the
shunt cannulas (see Section 2.3 in this chapter).
6.1. The technique
The device (see figure 2-2 in Chapter 2) is made by a straight or curved

silicone cannula and by two Teflon tips that have to be fitted into the cannula,
according to the caliber of the vessels. A straight cannula body is preferred if
placing the shunt at the wirst. For doing this, a trasverse skin incision, 5 cm in
length (the same as for the A VF; see A in figure 3-1), is made close to the wrist
to expose 2 cm of the radial artery and the cephalic vein. The radial artery is
ligated distally, and two ligatures are placed lightly (but not knotted) around
its proximal end. Once the Teflon tip has been fitted into the silicone cannula,
the artery is incised and the tip is gently introduced into its lumen, avoiding
any trauma to the arterial intima. The two proximal ligatures are tied around
the vessel wall surrounding the Teflon tip. The distal ligature is then brought
around the silastic cannula and tied for securing the cannula to the distal
portion of the artery. The cannula body is then brought out through a subcutaneous tunnel. This identical procedure is repeated for cannulating the
cephalic vein, which always accepts a larger sized Teflon tip than the artery.
Once the vessels are cannulated, the cannula bodies are connected to each
other, allowing the blood to flow. Flushing the cannula with heparinized saline
may resolve a vascula spasm, which may compromise the blood flow.
REFERENCES
1. Brescia MJ, Cimino JE, Appel K: Chronic hemodialysis using venipuncture and a surgically
created arteriovenous fistula. N Engl J Med 275:1089, 1966.
2. Mehigan JT, McAlexander RA: Snuffbox arteriovenous fistula for hemodialysis. Am J Sur
143:252, 1982.
3. Adar R, Antebi E, Iaina A, Mozes M: Retrograde arteriovenous fistula for chronic hemodialysis. Vasc Surg 26:99, 1975.
4. Geis WP, GiacchinoJL, Iwatsuki S, Vaz AJ, HanoJE, Ing TS: The reverse fistula for vascular
access. Surg Gynecol Obstet 149:901, 1977.
5. Shapira Z, Shmueli D, Yussim A, Servadio C: Antecubital arteriovenous fistula with reverse
flow. In: Kootstra G, Joming PJG (eds) Access Surgery. Lancaster, England: MTP Press, 1983,
p 313.
6. Enderlin, F, Harder F, Rittman W, Massini MA: Periodische hamodialysen mit thilfe der
arterialisierten vena saphena. Helv Chir Acta 38:346, 1971.
7. Santangelo ML, Di Salvo E, Belli G, Romano G, Manzo E, Tajana G: Haemodialysis and
aneurysms of the upper extremity. Surg in Italy 10:279, 1980.
8. Dal Canton A, Maione S, Russo D, Teti C, Serino C, Gallo R, Andreucci VE: Echocardiographic detection of cardiac effects of arteria-venous dialysis fistula. Clinical Experimental
Dialysis Apheresis 5:346, 1981.
4. AUTOGENOUS SAPHENOUS VEIN GRAFTS

AS VASCULAR ACCESS FOR HEMODIALYSIS
JOHN P. HARRISandJAMES MAY
Procedures for obtaining access to the circulation for hemodialysis should

have two fundamental aims. These are long-term patency and freedom from
complications. These aims can best be achieved by the use of an internal fistula
and the use of autogenous material in its construction. Implicit in this strategy
is the requirement to anticipate the need for hemodialysis and to preserve the
veins of the upper extremities. There is general agreement that the radial artery
to cephalic vein arteriovenous fistula described by Brescia and his colleagues
[1] is the best method of obtaining access to the circulation. There is, however, a significant group of patients whose arteries or veins are unsuitable for
the construction of such a fistula. It was for these patients that the autogenous
saphenous vein graft arteriovenous fistula was introduced by May et al. [2].
There is also a group of patients who have been on dialysis for many years
and a further group of patients who are returning to dialysis as renal grafts fail.
Patients in these two categories are frequently devoid of native veins suitable
for an internal fistula in the upper extremity.
1. INDICATIONS
A saphenous vein arteriovenous fistula may be indicated as a primary procedure or as a secondary procedure for access to the circulation. As a primary
procedure, it is useful in patients with congenitally unsuitable veins. Such
veins may be too small in caliber, too deep for ease of cannulation, or too
tortuous to allow satisfactory positioning of the dialysis canula. In this respect,
Andreucci. V.E. (cd.), VASCULAR AND PERITONEAL ACCESS FOR DIALYSIS.
45
46
. ,
Figure 4- 1. Aneurysmal dilatation in a radial artery to cephalic vein arteriovenous fistula.
it is important for surgeons to recognize that the mere formation of a direct

arteriovenous fistula in the upper extremity is no guarantee of its usefulness for
access . It may also'be indicated as a primary procedure in obese patients where
the native veins are neither visable nor palpable. Thrombosis of the native
veins in the forearm also constitutes a significant indication for a saphenous
vein graft fistula. Occlusive disease of the arteries of the forearm, while not
common, may preclude a radial artery to cephalic vein fistula and may thus
require the use of the saphenous vein.
When a radial artery to cephalic vein fistula fails, it may be possible to reconstruct it. If this is not feasible, a saphenous vein graft fistula is indicated as
the most appropriate secondary procedure. Failure of the primary fistula may
take the form of a thrombosis, a strictured segment that has failed to respond
to dilatation or aneurysm formation, as shown in figure 4-1. A saphenous
vein graft fistula may also be indicated as a secondary procedure when the
primary radial to cephalic vein fistula, although still patent, is either difficult
to cannulate or provides a poor flow on dialysis.
2. SITES OF INSERTION
The saphenous vein graft arteriovenous fistula was originally described as

a forearm loop between the brachial artery and the largest patent superficial
vein in the cubital fossa [2]. The saphenous vein may also be used as a straight
4. Autogenous saphenous vein grafts
47
Figure 4-2. Construction of saphenous vein arteriovenous fistula. Small transverse incisions are
used in constructing the tunnel to avoid longitudinal scarring over the vein graft.
forearm graft or an upper-arm brachial artery to axillary vein conduit [3].

The use of the saphenous vein in the thigh for access has also been described.
One method involves leaving the sapheno-femoral junction intact and anastomosing the mobilized distal saphenous vein to the superficial femoral artery
[2]. The second method involves a loop between the femoral vessels [4]. Although the forearm and thigh are the most commonly used sites for insertion,
other sites, such as the "necklace" site between the axillary artery and the contralateral axillary vein are possible.
3. PROCEDURE FOR INSERTION
The nondominant forearm is the site of choice so that the patient has a free
hand to use while on dialysis. The operation is best performed under general
anesthesia as a combined synchronous procedure with two operating surgeons. While the saphenous vein is removed from the leg, the brachial artery
and a suitable vein are exposed in the cubital fossa. The prepared saphenous
vein is tunneled subcutaneously in a loop on the forearm. Small transverse
incisions are used in constructing the tunnel to avoid longitudinal scarring
over the vein graft (figure 4-2). It is essential that the tunnel is formed directly
beneath the skin for ease of cannulation. It is also essential that the length of
the vein graft conforms to that of the tunnel. Tortuosity of the graft will occur
48
if there is excessive length. Consideration should also be given to the aspect of

the forearm of which the loop is placed. This should be on the anterior aspect,
with the forearm lying in its natural position. Placing the loop in a medial or
lateral position will make self-cannulation with the opposite hand diffIcult for
the patient. The ends of the vein graft are anastomosed end-to-side to the previously prepared brachial artery and vein in the cubital fossa. If there are no
suitable superficial veins, the venae comitantes of the brachial artery may be
used. If there is any doubt about the adequacy of the outflow, a catheter should
be passed proximally through the venotomy to ensure patency of the vein in
the upper extremity. The presence of a pulse in the completed vein loop is an
indication of an obstructed venous outflow, even if accompanied by a bruit.
A thrill and bruit are an indication of a satisfactory fistula. Intraoperative flow
measurement using a square-wave electro-magnetic flow meter is useful to
objectively assess the adequacy of the graft fistula. The mean intraoperative
flow rate in a group of 43 patients reported by the authors was found to be
296 mllmin [51.
4. CARE OF THE GRAFT
Ideally the graft should not be used for access for at least four weeks after insertion. This time allows healing between the graft and the surrounding subcutaneous tissues. If the graft is used before healing occurs, there is a risk of
a perigraft hematoma tracking along the tunnel following removal of the dialysis cannula. The parallel sides of the loop are the preferred sites for puncture.
The site of puncture should be varied for each cannulation to avoid weakening the wall of the graft. On withdrawing the cannula, pressure should be applied to the puncture site with sufficient firmness to prevent bleeding, but not
so great as to stop the flow in the graft. Vein grafts, however, are resilient to
excessive pressure and rarely thrombose due to this cause.
It is now possible to assess fistulas by sonography. Weber et al. [6] have reported the detection of stenoses, partial or complete thromboses, aneurysms,
and perivascular hematomas in 88 patients with clinical evidence of complications. The technique may be used regularly in saphenous vein graft arteriovenous fistulas to diagnose strictures before they become clinically apparent.
5. DURABILITY OF SAPHENOUS VEIN GRAFT ARTERIOVENOUS FISTULAS
The authors have reported a group of 71 grafts used for hemodialysis in 70

patients [5]. There were 44 women and 26 men, with a mean age of 44 12.9
years. The patency data for the 71 grafts is shown in table 4-1. The cumulative patency rates are shown in figure 4-3. Sixty six percent of the grafts were
patent at two years and 40% at three years. Renal transplantation was performed in 29 patients with a functioning vein graft. The remaining 41 patients
with 42 vein grafts did not receive a renal transplant. The patency rates for
the two groups are shown in figure 4-4. There was no statistically significant
difference in the cumulative patency rates for the two groups. Other series
49
100
90
80
70
60
PATENCY
(%)
50
40
30
20
10
12
18
TIME
24
30
36
42
48
(Months)
Figure 4-3. Cumulative patency of 71 saphenous vein arteriovenous fistulas. From May et al:
Am J Surg 140:387-390, 1980, with permission.
have demonstrated similar satisfactory results. Lomoy et al. [7] reported a

58% cumulative patency rate at five years and a 38% patency rate at eight
years for 20 patients with saphenous vein graft arteriovenous fistuals in the
arm. Valenta et al. [4] also reported a cumulative patency rate of 62% at six
years. The loop configuration has been questioned by Haimov et al. [3]. He
found that forearm loop grafts had a marked tendency to thrombosis, with a
patency rate of 7% at 24 months compared to 75% at the same interval for
the straight vein graft in the forearm.
6. COMPLICATIONS
Despite deaths due to other causes, no death was directly related to either
anesthesia or surgery for the construction of a saphenous vein graft arterioveTable 4-1. Life table data of71 saphenous vein arteriovenous fistulas
Interval
(months)
Duration
No. of
Occlusion Patency Cumulative Standard
grafts
Grafts
No. of of
error (%)
rate (%) rate (%)
at risk occluding deaths followup rate (%)
0-6
6-12
12-18
18-24
24-30
30-36
36-42
71
56
40
29
17
10
2
7
7
4
1
2
2
0
8
6
3
0
1
2
0
0
3
4
11
4
4
2
10.4
13.6
11.0
4.3
13.7
28.6
0.0
89.6
86.4
89.0
95.6
86.3
74.4
100.0
89.6
77.4
68.9
66.0
57.0
40.7
40.7
3.7
5.4
6.2
6.6
8.7
11.4
11.4
50
100
Transplant Group
Non-transplant Group
90
80
70
60
PATENCY
(%)
50
40
30
20
10
12
18
TIME
24
30
36
42
(Months)
Figure 4-4. Cumulative patency rates for 42 saphenous vein arteriovenous fistulas in patients
who did not receive a renal transplant compared to 29 similar fistulas in patients who did receive
a renal transplant. From May et al: Am] Surg 140:387-390, 1980, with permission.
nous fistula. Three patients required ligation of grafts for infective complications. All had episodes of septicemia. Cannulation sites were infected in two
patients, and a generalized thrombophlebitis of the graft occurred in the third.
Two patients developed "steal" syndromes that required ligation of their
grafts. Both had severe ischemic symptoms, but neither developed gangrene
or ischemic ulceration in the affected arm. There were no hemodynamic cardiac
complications due to excessive flow through the fistula. In two patients,
however, graft occlusion was associated with low cardiac output due to pericardial effusion. No patient developed graft stenosis or false aneurysm in the
reported series, but these have been seen subsequently.
7. MANAGEMENT OF COMPLICATIONS
7.1. Infection
Prophylaxis is the best treatment for infection. Scrupulous attention to asepsis

should be instilled in both dialysis staff and patients. Many infections begin
as paragraft hematomas, which serve as an ideal media for bacteria. Careful
hemostasis following withdrawal of the cannula is therefore an important
measure in preventing infection. Infections at cannulation sites should be cultured for organisms and their sensitivity. Should the infection progress to a
paragraft abscess, this can be treated by drainage and antibiotics. The majority
of these infections will then heal. This represents a major difference and advantage of vein grafts compared to prosthetic grafts, which require removal of
the graft to cure the infection. Should purulent infection involve the anastomotic site to the major artery, ligation of the artery is the safest course. In the
51
case of the brachial artery and the superficial femoral artery, this can usually
be done without interfering with the viability of the limb.
7.2. Steal syndrome
The flow through a saphenous vein arteriovenous fistula is of the order of 300
mllmin. In a patient with a normal arterial supply to the limb, this will not
produce a "steal" syndrome. These syndromes usually occur in patients with
defective circulation or occasionally is due to ectasia of the graft and its feeding
artery. An arteriogram should be performed to determine any inadequacies
in the distal circulation. If the steal occurs immediately after insertion of the
graft, technical error at the arterial anastomosis should be excluded. Similarly,
an acute thrombosis in the artery immediately distal to the anastomosis may
be responsible. If the steal develops in a more chronic manner, distal obliterative arterial disease is usually responsible. The options at this point are to
either close the fistula or to attempt to reduce the flow in it. In the authors'
experience, the latter is difficult due to the fine line between reducing flow
through the graft and totally occluding it. Whatever the treatment, it is desirable that it should be performed early to avoid any permanent distal ischemic
damage.
7.3. Stricture
Stricture formation should be treated by percutaneous balloon dilatation in

the first instance. Localized strictures respond well to this form of treatment
(figure 4-5). Dilatation of extensive or multiple strictures, however, is often
disappointing. These situations usually require excision of the involved segment of the vein graft and replacement with a new piece of saphenous vein.
The surgeon should be mindful of the need to leave the remainder of the vein
graft free for continuing access. This can usually be achieved by the use of
small transverse incisions. An upper-limb vein may be used for these short
replacement segments, but it has a greater tendency to dilate compared with
saphenous vein, as shown in figure 4-6.
7.4. Aneurysm formation
Aneurysm formation in saphenous vein grafts is rare but can occur. False aneurysm formation can usually be repaired by closing the defect in the side of
the vein graft with an autogenous vein or a direct suture. Fusiform aneurysmal dilatation requires replacement of the involved segment with an autogenous vein graft.
8. COMPARISON WITH PROSTHETIC ARTERIOVENOUS FISTULAS
The authors have reported their experience with 50 polytetrafluoroethyene

(PTFE) grafts [8]. They compared these with 70 patients who had saphenous
vein grafts for vascular access. The comparison was based on patency and
complication rate. The age and sex distribution was similar in both groups.
52
Figure 4-5. Localized stricture at the apex of a saphenous vein graft arteriovenous fistula
successfully treated by balloon dilatation. Smaller photographs show passage of the guide wire
and progressive dilatation to a normal lumen.
Twenty of the PTFE grafts were 8 mm in diameter and were placed in the
forearm. The remainder were 6 mm in diameter and were placed in the thigh.
The loop configuration was used in all thigh grafts and 17 of the 20 forearm
grafts. Figure 4- 7 shows the cumulative patency rate of the PTFE grafts superimposed on that depicting the patency of the saphenous venous grafts in
figure 4-3. At 18 months, the patency rate was 69.8% for PTFE grafts and
68.9% for vein grafts. The difference is not statistically significant. Of the 12
PTFE grafts that failed, seven thrombosed spontaneously, while the remaining five were surgically ligated for complications. The most serious complications in the PTFE grafts were purulent infection at the cannulation sites,
requiring ligation of the artery of supply in three patients, distal ischemia requiring further operation in three patients, and nerve paralysis in two patients.
Table 4-2 compares the complications in vein grafts and PTFE grafts. It
can be readily seen that the complication rate is far greater in the PTFE grafts.
9. DISADVANTAGES OF SAPHENOUS
VEIN GRAFT ARTERIOVENOUS FISTULAS
By providing a similar patency rate but a very much lower complication rate,
saphenous vein grafts would appear to be superior to prosthetic grafts. There
are, however, some disadvantages in the use of the saphenous vein as the graft
53
Figure 4-6. A segment of th e upper-limb vein has been used to repair this saphenous vem
arteriovenous fistula. The upper-limb vein (arrow) has a greater tendency to dilation.
100
90
80
,,
\,~
\
70
...~
-0
60
PATENCY
(%)
50
40
0--0
30
20
_ 0 Saphenous
0----0
Vein
P.T.F.E.
10
12
18
TIME
24
30
36
42
48
(Months)
Figure 4-7. C umulative patency rate of 50 PTFE grafts and 71 saphenous vein arteriovenousfistulas.
54
Table 4-2. Complications of71 autogenous saphenous vein

and 5U polytetrafluoroethylcne (PTFE) arteriovenous fistulas
Complications
Vein grafts (%)
PTFE grafts (%)
Infection
Inflammatory response
Distal ischemia
False aneurysm formation
Nerve paralysis
Graft stenosis
Bleeding
4.2
10
10
6
2.8
o
o
o
o
6
4
2
material. Because of the leg wound and the desirability of suction drainage,
the patient is in the hospital for a longer period when the saphenous vein is
used. Cannulation of the saphenous vein graft is marginally more difficult
than cannulation of a prosthetic graft. It has also been claimed that hemostasis
after removal of the cannula is more difficult with vein grafts. The authors,
however, have not found this to be a problem.
10. CONCLUSION
The provision of near complication-free, long-term access makes the saphenous vein graft arteriovenous fistula the procedure of choice in selected patients
undergoing primary procedures and in all patients requiring secondary procedures for hemodialysis.
REFERENCES
1. Brescia M], Cimino ]E, Appel K, Hurwich BJ: Chronic haemodialysis using venipuncture and
a surgically created arteriovenous fistula. N Engl] Med 275: 108<), 1966.
2. May], Tiller D, ]ohnson], Stewart], Sheil AGR: Saphenous vein arteriovenous fistula in regular dialysis treatment. N Engl] Med 280:770, 1969.
3. Haimov M, Burrows L, Baez A, Neff M, Slifkin R: Alternatives for vascular access for haemodialysis: Experience with autogenous saphenous vein autografts and bovine heterografts.
Surgery 75:447-452, 1974.
4. Valenta], Bilek], Opatrny K: Autogenous saphenous vein graft as a secondary vascular access
for haemodialysis. Dial Transplant 14:567-571, 1985.
5. May], Harris], Fletcher J: Long term results of saphenous vein graft arteriovenous fistulas.
Am] Surg 140:387-3<)0, 1980.
6. Weber M, Kuhn FP, Quintes W, Keidl E, Kohler H: Sonography of arteriovenous fistulae in
haemodialysis patients. Clin Nephrol 22:258-261, 1984.
7. Lornoy W, Becaus I, Gillardin ]P: Autogenous saphenous vein A V fistulas for haemodialysis:
Eight years experience with thirty patients. Proc Eur Dial Transplant Assoc 19:227-233, 1<)83.
8. May], Harris], Patrick W: Polytetrafluoroethyene (PTFE) grafts for haemodialysis: Patency
and complications compared with those of saphenous vein grafts. Aust NZ] Surg 49:639-642,
197<).
5. BOVINE HETEROGRAFT AND UMBILICAL

CORD GRAFT FOR ARTERIOVENOUS FISTULAS
JOHN L. HUSSEY
In the last half century, hemodialysis has steadily progressed to primary therapy for end-stage renal disease. The significant but still limited success of
vascular access procedures can be attributed directly to innovative advances
designed to provide a state of chronic vascular usability. However, this goal
has been elusive and remains the Achilles heel of the chronic dialysis patient.
Initially, hemodialysis was usually accomplished by percutaneous cannulation of appropriate blood vessels. This limited technique was discarded because of complications resulting from repetitive vascular puncture. In the late
1940s, Alwall and coworkers [1] first attempted a glass shunt bridging between
arteries and veins to gain more permanent vascular access. This failed because
of frequent clotting. In the late 1950s, O'Brien and coworkers [2] unsuccessfully attempted heparinized intravenous Teflon tubes for arteriovenous (A V)
cannulation. The first major contribution was by Scribner et al. [3] in the early
1960s, when external shunts were developed and used with repetitive success.
Chronic maintenance dialysis became a practical reality. The landmark work
of Cimino [4] and Brescia and coworkers [5] in establishing the gold standard
of A V fistulization for dialysis purposes was reported in 1966. In certain
patients, the Cimino-Brescia, or so-called wrist fistula, provided nearly ideal
vascular access for chronic hemodialysis and hence was a significant advance in
treatment of end-stage renal disease (ESRD), thus giving hope to thousands of
patients. But patients with vessels unsuitable for Cimino A V fistulization
remained a pathetically untreatable group. Early in the evolution of hemodiAndreucci. V.E. (ed.), VASCULAR AND PERITONEAL ACCESS FOR DIALYSIS.
55
56
alysis, patients were carefully chosen and dialysis was offered only when a
Scribner shunt or Cimino fistula (i. e., chronic vascular access) could be
performed and utilized with repetitive certainty and longevity. As the dialysis
population expanded, patients younger than 20 and older than 40 years of age,
and those with inadequate vasculature, were considered for dialysis. All too
commonly, the available access procedures, i.e., the external shunts or Cimino
fistulas, were inadequate for pediatric, geriatric, and diabetic individuals.
Hence, innovative experimentation began, using various conduits for vascular
access. Conduits other than biologic grafts are discussed elsewhere in this
book. However, this chapter will deal specificially with the placement, utilization, and results of carefully prepared bovine heterografts and intact and
modified human umbilical vein grafts for hemodialysis purposes.
Before discussing biologic conduits as A V fistulas for hemodialysis purposes, it is important to keep in mind the characteristics of an ideal dialysis
conduit. The ideal prosthesis should be readily available, have a long shelflife,
be easy to handle, have a high patency rate, resist infections and biodegradation, have no antigenicity, be antithrombotic at its blood interfaces, maintain
its structural integrity despite numerous needle punctures, remain soft and
pliable for ready needle access, have no tissue reaction for ease of reoperation
and revision, and be inexpensive. The ideal conduit structure has not yet been
identified. Some recently developed synthetic polymer textile grafts may more
closely approach these ideal characteristics than the biologic grafts discussed
in this chapter.
1. BOVINE HETEROGRAFTS
Introduction of the modified bovine carotid artery heterograft expanded A V

access via internal conduit shunting. By careful processing, the heterograft
was converted to a nonantigenic, primarily collagen tube permitting repetitive punctures for chronic maintenance hemodialysis. Several articles describe
the development, use, and complications of modified bovine arterial heterografts in the treatment of end-stage renal disease by chronic hemodialysis
[6-25].
Bovine carotid heterografts are conduits prepared from cow carotid arteries
from which musculoelastic tissue has been removed by the enzyme thycin.
The remaining tissue, consisting of over 76% collagen, is tanned with a dialdehyde starch. Most grafts range up to 50 cm in length and have a 7-14 mm
diameter. Histologic studies of these grafts implanted both in dogs and in
humans have demonstrated that bovine heterografts are suitable as nonliving
substitutes for arteries. Haimov and Jacobson [12] used 31 grafts as hemodialysis conduits and found them preferable to autogenous saphenous veins for
dialysis conduits, though vastily inferior as arterial replacements.
The first reported use of a modified bovine carotid artery as a vascular substitute in a dog was published in 1956 [26]. The first implanation in humans
was done 6 years later [27]. As early as 1972, Rosenberg [28] indicated that
5. Bovine heterograft and umbilical cord graft
57
3000 modified bovine heterografts had been placed in patients. With the exception of a few favorable clinical reports, the results from the majority of
these grafts have not been reported. It is suspected that the unfavorable experience of Haimov and Jacobsen with bovine grafts as arterial replacement
and dialysis conduits, especially when used as looped grafts in the forearm,
was not unique.
Vascular conduits for bypass or replacement of arteries, or for hemodialysis
purposes, have been placed in almost every conceivable anatomical site that
the imagination of the innovative surgeon can provide. Although the looped
forearm graft is most common, occasionally more exotic sites have been
utilized. Garcia-Rinaldi and Vonkoch [29] described subcutaneous tunneling
from the axillary artery to the contralateral axillary vein across the manubrium
of the sternum. This author (Hussey) has utilized that procedure in several
instances and has referred to the procedure as the necklace. Although both
Garcia-Rinaldi and I have found it satisfactory, it is a procedure oflast resort
involving the use of major vessels and hence is prone to major complications
from clotting, infection, aneurysm formation, graft disruption, etc. As such,
it is recommended only as a "last ditch" effort to obtain vascular access.
Salmon [30] reported experience at the University of Alberta, Canada with
the use of bovine and polytetrafluoroethylene (PTFE) conduits over a 31!2
year period during which 100 grafts were placed. The survival of primary
and secondary grafts is shown in tables 5-1 and 5-2 [30]. The percentage
of survival is appreciably lower for bovine grafts (68% primary and 38%
secondary) than for PTFE grafts (87% primary and 100% secondary). The
Table 5-1. Survival (in months) of primary grafts
Graft survival
Graft type
No. of patients
No. of grafts
Mean
Range
Patient survival
(%)
Bovine
Gore-Tcx
IMPRA
56
15
29
56
15
29
22
9.77
6.95
1-44
1-18
0.5-25
68
87
90
82
87
93
Used with permission from Salmon [30].
Table 5- 2. Survival (in months) of 16 secondary grafts in 11 patients

Graft survival
Graft type
No. of grafts
Mean
Range
Bovine
Gorc-Tex
IMPRA
8
7
1
15.4
11.7
1-32
1-36
Used with permission from Salmon [30].
Patient survival
(%)
38
100
100
100
100
100
58
100
,.
90
...
Z
UJ
80
70
a:
UJ
II.
60
50
40
2 4
8 1012 14 16 1820222426 283032343638 40

MONTHS
Figure 5-1. Failure rate of bovine grafts over a 3-year period. Used with permission from
Salmon [30].
incidence of complications, particularly thrombosis, aneurysm formation,

and infection, was much higher in the group with bovine grafts. Stenosis of
the graft-vein anastomotic sites was seen frequently, although Salmon reported a less frequent instance of graft-artery stenosis. Salmon noted that the
failure rate for bovine grafts (figure 5-1) was high and relatively steady for
the first 16 months after implantation. At that time, 58% of the grafts had
failed.
Salmon [30] stated that while the bovine graft has permitted long and successful dialysis, an unduly high incidence of complications is associated with
its use. However, a revision, replacement, or modification of the graft in
many instances saved the functional integrity of many grafts and maintained
the original site of graft placement, hence preserving graft life. Finally, the
author concluded that "in view of their results, bovine grafts are no longer
used" (p. 63) for vascular access purposes. This opinion is enthusiastically
shared by this author.
2. HUMAN UMBILICAL VEIN CONDUIT FISTULAS
Essentially two types of human umbilical vein grafts developed in recent years
have received adequate clinical trials and comments in the literature - the
Meadox and Bioflow grafts.
2.1. Modified human umbilical vein graft (Meadox graft)
The first of these to be discussed is the modified human umbilical vein graft,
the so-called Meadox graft developed by Drs. Irving and Herbert Dardik in
conjunction with Meadox Medicals, Inc. Through considerable experimental
investigation and widespread clinical use [31-37], they have reported successful use of the Meadox graft for arterial reconstruction. Additionally, in both
59
animals and humans [37], the graft has had a significant role as a mode of
angioaccess in hemodialysis.
Experimental studies, largely by Dardiks' group [32, 37-40], indicated that
the modified vein graft, that is, the umbilical vein graft devoid of umbilical
arteries and its surrounding tissue and without external support of any kind,
was subject to biodegradation, aneurysm formation, infection, and short patency and was an inadequate conduit for dialysis purposes. However, modified
human umbilical cord veins, initially surrounded by a Dacron sleeve and later
by a Teflon mesh, seemed to correct some of the problems of the unsupported
umbilical veins.
Dardik biografts are obtained from human umbilical cords under sterile
conditions, tanned with glutaraldehyde, and stored in 70% ethanol. The tanning process doubles the tensile strength and improves the graft's sutureholding capacity, while making it more immunologically inert, resisting
biodegradation. Through Meadox Laboratories, it became readily available in
lumen diameters ranging from 4 to 6 mm and lengths of 20 to 50 cm or more
that were easily stored. The current product is supported by a sleeve of polyester mesh to prevent dilatation. Unlike saphenous vein conduits, the graft
has no valves or branches that might present complications at the time of
implantation. Probably the greatest contribution to the use of this graft for
dialysis purposes is the polyester sleeve-supporting mesh that serves as a matrix through which collagen deposition occurs [33]. Examination of the surface
intima at the time of excision of the graft showed little or no endothelium,
but a neointima was shown to be present after several weeks of implantation.
The critical surface tension in the biocompatible range of20 to 30 dyn/cm was
maintained in experimental studies. Additionally, the graft retained its architecture for up to six months or longer with no evidence of cellular rejection,
and a contraction condensation of graft collagen occured with time, forming
an outer capsule at the polyester mesh interface.
The Meadox modified graft, the modified human umbilical cord vein graft,
has been very easy to use, being both pliable to position and easy to suture
because of the lack of thick surrounding tissue. Hence, the initial operative
procedure is performed with ease, and revision appears technically easier than
with the bovine heterograft. The problem of obstructing the graft technically
or by external compression (i. e., via serum or lymph) may result in a compromised flow and graft failure. Additionally, inadequate vessels (both inflow and outflow), erroneous vessel selection, and thrombosis leading to graft
failure are current problems with all conduit dialysis fistulas. Some problems
encountered in the Dardik studies might have been avoided by creation of
straight fistulas instead of loops and by a superior tunneling technique, substituting a tunnel of external diameter approximately the size of the graft for
the larger indiscriminate tunnel pockets originally used.
In a study by Wellington [41] published in 1981, he discussed his 26-month
experience with the Meadox graft used on 23 occasions in 21 patients. He con-
60
cluded that these early results suggested it was a satisfactory prosthesis for
chronic dialysis patients. He added that the greatest difficulty with these grafts
was encountered at reoperation, where a dense fixation to soft tissue was encountered, making thrombectomy, graft revision, or graft removal extremely
difficult.
The longest and largest clinical series utilizing the Meadox graft was reported by Dardik et al. [42]. In this study, from November 1975 to April
1983, 756 glutaraldehyde-stabilized umbilical vein grafts were implanted.
Although the primary indication for such implantation was not angioaccess
for hemodialysis purposes, but rather severe peripheral vascular disease requiring bypass grafting or arterial replacement, some of the observations
made in this long and extensive study also apply to the Meadox A V fistula
graft.
Aneurysm formation was a common occurrence. Two distinct morphologic types of aneurysms were identified. The first consisted of actual dilation
of the graft and the polyester mesh. The second was attributed to graft erosion, with stretching and rupture of the polyester mesh resulting in multiple
false aneurysms of the graft. This second result has limited usefulness of the
grafts for long-term hemodialysis patients. Furthermore, graft aneurysms
were greater in patients with aneurysmal disease than in those with obliterative disease. An additional problem noted was a relatively high incidence of
early biodegradation, which resulted not only in graft aneurysms but also
decreased blood flow and thrombosis. The mechanisms of degradation and/
or aneurysmal formation are currently unknown; however, physical forces
causing fatigue of the umbilical vein and the supporting mesh seem to be reasonable possibilities, and additional factors also may be operative. Because
the suture commonly used over the past 7Vz years has been the expanded polypropylene (Prolene) suture, known for its elasticity, it was postulated than
anastomotic aneurysms could be caused by the elastic properties of the suture.
It may be that as a more refined suture is available, this problem will be resolved. Similarly, the role of processing and storing these biologic grafts is
unknown. Perloff[43] has shown residual immunologic reactivity using glutaraldehyde and has shown that such morphologic changes are related, at least
in part, to the concentration of glutaraldehyde employed in processing the
grafts. Tilson [44] is currently looking at the possibility that a sex-linked inaccuracy of the enzyme lysyl oxidase resulting from copper deficiency may
lead to deficient collagen and elastin cross-linkage and perhaps aneurysm formation. This was noted in the Dardiks' work in patients predisposed to aneurysmal formation of their own vessels, who demonstrated an increased risk
and incidence of graft aneurysms and degradation [42]. These investigators
admit the reasons for these phenomena remain speculative but postulate that
different rates of lipid disposition and inhibition may playa role.
The author concluded that although the modified human umbilical cord
vein graft is a definite advance in conduit utilization for hemodialysis pur-
100
61
.t
80
70
I-
60
U
II:
50
...w
40
30
20
10
0
2
10 12 14 16
MONTHS
18 20 22 24
Figure 5-2. Comparison of Bioflow and bovine graft survival over a two-year period. Used
with permission from Mindich et al. [46].
poses, it still represents a less than optimal prosthesis for the needs of patients
with end-stage renal disease. However, the author acknowledges the tremendous investigational interest, both animal and clinical, that has resulted in the
increased understanding of conduit A V fistulas used for hemodialysis.
2.2. Intact human umbilical vein graft (Bioflow graft)
The second type of human umbilical vein graft to be discussed, the Bioflow
graft (figures 5-2 and 5-3) [45], was developed by Genetic Laboratory, Inc.
and has been investigated extensively by Mindich et al. experimentally [46]
and by Hussey clinically [47, 48].
In 1973, Mindich and coworkers [46] utilized human umbilical cords obtained from normal deliveries for vascular replacement and access for hemodialysis. This human umbilical cord vein allograft (HUCV AG) offered a
valveless, unbranched, intimal-lined, biologic allograft conduit. Using the
intact cord with the umbilical arteries and supporting adventitia remaining
with the vein, the investigators postulated that prosthetic support (i. e. Teflon
mesh, etc.) was not necessary to prevent graft aneurysm formation so common in thc bovine and Meadox grafts. HUCV AGs are modified by sequential
treatment with 95% ethanol and 1.3% dialydehyde starch, and are stored in
75% ethanol. Tensile-strength measurements of the HUCV AG ranged between those of canine aorta and bovine heterograft. Interestingly, surface
clotting was prolonged to four times that of preclotted Dacron velour and
twice that of a bovine carotid heterograft. Microscopic examination of removed grafts showed a smooth surface intima with neither fibrin deposition
nor evidence of rejection. The grafts demonstrated excellent basic qualities
as a vascular substitute when used, removed, and examined several weeks
62
100
- - - - - M '
I . _.Iotlow ar.tt
........... M.,t , 76-a.w'". gr.n.
" ..... t.7,; A,clt ,.,,_
90
V.I, t,a
_ _ " , at - wl Gt.U.
80
"0"0, :It
_ wl ...
Gr.tu
... ,. , '71; IGIO
70
~
80
50
40
a:
CL
vol. '4'
oe
30
20
10
0
10 12 14 16 18 20 22 24
MONTHS
Figure 5-3. Comparison of Bioftow and bovine graft survival over a two-year period. Used
with permission from Mindich et al. [461
after implantation. Similarly, the graft seemed to tolerate repetItIve percutaneous punctures much better than the bovine carotid heterograft or Dacron
velour grafts. Results suggested that the HUCV AG was readily available,
had a long shelf life, and was suitable as an A V fistula for blood access in
maintenance dialysis.
I [47] compared 30 Bioflow grafts with a similar group of 31 carotid heterografts. At 24 months, 19 Bioflow grafts (63%) were functional. Of the
bovine grafts, 40% were patent in the same 24-month period. Both bovine
and HUCV AG tended to fail at approximately the same time until about ten
months following implantation. At that point, the patency rate of the bovine
graft slowly decreased to about 40%, as opposed to some 55% to 60% patency for the umbilical vein graft, with stable results for the latter prosthesis
over the ensuing 12 months (figure 5-3). Experience with the bovine heterograft compares favorably with that reported by Hertzer and Beven [49] in
1978, in which the two-year patency rate for 75 bovine grafts was 40%, and
with the results of 21 grafts implanted by Rolley et al. [20] that had a twoyear patency rate of only 15%. In my experience, umbilical graft loss resulted
from graft thrombosis in four patients. Three grafts lost clotted, probably
primarily due to inadequate vessel inflow or runoff, and one clotted following
the discontinuance of platelet inhibitors such as aspirin. I advise platelet inhibitor anticoagulation in all prostheses for dialysis purposes, whether they
are bovine heterografts, umbilical vein grafts, or textile grafts. Three patients developed generalized sepsis unrelated to the graft; one of these became
hypotensive and developed graft thrombosis. Bleeding and hematoma formation occurred in one patient one week postoperatively due to early dialysis
use. One graft eroded through the skin because of improper closure of counterincisions then being used for tunnel placement.
63
Although my series of 30 umbilical vein grafts was small, I concluded that

the two-year survival rate was comparable to rates for the synthetic prostheses
and superior to other biologic grafts [47]. Further, in measuring flow rates
in the biologic grafts in seven patients, I found that with the graft flow high
(greater than 1000 mlimin), all grafts remained open, while grafts with flows
less than 66 mllmin tended to clot frequently, regardless of the routine anticoagulation therapy used. I concluded that the human umbilical cord vein
graft (Bioflow) was a step forward in the search for an ideal prosthesis for
hemodialysis purposes.
The intact umbilical cord graft for vascular access has several unique advantages: 1) It is unbranched, hence inadvertent hematoma formation from an
unsecured branch is impossible. 2) The intimal lining is intact and hence more
thromboresistant. 3) The elasticity inherent in a normal umbilical cord is
believed to remain intact and to confer resistance to unwanted neointimal
formation. 4) A precurved stylet, present only with the Bioflow graft, allows
easier placement in the common configuration of the forearm and thigh without risk of obstruction due to inadvertent twisting or improper positioning
within the subcutaneous tunnel. 5) A shelf life of more than two years and a
variety of diameters, 4 to 10 mm, and oflengths, 30 to 50 cm, allow for greater
flexibility in use of the graft. 6) The tapered graft provides more control in
regulating graft flow and may prevent "steal" syndromes seen in patients
with advanced diffuse arterial atherosclerosis and diabetes. The elasticity and
wall thickness of the graft renders it relatively leakproof after puncture, reducing hemorrhage and the likelihood of infection and pseudoaneurysm formation.
An important conclusion is that the technique of placement of any conduit,
especially biologic conduits such as the Dardik and Bioflow grafts, may be
one of the most important aspects in the overall longevity of grafts.
3. CONDUIT PLACEMENT
While the vessels and tunnel are being prepared, the conduit graft is removed
from its container and all of the preservative solution discarded. The graft is
liberally rinsed with normal saline, then allowed to soak in a solution containing 250 ml of normal saline and 25,000 IU of heparin and 25,000 IU of
penicillin for at least 30 minutes. This is performed empirically in an effort to
completely remove the preservative and to provide some degree of antisepsis
and anticoagulation.
After soaking in the solution, the graft is carefully blotted dry. The precurved shape of the Bioflow grafts allows a gentle, unobstructed curvature for
a looped placement in the forearm. The most common placement for vascular
access conduits for hemodialysis is in the volar surface of the forearm. In fact,
our first choice for conduit vascular access is a forearm loop with an end-toside anastomosis of the brachial vessels 2 cm below the antecubital fossa. After
the suitability of antecubital vessels is determined by inspection and palpation,
the position of the graft is outlined on the volar surface of the forearm by means
of a sterile marking pen; the direction of blood flow is appropriately marked
64
Figure 5-4. A: marking proposed position of looped forearm graft; B: conduit marking.
on the arm to aid dialysis technicians in needle placement (figure 5-4A). Similarly, the graft is marked with a methylene blue pen for placement purposes.
To ensure a heavy, straight line, the graft is marked on a flat, hard surface
while the wall is compressed against that surface (figure 5-4B). The umbilical
arteries and supported cord tissue can be seen to swirl around the Bioflow
graft but do not hinder marking the graft. I have found it extremely useful to
inject an antibiotic solution subcutaneously. A broad-spectrum cephalosporin
is commonly used. This accomplishes several things: 1) It infiltrates the surrounding tissues through which the tunnel will be made and greatly reduces
the probability of infection. 2) It tends to push away superflicial veins and
nerves in the tunnel area so that these will not be injured during the formation
of the tunnel or the passage of the conduit through the tunnel. 3) It hinders
bleeding in the tunnel by compressing the small vessels that might be torn
during graft placement in the tunnel. This can be easily accomplished using a
60 cc syringe and an 18-gauge spinal needle.
With the position of the conduit outlined on the forearm, the needle is
placed subcutaneously and an antibiotic in an isotonic saline solution is injected along the proposed tunnel route (figure 5-5). A counterincision is made
below the apex of the graft loop to facilitate placement of the graft (figure
5-6). With the tunnel site well defined, a modified chest-tube trocar (size 32)
Figure 5-5. Subcutaneous injection of antibiotic along proposed tunnel.
Figure 5-6. Incisions to aid proper conduit placement.
65
66
Figure 5-7. A: trocar tunneler in place with marked graft attached and slightly distended;
B: graft sutured to trocar tunnel.
can be gently insinuated subcutaneously through the solution-raised area so

that an appropriate tunnel is created. This must be carried out very carefully,
especially at the apex of the tunnel, to ensure that adequate space is provided to
prevent obstruction of the conduit and yet not so much as to allow unwanted
dead space in which serum or lymph can accumulate, increasing the possibility
of infection.
With the conduit gently distended by a heparinized antibiotic solution,
and care taken not to overdistend the graft, the conduit is sutured to the tunneling trocar and pulled into the tunnel (figures 5-'-7 A and 5-7B). The line
previously drawn on the conduit is carefully observed as it passes through the
tunnel to be sure that it remains in proper position and does not obstruct the
graft (figure 5-8). By means of sequential passage of the tunnel trocar and
careful manipulation of the graft, one can achieve a hand-in-glove fit of the
graft into the subcutaneous tunnel. No attempt is made to strip the umbilical
arteries from the biograft, even for a short distance, in order to avoid altering
the tensile strength of the umbilical vein graft. The umbilical arteries and
supportive tissue can be excluded from the anastomosis by careful technique.
Anastomosis of the bovine and Meadox grafts is accomplished in the routine
manner. The polymer sleeve support of the Meadox graft is incorporated
into the anastomosis. The graft is checked for patency after its placement by
67
Figure 5-8. Technique of conduit placement in prepared looped forearm tunnel.
injection of heparinized antibiotic solution. With a gentle pulselike motion

of the syringe, the exact position of the graft can be palpated to be sure that
it is appropriately placed subcutaneously for dialysis purposes. Rapid flow
with little resistance indicates the graft is not partially obstructed (figure 5-9).
High resistance and low flow may result in obstruction and failure of the graft
for dialysis purposes.
The ends of the graft are beveled using a hemostat guide and sewed endto-side to the selected vessels (figure 5-10) using an appropriate monofilament Gor-Tex suture (CV-7 TT-13) in a standard running manner. We have
found Gor-Tex suture to be superior to Proline because it is easier to tie, has
greater tensile strength, and lacks the annoying elastic memory of Proline,
and because its construction of needle-to-suture ratio minimizes needle-hole
bleeding. The venous anastomosis is carried out first to prevent prolonged
ischemia of the arm.
Upon completion of both anastomoses, the vascular clamps are released,
with the expectation of a palapable thrill and audible bruit if all is well (figure
5-10). Elective dialysis using the graft can begin approximately 2 to 3 weeks
later in all conduits.
Patency rates of the various conduits described in this chapter have ranged
from 70% [46] to 15% [20]. Usually, the arm is utilized first, reserving the
68
Figure 5-9. Pulse injection of solution demonstrating free flow versus no obstruction.
leg or other areas for more desperate situations, as complications in the thigh
and groin involving major vessels are much more common and difficult to
control. In my experience, grafts 6 to 8 mm in diameter usually allow proper
flow with few unwanted side effects. However, diabetic patients, patients
with severe peripheral vascular disease, and elderly patients may develop vascular steal syndrome. This can often be controlled by careful banding procedures. The newer, tapered PTFE grafts seem to offer an added advantage of
preventing the steal syndrome over the bovine, Meadox, and Bioflow grafts.
Graft infection is a major complication. Although infiltration of the tissues on the forearm with appropriate antibiotic solution has been mentioned,
when infections occur they generally are of two types: gram-positive and
gram-negative. The gram-positive infections often can be treated by incision
and drainage of the abscess along the track with the use of local wound irrigation and appropriate systemic antibiotics. About 70% of such infections can
be cleared and the graft perserved. However, the gram-negative organisms
seem to involve the graft substance itself and are more resistant to local treatment, as they tend to migrate toward the anastomotic site, possibly resulting
in major hemorrage or thrombosis. Most gram-negative infected grafts have
been lost despite intensive antibiotic treatment and local care. When removal
69
Figure 5-10. Hemostat guide (to right) to help bevel graft. Note incision under hemostat so
conduit end is not crushed.
of a graft is determined, it is important that local sepsis be controlled with

appropriate antibiotics utilized for 24 to 48 hours, if possible, before removal of the graft. At surgery, the entire graft should be removed, with closure
of the arteriotomy either by direct suture or autologous vein patch grafting,
whichever is appropriate. Interestingly, I have observed that it is common
for collateral blood supply to the forearm to develop. This may be from relative distal ischemia via the graft shunting of blood, causing decreased flow
to the distal forearm. With such collateral flow, a narrowed or occluded artery
often will not render the hand ischemic, as might be expected.
Because infection can be dangerous, resulting in limb loss or even death,
it is important to take every precaution to prevent infection. Sterile placement of the conduit in the subcutaneous tunnel should be achieved. The previously described method of subcutaneous antibiotic injection has been very
helpful in the author's experience and has not resulted in a single postoperative infection in several hundred biologic and textile grafts.
An equally important aspect of maintaining long-term fistulization is meticulous technique by adequately trained hemodialysis technicians. It is important not to puncture the graft in the same place twice in succession, but instead
to move up and down the conduit for successive dialysis procedures and, of
70
course, to maintain superb sterile technique (mask, gloves, iodine-containing

preparatory solution, etc).
Do not hesitate to remove thrombus from clotted or compromised grafts,
even if the graft has been clotted for several days, as it has been determined
that thrombus may be removed by judicious use of a Fogarty catheter. In
many instances, a balloon angioplasty will prolong the life of the graft. However, anastomotic revision may be needed to prevent recurring thrombosis
in a narrowed anastomosis.
The development of antibiotic- and/or anticoagulant-impregnated grafts
or suture materials may aid in the prevention of both early and late conduit
infections and clotting problems. To date, no such suture or graft materials
are available. Some may believe that such antibiotic preference would select
out organisms or prolong needle-hole bleeding. However, the author tends
to think that using a suitable choice of a graft or suture material would be of
major clinical importance.
4. CONCLUSIONS
The use of bovine carotid heterografts, modified umbilical vein grafts, and
the human umbilical cord allograft conduit has been described and discussed
in this chapter. Each has its advantages and disadvantages. The availability,
cost, usability, and complications are generally similar in all three types of
grafts. Hence, it is the author's opinion that essentially it is a surgeon's choice
which of these conduits is used for hemodialysis. Expense, although a consideration, does not determine that one conduit is better than the others, as
they are essentially equal. It is the author's impression that when properly
used, the human umbilical cord vein allograft is slightly superior to the other
biologic conduits for the reasons mentioned above. However, none of these
grafts represents the ultimate in conduit availability for chronic hemodialysis
patients, and it is likely that synthetic materials discussed elsewhere is this
book will provide a more acceptable mode of vascular access for the needy
end-stage renal disease patients.
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1. Alwall N, Norviit L, Steins AM: On the artificial kidney. VII. Clinical experience of dialytic
treatment of uremia. Acta Med Scand 132:587-602, 1949.
2. O'Brien TF, Baxteer CR, Teschan PE: Prophylactic daily hemodialysis. Trans Am Soc Artif
Intern Organs 5:77-80, 1959.
3. Scribner DH, Buri R, Caner JEZ, et al: Treatment of chronic uremia by means of intermittent hemodialysis: Preliminary report. Trans Am Soc Artif Intern Organs 6:114-122, 1960.
4. Cimino JE: Discussion. Trans Am Soc Artif Intern Organs 12:227, 1966.
5. Brescia MJ, Cimino JE, Appell K, Hurwich BJ: Chronic hemodialysis using venipuncture
and a surgically created arteriovenous fistula. N Engl J Med 275: 1089-1092, 1966.
6. BiggersJA, Remmers AR, Glassford DM, Lindley JD, Saries HE, FishJC: Bovine graft fistulas in patients with vascular access problems receiving hemodialysis. Surg Gynecol Obstet
140:690-692, 1975.
7. Burbridge GE, BiggersJA, Remmers ARJr, Lindley JD, Saries HE, FishJC: Late complications and results of bovine xenografts. Trans Am Soc Artifintern Organs, 22:377-381,1976.
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8. Butt KM, Rao TKS, Maki T, Mashimo S, Manis T, Delano BG, Kountz SL, Friedman EA:
Bovine heterograft as a preferential hemodialysis access. Trans Am Soc Artif Intern Organs,
20A:339-342, 1974.
9. Dale Wa, Lewis MR: Further experiences with bovine arterial grafts. Surgery 80:711-721,
1976.
10. Fee HJ, Golding AL: Lower extremity ischemia after femoral arteriovenous bovine shunts.
Ann Surg 183:42, 1976.
11. Foran RF, Shore EH, Levin PM, Trieman RL: Bovine heterografts for hemodialysis. West J
Med 123:269-274, 1975.
12. Haimov M, Jacobson JH: Experience with the modified bovine arterial heterograft in peripheral vascular reconstruction and vascular access for hemodialysis. Ann Surg 180:291-295,
1974.
13. Hutchin P, Jacobs JR, Devin JB, Shaughnessy S, Roland AS: Bovine graft arteriovenous
fistulas for maintenance hemodialysis. Surg Gynecol Obstet 141 :255-258, 1975.
14. Johnson JM, Kenoyer MR: Bovine graft arteriovenous fistula for hemodialysis. Am J Surg
128:728-731,1974.
15. Johnson JM, Kenoyer MR, Johnson KE, Potter DJ, Nickas GM, Williams T: The modified
bovine heterograft in vascular access for chronic hemodialysis. Ann Surg 183:62-66, 1976.
16. Keshishian JM, Smyth NP, Adkins PC, Camp F, Yahr WZ: Clinical experience with the
modified bovine arterial heterograft. Ann Surg 172:690- 702, 1970.
17. Kumar SS, Rattazzi LC, Vander Werf BA: A new treatment for infected bovine graft arteriovenous fistulas. Proc Clin Dial Transplant Forum 22:89-91, 1976.
18. Merickel JH, Andersen RC, Knutson R, Lipschultz ML, Hitchcock CR: Bovine carotid artery shunts in vascular access surgery. Complications in the chronic hemodialysis patient.
Arch Surg 109:245-250, 1974.
19. PayneJE, Chatterjee SN, Barbour DH, Berne TV: Vascular access for chronic hemodialysis
using modified bovine arterial graft arteriovenous fistula. Am J Surg 128:54-57, 1974.
20. Rolley RT, Sterioff S, Williams GM: Arteriovenous fistulas for dialysis using modified bovine arteries. Surg Gynecol Obstet 142:700-704, 1976.
21. Sannclla NA, Mehigan JT, Pennell JP, Halpren B, Fogarty TJ: Initial approach to blood
access for the chronic hemodialysis patient - the bovine heterograft. Trans Am Soc Artif
Intern Organs 22:394-397, 1976.
22. Sterling WA, Taylor HL, Diethelm AG: Vascular access for hemodialysis by bovine graft
arteriovenous fistulas. Surg Gynecol Obstet 141 :69- 72, 1975.
23. Vander WerfBA, Rattazzi LC, Katzman HA, Schild AF: Three year experience with bovine
graft arteriovenous (A- V) fistulas in 100 patients. Trans Am Soc ArtifIntern Organs 21 :296299, 1975.
24. Vander Werf BA, Kumar SS, Rattazzi LC, Perez G, Katzman HA, Schild AF: Long-term
follow-up of bovine graft arteriovenous fistulas. Proc Clin Dialysis Transplant Forum 6:8588, 1976.
25. Yokoyama T, Bower R, ChinitzJ, Schwartz A, Swartz C: Experience with 100 bovine arteriografts for maintenance hemodialysis. Trans Am Soc Artif Intern Organs 20A:328-333,
1974.
26. Rosenberg N, Gaughran ERL, Henderson J, Lord GH, Douglas JF: The use of segmental
arterial implants prepared by enzymatic modification of heterologous blood vessels. Surgical
Forum 6:242, 1956.
27. Rosenberg N, Henderson J, Lord GH, Bothwell JM: An arterial prosthesis of heterologous
vascular origin. JAMA 187:741, 1964.
28. Rosenberg N: The modified bovine arterial graft (editorial). Archi Surg 105:547-548, 1972.
29. Garcia-Rinaldi R, Von Koch L: The axiallary artery to axillary vein bovine graft for circulatory
access. Am Surg 135:265-268, 1970.
30. Salmon PA: Vascular access for hemodialysis using bovine heterografts and polytetrafluoroethylene conduits. Can J Surg 24:59-63, 1981.
31. Dardik H, Ibrahim I, Dardik 1.: Modified and unmodified umbilical vein allografts and xenografts as arterial substitutes: Morphologic assessment. Surg Gynecol Obstet 140:567, 1975.
32. Dardik II, Dardik H: The fate of human umbilical cord vessels used as interposition arterial
grafts in the baboon. Surg Gynecol Obstet 140:567-571, 1975.
33. Dardik HD, Ibrahim 1M, Sprayregen S, Dardik II: Clinical experience with modified human
72
umbilical cord vein for arterial bypass. Surgery 79:618-624, 1976.

34. Dardik H, Ibrahim 1M, Baier R, Sprayregen S, Levy M, Dardik II: Human umbilical cord. A
new source for vascular prosthesis. JAMA 236:2859-2862, 1976.
35. Dardik H, Ibrahim 1M, Dardik I: Evaluation of glutaraldehyde-tanned human umbilical cord
vein as a vascular prosthesis for bypass to the popliteal, tibial, and peroneal arteries. Surgery
83:577-588, 1978.
36. Baier RE, Akers CK, Perimutter S, Dardik H, Dardik I, Wodka M: Processed human umbilical cord veins for vascular reconstructive surgery. Trans Am Soc Artif Intern Organs
22:514-526, 1976.
37. Dardik H, Ibrahim 1M, Dardik I: Arteriovenous fistulas constructed with modified umbilical
cord vein graft. Arch Surg 111 :60-62, 1976.
38. Dardik I, Dardik H: Vascular heterograft: Human umbilical cord vein as an aortic substitute
in baboon. A preliminary report. J Med Primatology 2:269-301, 1973.
39. Dardik H, Ibrahim 1M, Dardik I: Modified and unmodified umbilical vein allografts and
xenografts employed as arterial substitutes: A morphologic assessment. Surg Forum 26:286287, 1975. (Read before the American College of Surgeons, San Francisco, CA, October 15,
1977).
40. Dardik H, Dardik II: Successful arterial substitution with modified human umbilical vein.
Ann Surg 183:252-258, 1976.
41. Wellington JL: Umbilical vein grafts for vascular access in patients on long-term dialysis.
Can J Surg 24:608-609, 1981.
42. Dardik H, Ibrahim M, Ibrahim MD, Sussman B, Kahn M, Sanchez M, Klausner S, Baier
RE, Meyer AE, Dardik II: Biodegradation and aneurysm formation in umbilical vein grafts.
Ann Surg 199:61-68, 1984.
43. Perloff LJ: Vascular allografts. In: Stanley JC (ed) Biologic and Synthetic Vascular Prostheses. New York: Grune & Stratton, 1982, pp 365-395.
44. Tilson MD: Decreased hepatic copper levels. Arch Surg 117:1212-1213,1982.
45. Hussey JL: Experience with 30 human umbilical cord grafts as conduits for hemodialysis.
Dialysis and Transplantation 9:341-344, 1980.
46. Mindich BP, Silverman MJ, Elguezabal A, Levowitz BS: Umbilical cord vein fistula for
vascular access in hemodialysis. Trans Am Soc ArtifIntern Organs 21:273-280,1975.
47. Hussey JL: Conduit placement for hemodialysis: Experience with the human umbilical cord.
Contemporary Dialysis VS (Jan.}:229-230, 1983.
48. Hussey JL: Conduit placement for hemodialysis. Am J Surg 148:284-286, 1984.
49. Hertzer NR, Beven ED: Venous access using the bovine carotid heterograft. Arch Surg
113:696- 700, 1978.
6. PROSTHETIC GRAFT FISTULAS: THE EXPANDED PTFE GRAFT
L. RICHARD ROEDERSHEIMER
Multiple technological and procedural advances in the technique for hemodialysis have evolved since Kolff in 1944 described his original "dialyzer" [1].
This expansion in methods of angioaccess has an implicit bearing on the proliferation of hemodialysis, so that today virtually no patient in renal failure is
denied such therapy. An estimated 70,000 patients in the United States alone
are currently enrolled in a hemodialysis program. Progressive knowledge of
the management of renal failure and its complications has placed demands on
vascular surgeons to create and maintain access to the arteries and veins for
the purpose of achieving successful hemodialysis. External shunts, internal
shunts, percutaneous venous catheters, primary arteriovenous (A V) fistulas,
autogenous bridge fistulas, and prosthetic fistulas have all been used for hemoaccess with variable success. The gold standard for hemoaccess remains the
primary A V fistula as described by Brescia and Cimino in 1966 [2]. However,
conditions for creation of this classic fistula are not always present and some
alternative form ofhemoaccess is indicated. Expanded polytetrafluoroethylene
(e-PTFE) has evolved as a highly successful prosthetic material for use in the
creation of secondary forms of hemoaccess.
1. PREOPERATIVE EVALUATION
A standard type of evaluation should be followed for a patient who requires

long-term hemodialysis. The preferred initial site of placement of a fistula is
the upper extremity. The arms are more easily cleansed and it is easier to canAndreucci. V.E. (ed.), VASCULAR AND PERITONEAL ACCESS FOR DIALYSIS.
73
74
nulate the upper-extremity veins. It is the venous side of the circulation that
limits the choice of access. Therefore, the venous system is evaluated first.
The upper arm and forearm are inspected with a tourniquet in place so that the
superficial veins are distended, permitting the examiner to determine whether
the veins are suitable in size and length to support an autogenous A V fistula.
While the nondominant arm is the preferred side for fistula creation, every
effort should be made to utilize primary venous structures regardless of the
dominance of the extremity.
In the event that the superficial veins are not readily visible, reactive hyperemia can be induced prior to examining the veins. A blood pressure cuff is
inflated to suprasystolic pressures for five minutes, then deflated. During the
phase of enhanced blood flow, after release of the blood pressure cuff, the cuff
is reinflated to 60-70 mmHg, to trap the increased volume of blood in the
now-dilated veins of the arm. This technique of examination permits a more
thorough evaluaton of the veins.
The arterial side of the circulation also requires evaluation. The amplitude
of pulsation at the proximal and distal arterial sites should be noted and recorded. Palpation may also disclose the presence of calcium in the underlying
arteries. If bruits can be auscultated, bilateral segmental systolic blood pressures should be measured to rule out the presence of stenotic segments in the
arterial tree. Stenosis of arterial inflow vessels can result in vascular steal in
the face of an A V fistula. Stenotic areas should be avoided or repaired prior
to construction of a fistula.
The absence of well-developed superficial veins is the most common indication for creation of a prosthetic fistula. The veins may have been obliterated
by thrombosis induced by multiple intravenous lines. Obesity also obscures
superficial veins. In such patients, ultrasound imaging of the superficial veins
visualizes stenotic venous segments and permits measuring of the underlying
veins (figure 6-1). In patients without useful veins in the forearm, the caliber
and continuity of the cephalic and basilic veins in the upper arm can be determined by ultrasound imaging. These proximal veins are most commonly used
as outflow conduits for prosthetic fistulas, and it is helpful to know which
veins are free of thrombi and stenoses. Veins that have a transverse diameter
of 2 mm or greater after reactive hyperemia and in the presence of tourniquet
occlusion are selected for use, providing there are no stenoses downstream
from the planned venous anastomosis.
2. OPERATIVE MANAGEMENT
Prior to implantation of an e-PTFE graft, care must be taken to prevent infection. The extremity selected to receive the fistula should be cleansed with an
antiseptic cleansing solution. Antibiotic agents in the form of first- or secondgeneration cephalosporins or vancomycin should be given intravenously.
The selection of anesthetic varies between regional (axillary block in the
arm or epidural block in the leg) and local infiltration of anesthetic. Intravenous sedation is provided regardless of the type of anesthetic selected. The most
6. Prosthetic graft fistulas
75
Figure 6-1. Ultrasound imaging of an expanded PTFE graft. A: longitudinal view; B:

transverse view. Ultrasound imaging allows measurement of venous diameter and determination
of venous patency and continuity.
commonly used agents for sedation are Versed (midazolam) and Sublimaze
(fentanyl). Our initial preference was regional anesthesia via axillary nerve
blockade; however, after several episodes of brachial plexopathy occurred
following axillary block (unpublished data), our endorsement of this type of
anesthetic has lessened. Brachial plexopathy is most commonly observed in
diabetic females undergoing fistula creation. The exact etiology of this complication remains unclear. Our preference presently is to induce anesthesia by
means of local infiltration into the operative sites.
An accepted nomenclature has now been developed for PTFE fistulas. The
76
Figure 6-2. Anatomic sites of implantation for bridge e-PTFE fistulas: A: radial-antecubital;
B: ulnar-antecubital; C: brachial-basilic.
graft is usually described according to its arterial inflow, venous outflow, and
configuration. The configuration of the grafts varies between loop grafts and
bridge grafts. Several factors should be taken into account when deciding on
the type of configuration to use. There are data to suggest that loop grafts have
a lower incidence of thrombosis than bridge grafts and thus have a better longterm patency [3]. This lower incidence of thrombosis is attributable to the
high flow rates (400-600 mIl min) in loop grafts as opposed to lower flow
rates (200-300 ml/min) in bridge grafts [4]. Bridge grafts, however, have a
lower incidence of vascular steal symptoms. This is also related to the difference in flow rates. Placement of the bridge graft requires only straight tunneling, which results in fewer wound problems that may occur as a result of
the counter incisions required to implant the loop graft.
In selecting the sites for positioning of the e-PTFE fistula, both the arterial
inflow vessels and the venous outflow vessels should be examined (see above).
Bridge grafts are most commonly placed between the radial artery at the wrist
and the median cubital vein in the elbow region (figure 6-2). Venous outflow
may be extended to the basilic or cephalic vein as indicated. A 6 mm PTFE
(figure 6-3A) or a tapered 4- 7 mm (figure 6-3C) graft should be selected.
The tapered graft offers a better match of size between the small radial artery
and the larger caliber vein. This prosthetic is also reported to be associated
with a lower incidence of vascular steal [5]. The newer grafts supported by
a polypropylene ring structure (figure 6-3B) can also be used to cross the
elbow crease should this be necessary. The external support helps prevent kinking of the graft. In addition to the radial artery-median cubital (antecubital)
77
Figure 6-3. Types of e-PTFE material: A: straight 6 mm graft with imprinted line for
maintenance of orientation; B: externally supported graft with polypropylene rings added to
prevent kinking at sites of curves and at flexion creases; C: tapered 4- 7 mm graft.
vein configuration (figure 6-2A), bridge grafts can be placed between the
ulnar artery and the median cubital (antecubital) vein (figure 6-2B), from the
brachial artery at the elbow to the basilic or cephalic veins in the upper arm
(figure 6-2C), or across the chest wall between the axillary artery and the
contralateral axillary vein (figure 6-4A).
The loop fistula is typically placed between the brachial artery distal to the
elbow crease and the median cubital (antecubital) vein (figure 6-4B). The
basilic or cephalic veins can also be used, but if the elbow flexion crease is
crossed, the externally ring-supported e-PTFE graft should be placed across
the point of flexion. Care should be taken to maintain orientation of the graft
during the tunneling process. An imprinted line on the graft facilitates this
maneuver (figure 6-3A). Additional sites for implantation of the loop include
the femoral artery and the saphenous vein in the groin (figure 6-4C). This
78
A
Figure 6-4. Anatomic sites of implantation for loop e-PTFE fistula: A: axillary-axillary;
B: brachial-antecubital; C: femoral-saphenous.
type of graft should be placed only if the ankle-brachial pressure index on the
involved extremity is greater than 0.8 [4]. Arterial perfusion of this magnitude
is less likely to result in vascular steal symptoms. Use of the superficial
femoral artery for inflow allows preservation of the common femoral artery
should infection necessitate removal of the graft. Grafts in the groin carry a
high potential for infection because it is difficult to maintain adequate hygiene
in this region of the body.
After placement, the prosthetic device is given time to heal in its subcutaneous tunnel. Within two weeks, the perigraft hematoma resolves and extremity swelling and wound edema subside. Intermittent elastic bandaging
and arm elevation are recommended to encourage more rapid resolution of
the postoperative changes. The two-week delay also allows a period of time
for initiation of formation of the fibrous capsule that will encase the graft.
3. MANAGEMENT DURING DIALYSIS
When dialysis is initiated through the e-PTFE fistula, care must be taken by
the hemodialysis nurses to preserve the integrity of the graft. Prior to cannulating the graft, the patient's arm should be checked for the presence of a bruit
and the absence of hematomas, infections, and pseudoaneurysms. The extremity overlying the graft is prepared with an antiseptic solution and all efforts are made to maintain sterility. Cannulation of the graft is accomplised
with 11/4" 15- or 16-gauge angiocath or metal needles. In carrying out needle
placement, the graft should be entered at a 30-45 angle so that the skin entry
site and the graft entry site are at different positions (figure 6- 5). Entry into
the graft at angles greater than 45 (figure 6-6) may result in penetration of
the deep wall of the graft [6]. The puncture sites should be kept 2.5-5.0 em
79
Figure 6-5. A: position of the needle during dialysis. B: aspect of puncture site: a, skin; b,
subcutaneous tlss.ue; c, PTFE graft; d, blood-stream. A 45 needle entry into the graft allows
creatIon of a flaphk~ effect 10 the graft puncture site. This helps minimize puncture-hole bleeding
to form a ~echantcal-type valve at the blood-graft interface. The 45 angle also reduces the
chance of pIercmg the deep graft wall with its attendant hematoma formation.
away from the anastomosis, and the entire length of the graft should be utilized for puncturing. Wide scattering of the puncture sites helps to prevent
pseudoaneur.ysm formation and reduces scarring in the tissue adjacent to the
graft. Care should be taken to prevent penetration of the deep wall of the graft
to prevent hematoma formation. During two-needle dialysis, the arterial needle
can be placed either against or with the direction of blood flow, but the venous needle should always be with the direction of the blood flow. A distance
of at least 5 cm should be maintained between the two needles to prevent recirculation of blood during the dialysis treatment. With single-needle dialysis,
the needle should be placed with the direction of blood flow.
At the completion of the dialysis treatment, the needles are removed and
compression is maintained over the entry site on the graft. Compression should
be maintained for 5-10 minutes and the pressure over the graft should be
firm enough to maintain hemostasis without obliterating flow through the
graft. Proper graft maintenance prevents formation of hematomas, infections,
pseudoaneurysms, and graft stenoses.
4. COMPLICATIONS
PTFE fistulas are associated with complications twice as frequently as are

autogenous fistulas [7]. These complications can be subdivided into categories
80
I
I
Figure 6-6. A needle entering the graft at an angle greater than 45 is more likely to result in
prolonged or excessive bleeding through the puncture site. Lettering is the same as in figure 6-5.
of early and late thrombosis, infection, pseudoaneurysm, vascular steal, and

miscellaneous events.
4.1. Early thrombosis
Early thrombosis is defined as clotting of a PTFE fistula within 30 days of

implantation. The reported incidence varies from 4% to 17% [7-10]. Postoperative hypotension seen in dehydrated patients is suspected of being the
most common cause of this complication. Technical mishaps, such as twisting of the graft, kinking of the prosthetic in its subcutaneous tunnel, and
anastomosis of the graft to stenotic arteries or to veins with occluded runoff
are likewise implicated as potential sources of early failure. The specific cause
may not be clearly evident; however, in almost all such cases, if the initial
operation was technically adequate, the PTFE fistula with an early thrombosis can be retrieved by simple thrombectomy. If technical abnormalities are
found, they should be corrected at the time of thrombectomy.
4.2. Late thrombosis
Late thrombosis occurs after 30 days of implantation and typically is associated with use of the prosthetic device for hemodialysis access. This complication is reported to occur in 18%-40% of implantations [7-15]. The most
common cause of late thrombosis is fibrous hyperplasia that accumulates at
81
the venous anastomosis. This fibrocellular reaction results from the shear
stresses of the turbulent arteriovenous flow. Thromboses from this cause are
frequently heralded by the development of venous hypertension within the
dialysis exchanger during treatments. Other causes of thrombosis include
excessive pressure over needle puncture sites, postdialysis hypotension, and
hypercoagulability of the blood.
If venous hypertension or low fistula flow are detected during dialysis,
ultrasound or angiographic evaluation of the fistula should be undertaken.
These studies allow identification of stenotic lesions prior to the occurrence
of thrombosis. When arterial, venous, or graft stenoses are visualized, they
should be repaired. Such repair can be accomplished by vein patch, extension
of the venous outflow to a more proximal site using an interposition graft,
balloon dilatation, or graft replacement. These procedures can be done easily
in an outpatient setting prior to total-graft thrombosis.
With the advent of balloon angioplasty, stenotic segments of e-PTFE fistulas have been submitted to this dilatation technique. The intimal hyperplasia
at the venous anastomosis and the intraluminal sites of graft stenosis can be
treated in this manner. A recent report comparing angioplasty versus surgical
revision for stenosis at the venous end of the grafts shows a median patency
of four months for the dilated group versus 12 months for the surgical group
[13]. Therefore, the selection criteria for use of trans luminal balloon dilatation
remain unclear.
Once graft thrombosis occurs, an aggressive management program should
be established in an effort to salvage the current fistula. This preservative
approach avoids the need to construct an entirely new fistula that consumes
additional arterial and venous sites and also requires maturation time. If a new
maturation period is required, some temporary means of vascular access must
be provided so that the patient may proceed with hemodialysis. This entails
extended hospitalization at increased cost. If the thrombosed fistula can be
retrieved, it can be readily used with no interruption to the usual schedule for
outpatient hemodialysis.
Restoration to patency by a variety of techniques is possible in 75% -85%
of thrombosed PTFE grafts. [11, 12]. Simple thrombectomy with a balloon
catheter is frequently successful. The skilled operator is able to evaluate the
inner lining of the graft and the inside contour of the donor artery and runoff
vein through tactile information provided by the inflated balloon. If a stenosis
is encountered, there is increased resistance associated with withdrawal of the
catheter and the balloon can be felt to distort as it passes through the stenosis.
When encountered, such a stenosis should be corrected.
At the time of thrombectomy, the opening into the graft is usually made
on the venous outflow limb where the e-PTFE fistula is anastomosed to the
vein. This provides access to the site where intimal hyperplasia is most likely
to occur. Thrombectomy is performed, making several sweeps with the catheter until the arterial plug (figure 6- 7) has been removed and no further solid
82
Figure 6-7. Plug of thrombus found at arterial end of the graft at the time of thrombectomy.
This plug must be retrieved to ensure adequate arterial inflow.
thrombotic material can be retrieved. Removal of the arterial plug ensures

adequate inflow. During the course of thrombectomy, fragments of pseudointima may be removed from the graft lining. This event may result in areas
of flap formation, which, iflarge enough, may inhibit flow through the PTFE
conduit. Repeated passes of the thrombectomy catheter should be made to
remove as much of the pseudointima as possible. If intimal hyperplasia is encountered at the venous outflow site, a patch should be placed to widen the
venous anastomosis. If the area of venous stenosis exceeds 2 cm in length,
the venous outflow should be extended to a more proximal venous site in the
forearm. This is accomplished by placement of an e-PTFE interpos{tion graft.
Stenoses may be seen diffusely throughout the body of the e-PTFE fistula
(figure 6-8). These stenoses result from the clustering of needle punctures
into small areas of the PTFE graft. As the graft heals, a fibrotic stenotic reaction occurs in these puncture wounds. Long segments of the graft involved
in stenoses should be replaced in a staged manner, so as to preserve a length
of matured PTFE through which hemodialysis may be continued until the
new segment of graft is ready for use.
Once thrombectomy has been completed, the inflow to the loop can be
controlled by placjng the thrombectomy catheter into the inflow artery and
inflating the balloon. An angioscope can then be utilized to inspect the inner
lining of the e-PTFE fistula. This procedure confirms the absence of mechanical factors that might result in rethrombosis. If angioscopy is not available,
an intraoperative arteriogram is useful. This procedure is performed after correction of all known mechanical problems and after closure of the graft. The
intraoperative arteriogram has allowed identification of potentially significant
vascular lesions in 64% of thrombectomy cases studied by Bone and Pomajzl
83
Figure 6-8. Angiographic appearance of e-PTFE graft that has developed multiple sites of
stenoses (arrows) from repeated puncture at the time of dialysis.
[81. Such mechanical defects may result from fibrosis in the graft or from dislodgement of pseudointima into a flap configuration. The operating surgeon
must decide which defects are hemodynamically significant and need repair.
If an intraoperative ultrasound imaging device is available, it may be used in
lieu of angiography to identify these defects.
The e-PTFE prosthetic with its smooth lining lends itself to ease of thrombectomy. This is a favorable characteristic of this type of material. The combination of thrombectomy and repair of hemodynamic stenoses in the system
prolongs the life of the fistula. Data from Etheredge et al. show that 60% of
the salvaged fistulas will remain functional for one year after the salvage procedure [11]. Multiple revisions may be required, but in general, even with
grafts that have failed on several occasions, the chance of successful revision
after each episode of failure is greater than 50% [121.
Data on thrombosis can be submitted to life-table analysis for construction
of cumulative patency curves. Comparative cumulative patency curves for autogenous A V fistulas, bovine heterografts, and PTFE fistulas have been generated
by the manufacturers of Gore-Tex PTFE grafts from published data and data
collected from their graft registry [14], as shown in figure 6-9. PTFE fistulas
demonstrate a two-year patency rate of 67% and a three-year patency rate of
51 %, slightly less than those seen for autogenous fistulas, but far greater than
84
l00~----------------------------'
80
~---------------C-~--~---Bi . . I
Imlno~
reSCla Flstu a
11059)
..
GORE-TEX Vascular Grafts

.................
12296)
20
Bovine Heterografts
1895)
2
3
Years Since Implant
Figure 6-9. Cumulative patency for Brescia-Cimino, Gore-Tex, and bovine heterograft fistulas
determined by life-table analysis.
those for bovine heterografts. In addition, the ease of salvage of the e-PTFE
fistula compared to the other two types of fistulas will allow much better
secondary patency curves for the PTFE fistula.
4.3. Infection
Infection ranks second to thrombosis as the most common complication involving e-PTFE fistulas, as is known to occur in 2% -25% of implantations
[3, 4, 7, 9, 12, 15, 16]. Infections can be divided into primary and secondary
types. Primary infections occur as the result of the insertion procedure, and
secondary infections result from repeated graft cannulations during hemodialysis. Most infections occur at a mean of about 7.5 months postplacement.
With passage of time, the graft becomes encased in its fibrous capsule and the
incidence of infection decreases.
Staphylococcus aureus and staphylococcus epidermidis are the causative organisms
in infections. Stringent efforts should be made to prevent invasion of these
organisms during placement of the graft or contamination during hemodialysis.
At operation, graft sepsis is a most dire complication. All measures must be
taken to prevent it. The skin should be well prepared and extreme care should
be taken to prevent contact of the graft with the skin. The graft should be
tunneled deeply enough in the subcutaneous fat to allow sufficient superficial
tissue for skin closure without undue tension. Graft and wound irrigation with
a first-generation cephalosporin is routinely used. Prophylactic intravenous
85
antibiotic agents like cefazolin or vancomycin are provided preoperatively.

In the hemodialysis unit careful skin preparation should be observed and there
should be a pattern rotation of needle puncture sites along the entire length of
the graft.
The e-PTFE graft material shows a peculiar resistance to the spread of infection and, should the graft become infected, removal is rarely indicated. But
if infection occurs in a thrombosed graft, the entire graft should be removed.
If the infection does not involve the segments of graft sewn to the artery and
vein, these segments can be left in place, to avoid injury to the host artery
and vein at the time of explantation. Infection in proximity to the host artery
and vein also warrants graft removal for fear of hemorrhage from disruption at
the anastomotic site.
When the graft remains patent in the presence of infection, there are several
acceptable methods of management. If the infection is localized over the body
of the graft, the infected area can be incised and drained. Intravenous antibiotic
agents are given and topical povidone-iodine dressings are applied. This conservative type of management eradicates infection and achieves wound healing successfully in 67%-80% of the cases treated in this manner [7, 16]. In
the remaining cases, the infection can be controlled, but wound healing does
not occur. Muscle flaps and skin grafting to cover the exposed graft are called
for. Loss of skin coverage over the graft results from hypovascularity, and
skin rotation flaps have been unsuccessful in achieving adequate healing. A
more durable means of coverage is provided by the more vascular muscle rotation flap with its separate vascular supply. The flexor carpi ulnaris muscle and
the sublimis muscle in the forearm have been used to provide graft coverage
with minimal hindrance to hand function [17, 18].
If infection cannnot be controlled or if graft coverage is unsuccessful, the
infected portion of the graft can be excised and a new graft placed through
clean tissue. The site of graft removal is left open and submitted to local dressing changes. This method of treatment allows preservation of graft function
and adequate eradication of infection.
4.4. Pseudoaneurysm
Pseudoaneurysm occurs in PTFE fistulas at a reported frequency of 0% -6%

and usually occurs between 16 to 20 months after implantation [7, 9, 12, 19].
The primary etiology of this complication is improper management during
dialysis. Needle entry into the graft should be made at a 45 angle, with displacement of the skin entry point away from the point of graft entry (figure
6- 5). This technique provides a flap of tissue to cover the defect in the graft at
the time of needle withdrawal. Compression is maintained until a stable clot
forms. If the graft is entered at an angle greater than 45, the tissue flap is
unavailable for the coverage of the graft and a hematoma is more likely to
occur. A hematoma surrounding a nidus in the graft may provide an environment favorable for pseudoaneurysm formation. A more common method
86
Figure 6-10. Inner lining of an excised PTFE graft segment showing a large defect in the graft
wall that resulted in the form ation of a pseudoaneurysm. Arrow indicates aneurysm.
for pseudoaneurysm formation is excessive clustering of needle punctures in

the graft. This mechanism results in a large defect in the graft itself, with subsequent formation and expansion of a pseudoaneurysm (figures 6-10 and
6-11). Pseudoaneurysms are generally diagnosed by physical examination,
but ultrasound visualization has also been useful. Pseudoaneurysms should be
excised and the excised segment of graft replaced with a new length of PTFE
to maintain fistula function.
4.5. Vascular steal
Fortunately, vascular steal occurs infrequently in PTFE grafts. It is observed

more commonly in diabetic patients. The presenting symptoms are pain and
coolness in the distal parts of the affected extremity. Pallor is present in the
digits and distal pulses are usually not palpable. The burning pain experienced
by the patient inhibits the use of the involved extremity, and muscle atrophy
and deformities of the hand may develop. In severe cases of vascular steal,
digital gangrene can occur. Diagnosis can be confirmed by digital plethysmography, which typically shows absent or very low amplitude arterial waveforms in the digits. When graft compression is carried out during performance
of plethysmography, the arterial waveform is seen to augment. Similarly,
augmentation or return of digital Doppler arterial signals at the distal digits
during fistula compression confirms the diagnosis. This abnormality results
87
Figure 6-11. Angiographic appearance of pseudo aneurysm (arrow).
from high flow in the graft itself or from an unsuspected stenosis in the arterial inflow. In evaluating patients with vascular steal, the arterial inflow system
should first be inspected. Auscultation for bruits and a search for systolic pressure gradients should be made. If an arterial stenosis is suspected, an arteriogram should be obtained. Arterial stenoses confirmed by x-ray can be dilated
by balloon angioplasty and the steal syndrome reversed. If the arteriogram
shows no stenoses, consideration should be given to performing a banding
procedure on the venous outflow of the fistula. A method described by Mattson [20] involves placement of a 1 cm segment of an e-PTFE patch in a crisscross fashion around the vein or the PTFE graft. This band is secured, so as
to allow return of digital arterial waveforms on a plethysmography monitor.
The banding reduces the volume of flow through the graft and allows increased perfusion to the distal extremity and digits. Since diabetic patients
appear to be more prone to development of the vascular steal syndrome, bet-
88
ter results might be obtained by creating access in this patient population with
the tapered type of PTFE graft. Rosenthal et al. have proposed a 4-7 mm
tapered graft to reduce the chance of development of the vascular steal syndrome [5]. This configuration reduces the volume of blood passing through
the fistula and allows more blood to proceed to the distal areas of the extremity. The symptoms of vascular steal can be devastating and disabling. For
this reason, if at all possible, the nondominant extremity should be chosen as
the site for access placement.
4.6. Seroma formation
Peculiar to the PTFE fistula is a process of seroma formation. A serous type

of fluid leaks and accumulates into the tissue space around the graft at the site
of leakage. Experimental studies have shown that the problem results from
high flow rates, wetting of the graft during implantation, and the presence
of sharp angles in the graft [21]. The high flow rates and the sharp angles in
the graft allow the red blood cells to move from the low-velocity boundary
layer to the high-velocity layer of flow in the central lumen of the graft. Red
blood cells can effectively decrease the rate of plasma leaking through the graft
wall. The subsequent decrease in red blood cells in the boundary layer of the
graft during high flow provides an environment favorable for the loss of
plasma through the graft. Plasma leakage is further promoted by wetting of
the graft prior to instituting blood flow. This phenomenon is seen more commonly in patients who are anemic [21]. Therefore, to prevent this complication,
the graft should be tunneled without being exposed to blood or saline solution, and care should be taken to avoid acute angulation of the graft at the
anastomoses and at the curve of the loop graft. If a seroma occurs, it should
be needle aspirated until it disappears. Several aspirations may be necessary
to eradicate the collection. If leakage persists despite multiple aspirations,
consideration should be given to excision of the leaking segment of the graft.
Granted that the incidence of complications is higher in the e-PTFE fistula
than in the autogenous A V fistula, it nevertheless remains useful as a conduit for angioaccess. Its ease of thrombectomy, relative resistance to infection, long-term durability, and acceptable patency rates make e-PTFE clearly
superior to other currently available synthetic and biologic materials. Questions remain as to whether straight or loop configurations are preferable;
whether endothelial seeding can improve patency and lower infection rates;
and what role lasers and angioscopes will play in the management of A V
fistulas.
REFERENCES
1. Kolf W), Berk HTJ: The artificial kidney: A dialyser with a great area. Acta Med Scand
117:121-131,1944.
2. Brescia M), Cimino JE, Appel K, Hurwich BJ: Chronic hemodialysis using venipuncture and
a surgically created arteriovenous fistula. N Eng) Med 275: 1089-1 092, 1966.
89
3. Munda R, First MR, Alexander ]W, Linnemann CC, Fidler ]P, Kittur D: Polytetrafluoroethylene graft survival in hemodialysis. ]AMA 249:219-222, 1983.
4. Anderson CB, Sicard GA, Etheredge EE: Primary and secondary operations for vascular
access. In: Bergan]], Yao]ST, (eds) Evaluation and Treatment of Upper and Lower Extremities. Orlando, FL: Grune & Stratton, 1984, pp 464-470.
5. Rosenthal ]], Bell DD, Gaspar MR, Movius H], Lemira GG: Prevention of high flow problems; development ofa new tapered graft. Am] Surg 140:231-233,1980.
6. WL Gore and Associates, Inc: Technical considerations concerning puncturing of the GoreTex Vascular graft for hemodialysis, April, 1980.
7. Kherlakian GM, Roedersheimer LR, Arbaugh ]A, Newmark K], King LR: Comparison of
autogenous fistula versus expanded polytetrafluorethylene graft fistula for angioaccess in
hemodialysis. Am] Surg 152:238-243,1986.
8. Bone GE, Pomajzl MJ: Prospective comparison of polytetrafluoroethylene and bovine heterografts for dialysis. ] Surg Res 29:223-227, 1980.
9. Mohaideen AH, Tanchajja S, Avram MM, Mainzer RA: Arteriovenous access for hemodialysis. Utilizing polytetrafluoroethylene grafts. NY State] Med 80:190-195, 1980.
10. Butler HG, Baker LD, Johnson ]M: Vascular access for chronic hemodialysis: Poly tetrafluoroethylene (PTFE) versus bovine heterograft. Am] Surg 134:791-793,1977.
11. Etheredge EE, Haid SD, Maser MN, Sicard GA, Anderson CB: Salvage operations for malfunctioning polytetrafluoroethylene hemodialysis access grafts. Surgery 94:464-470, 1983.
12. Palder SB, Kirkman RL, Whittemore, Whittemore AD, Hakim RM, Lazarus]M, Tilney NL:
Vascular access for hemodialysis; patency rates and results of revision. Ann Surg 202:235239, 1985.
13. Brooks ]L, Sigley RD, May KI, Mack, RM: Transluminal angioplasty versus surgical repair
for stenosis of hemodialysis grafts. Am] Surg 153:530-531,1987.
14. Mehta S: Statistical summary of the results of vascular access procedures for hemodialysis.
Published and/or presented during 1966-1980. WL Gore and Associates, Inc, Newark,
Delaware.
15. Connolly]E, Brownell DA, Levine EG, McCart PM: Complications of renal dialysis access
procedures. Arch Surg 119:1325-1328, 1984.
16. Bhat D], Tellis VA, Kohlberg WI, Driscoll B, Veith FJ: Management of sepsis involving
expanded polytetrafluoroethylene grafts for hemodialysis access. Surgery 87:447-450, 1980.
17. Hodgkinson D], Shepard GH: Coverage of exposed Gore-Tex dialysis access graft with local
sublimis myocutaneous flap. Plast Reconstr Surg. 69:1010-1012, 1982.
18. Leadbetter MR, Ireland G, Slagle R, McKenna P, Newmark KK, Roedersheimer LR,
Arbaugh]J: Salvage of chronically exposed vascular access grafts in the hemodialysis patient.
Plast Reconstr Surg, in press, 1988.
19. Tellis VA, Kohlberg WI, Bhat D], Driscoll B, Veith FJ: Expanded polytetrafluoroethylene
graft fistula for chronic hemodialysis. Ann Surg 189:101-105, 1979.
20. Mattson WJ: Recognition and treatment of vascular steal secondary to hemodialysis prostheses. Am] Surg 154:198-201,1987.
21. Bolton W, Cannon ]A: Seroma formation associated with PTFE vascular grafts used as
arteriovenous fistulas. Dial Transplant 10:60-63, 1981.
7. BLOOD ACCESS WITHOUT NEEDLES:

THE HEMASITE TITANIUM VASCULAR ACCESS DEVICE
WILLIAM P. REED
1. BACKGROUND
Vascular access for hemodialysis should ideally be safe, painless, convenient,

easy to employ, available for use soon after placement, resistant to infection
and thrombosis, and adaptable to the patient with poor peripheral vessels.
None of the standard forms of vascular access fulfills all of these criteria.
External shunts provide access that is painless, easy to usc, and immediately
available. Longevity is limited by frequent infections, thromboses, and vessel
erosion, however, so that this type of access is seldom used today [1]. External
cannulae are also inconvenient because the tubing needs to be protected from
trauma, limiting the activities for which the patient can use the involved limb.
The addition of a Dacron cuff between the skin and vascular anastomosis, as in
the Allen-Brown or Thomas shunt [2], has improved the longevity, but not
the convenience, of this type of access. Finally, all external shunts risk severe
or fatal hemorrhage in the event of separation of the arterial from the venous
cannula.
Internal fistulas between autologous veins and arteries provide the most
durable and convenient form of vascular access. They also require greater skill
on the part of both the access surgeon and the dialysis therapist [3]. Maturation
requires 4 to 6 weeks, during which time some form of temporizing dialysis
may be necessary. This is a particularly troublesome problem for the patient
with few remaining access sites who develops a sudden access failure. Internal
fistulas also require venipuncture for entry. Bleeding and painful hematoma
91
92
/j;
Locking Ring
Pressure Plate
\.:::::::1// Self-Seahng
Septum Assembly
fgG~
Q~.
~
@.
Rer\ak)y'" Body /
'L-it"Y
......,y
/ " -=
/ " .....
~-
Venous
PTFEGratt
Altgnment Slot
Dacron
V~our
Covering
Figure 7-1. Hemasite access device showing its component parts and blunt-tipped needle set.
Matching notches on the body and needle set permit proper alignment.
formation may accompany needle withdrawal, and the pain associated with
the venipuncture itself limits the willingness of some patients to participate in
home dialysis programs. The trauma of venipuncture also produces repeated
minor vascular damage, which in time leads to fistula loss through infection,
pseudo aneurysm formation, or thrombosis of tortuous channels. Finally, not
every patient will have peripheral vessels that are adequate for the formation of
an internal fistula. When veins are lacking, graft substitutes will be needed.
These are associated with more frequent need for surgical intervention to
maintain patency rates.
The Hemasite access device was developed to combine the favorable features
and to minimize the unfavorable ones of standard external and internal access
techniques [4]. The Hemasite consists of an internal fistula of expanded polytetrafluorethylene [PTFE), equipped with an external sideport wrapped in
Dacron velour, and offers convenient access that requires no maturation time.
Specially designed needles allow repeated entry into the fistula stream, without
disrupting the integrity of the PTFE forming the conduit [5]. Since the port is
above skin level, access is also technically simple and pain free. A self-sealing
septum minimizes blood loss associated with needle withdrawal and eliminates
the danger of hemorrhage associated with standard external cannulae. The
Dacron wrap is designed to isolate the exit port from the underlying graft to
delay the onset of bacterial invasion of the graft material and vascular
anastomoses.
2. DESCRIPTION OF THE DEVICE
The Hemasite device (Renal Systems, Minneapolis, MN) consists of a titanium

T-shaped tube, or body, which is covered with Dacron velour to promote
tissue ingrowth (figure 7-1). The two arms that make up the crossbar of the
body form the flow tube of the device, and the perpendicular sidearm forms
7. Blood access without needles
93
Figure 7-2. Insertion of double-pronged access set into Hemasite stabilized by holding tool.
Inset: appearance of Hemasite well, or button, with C ring locked over pressure plate. Slitted
septum is visible through two holes in pressure plate. Reprinted by permission from Reed WP,
Sadler JH: Experience with a needleless vascular access device (Hemasite) for hemodialysis. SMJ
77:1501-1505, 1984.
the percutaneous access shaft. Expanded polytetrafluoroetylene (PTFE) tubular

grafts are attached to each end of the flow tube to provide the arteriovenous
conduit to and from the body. A tapered 4 to 6 mm graft is provided for the
arterial anastomosis and a straight 6 mm graft for the venous one. A silas tic
diaphragm is housed in the perpendicular shaft as a seal between the bloodstream and the outside. This septum is held in place by a pressure plate and a
locking C ring. Two holes in the pressure plate expose the silas tic directly over
preslitted portions of the septum (figure 7-2, inset). Access to the flow chamber is accomplished by means of a blunt-tipped, double-pronged needle set,
which is pushed through the holes in the pressure plate in much the same way
that an electric plug is pushed into a socket (figure 7-2). As the needle prongs
move through the septum, the preformed slits separate to allow entry into the
bloodstream (figure 7-3). Removal of the needle set allows these slits to snap
shut, sealing the flow chamber. Since entry does not actually puncture the
silas tic material, repeated access is possible without damage to the septum.
Should the septum begin to leak in time, the C ring can be unlocked, to permit
replacement of the damaged septum. A septum replacement kit is available to
facilitate this procedure. The space external to the pressure plate forms a well,
which can be filled with povidone-iodine (Betadine) solution when the device
is not in use. This solution is held in place by a silas tic cap that fastens to the
rim of the well (figure 7-4).
94
- ....
...
Figure 7-3. Cross-section of the Hemasite in position with the access set. Pressure differential
from inflow to outflow points is a function of flow rate in the fixed geometry of the titanium body,
Flow = K (Pa~Pv). Reprinted by permission from Reed WP, Sadler JH: Experience with a needleless vascular access device (Hemasite) for hemodialysis. SMJ 77:1501-1505, 1984.
Figure 7-4. Placement of protective cap keeps povidone-iodine in well when device is not in use.
95
Figure 7-5. Preferred implantation site using the brachial vessels of the medial arm.
At one time the Hemasite body was provided without attached PTFE [6] for
implantation into an existing fistula (figure 7 -3, inset). Experience with this
modified device was unsatisfactory. Without the graft material, the titanium
eroded through the native fistula in 12-14 months, producing hemorrhage
that was often severe and required fistula ligation for control [7, 8]. The graftless Hemasite is no longer available as a result of this experience.
3. HEMASITE IMPLANT A TION
The grafted Hemasite can be implanted at any site where there is an adequate
artery and vein, and sufficient overlying subcutaneous tissue to stabilize the
exit port. The medial arm [8,9] is the preferred site (figure 7-5), but the upper
thigh and subclavian vessels can also be used. The forearm does not appear to
be a good choice because of the constant tissue motion that accompanies pronation and supination [10, 11]. The calf has been avoided by most surgeons
for fear of causing irreparable harm to arteries already compromised by
atherosclerosis.
Graft insertion can be carried out under local anesthesia as an outpatient procedure. Prophylactic antibiotics are recommended. Our own preference is for
vancomycin hydrochloride, a drug that is effective against staphylococcus
and is only cleared from the circulation of patients in renal failure at the time of
dialysis.
For standard arm insertion, the basilic vein and brachial artery are exposed
96
through separate incisions under lidocaine anesthesia after povidone-iodine

skin preparation and aseptic draping. In patients who have had previous fistulas,
it is important to verify the adequacy of the available vein as a first step. This is
accomplished through a longitudinal incision along the groove posterior to
the medial surface of the biceps muscle starting at the junction of the middle
and upper third of the arm. Placement of the venous anastomosis at this level
minimizes the amount of graft needed and preserves proximal vein for later
revision. The longitudinal incision allows proximal extension in cases where
the more distal vein is scarred or absent.
The brachial artery can be isolated through a small transverse incision 3 to 4
cm above the antecubital crease. The transverse incision at this level provides a
more cosmetic scar where the arm is likely to be uncovered and also leaves the
greatest possible length of undisturbed skin between the two incisions for the
exit site.
Once an adequate artery and vein have been isolated, a subcutaneous tunnel
is developed between the two incisions. Lidocaine anesthesia is usually sufficient for this dissection, but supplemental sedation with intravenous meperidine and diazepam may be needed in some patients. The depth of the tunnel at
the exit site must be approximately 1 em so that the side arm will neither retreat below skin level on its own nor protrude more than 4 to 5 mm above it.
Following the plane that is just deep to the deep fascia of the arm will produce
a good level for the tunnel, except in obese patients. A skin excision no larger
than three-fourths the diameter of the side arm will provide sufficient space for
the rim of the button to exit without exposing the Dacron. The device is packaged with a domed cap fitted to the exit well [6]. This cap is held in place with
sutures and serves as a prow to stretch the skin as the side arm is directed
through the exit site. With a finger directed along the tunnel deep to the device, the surgeon can facilitate the seating of the port with gentle outward
pressure, using the fingers of the opposite hand to manipulate the skin down
around the dome. Once the side arm is in position, the dome is removed from
the well by dividing the sutures that hold it in place.
With the device now positioned in the tunnel and the button exiting the
skin, the surgeon can perform the vascular anastomoses by standard end-toside technique. Running 6-0 polypropylene glycol is preferred in most centers,
but other permanent vascular sutures are acceptable. First the venous graft is
beveled and a 1.5 cm anastomosis is performed. After the graft is flushed with
heparinized saline (500 IU/500 ml saline), a smaller 6 to 8 mm arterial anastomosis is completed to secure the implant. The arterial vascular clamps are
removed first to allow any remaining air in the graft to escape through the
venous suture line. After removal of the venous clamps, a palpable thrill can be
detected over the vein if the flow is adequate. Anastomotic bleeding is usually
controlled quite easily by gentle presure, following which a two-layered closure
of subcutaneous tissue and skin is carried out. The device well is then filled
with povidone-iodine solution and sealed with its protective cap. The incision
and exit site are dressed with sterile gauze.
97
Figure 7-6. Rim-holding tool, used to stabilize the device during access.
4. HEMASITE CARE
Although the Hemasite can be used immediately for dialysis in cases of emergency, it is preferable to wait a few days to reduce the chances of suture-line
hemorrhage from heparinization and to allow early healing to stabilize the
device. If dialysis can be delayed, the patient is discharged from the outpatient
operating suite with the instruction to elevate the implanted arm on one or two
pillows when recumbant. A sling provides a useful reminder to the patient to
protect and elevate the extremity. Oral analgesics are prescribed, but no further
antibiotics are given. The patient is instructed to keep the bandage dry and in
place until the first postoperative visit.
When the patient returns for dialysis, the bandage is removed. If a subcuticular skin closure with absorbable suture has been employed, the incision
will require no further dressing at this point. The exit site is inspected for signs
of erythema or drainage, and gently cleaned with peroxide on cotton-tipped
swabs. Povidone-iodine solution is then applied around the exit port.
Access to the port is gained by removing the protective cap, absorbing the
povidone iodine in the well with sterile cotton applicators, washing the well
with hydrogen peroxide to remove traces of the iodine, and inserting the needle
set. A holding tool (figure 7-6) is fastened to the well rim to prevent its being
pushed below the skin surface during insertion of the needle set. There is a
small notch on the needle set that must be aligned with a similar mark on the
rim of the exit button to ensure that the inflow prong is facing upstream (figure
7-1). A locking clip, which works like a clothes pin (figure 7-7), secures the
access set to the rim of the button during dialysis. Since the septum is selfsealing, the worst outcome of accidental dislodgment of the access set during
dialysis would be the loss of the blood in the dialyzer.
Upon completion of dialysis, the holding tool is reapplied to stablize the
button during removal of the needle set. The septum should seal without blood
98
Figure 7-7. Locking clip to prevent needle-set dislodgment during dialysis.
loss. The well is washed once more with peroxide, filled with povidone iodine,
and capped. Povidone-iodine solution is then applied around the exit site and
allowed to dry. Until healing is complete, a small gauze pad is taped in place
over the exit site. This becomes unnecessary in time.
Patients are instructed to inspect the exit site daily for signs of erythema,
tenderness, swelling, or drainage. They are taught to feel the thrill along the
limbs of the fistula and asked to check this daily. They are also instructed to
keep the exit site dry. Daily home cleaning of the area is not recommended.
The patient may shower or bathe, once healing is complete. Plastic shower
covers are available to keep the exit site dry at these times (figure 7-8). These
covers have an adhesive ring to provide a 360 0 seal around around the exit site.
It is recommended that the skin around the button be gently dried with a clean
towel once the cover is removed at the end of bathing. Povidone-iodine solution is then applied with a swab around the button and allowed to dry. At no
time is the cap protecting the well itself removed.
5. COMPLICATIONS
5.1. Infection
Infection has been the most troublesome complication of the Hemasite device.
This is not really surprising considering that the skin about the exit site can
99
Figure 7-8. Shower cap protects exit site during bathing.
never completely close. The Dacron barrier does protect the underlying PTFE
and vascular anastomoses, so that many infections can be successfully treated
with antibiotics if recognized early. Patients are instructed to report any fever
or signs oflocal infection so that therapy can be established as early as possible.
Once infection extends deep to the Dacron shield, organisms establish
themselves in a sheath ofbiofilm about the PTFE (figure 7-9). This biofilm
tends to interfere with bacterial release of toxins and tissue invasion, while it
protects the bacteria from antimicrobials and host factors. The resulting infections are therefore indolent but nearly impossible to eradicate completely [12].
Occasionally, these indolent infections may rapidly spread to produce severe
sepsis, however. For this reason it is recommended to remove the Hemasite if
local signs of infection, such as drainage, persist after two weeks of appropriate
antibiotics or recur rapidly after cessation of four weeks of therapy. Another
sign of progressive infection is graft thrombosis. When thrombosis develops
during an episode of infection, the graft should not be declotted, but removed.
2.5. Thrombosis
Thrombosis of a Hemasite can occur as a result of infection, of stenosis of a

vascular anastomosis, usually the venous one, or from low flow due to hypotension. When thrombosis occurs as a complication of graft infection, the
required treatment is clear. One should remove the Hemasite. Thrombectomy
100
Figure 7-9. Scanning electron microscopy of explanted Hemasite showing mixed infection of
coccoid bacterial cells (small arrows) and four sizes of rod-shaped bacteria (large arrows) in a
matrix of exopolysaccharide biofilm (bar = 5 mm). Reprinted from Reed WP, Moody MR,
Newman KA, Light PD, Costerton JW: Bacterial colonization of Hemasite access devices.
Surgery 99:308-316, 1986, with permission.
will only briefly restore flow under these circumstances, and it risks dissemination of the infecting organisms .
. Thrombosis due to anastomotic stenosis can usually be reversed by appropriate revision or bypass of the stenotic area. One can often anticipate such
thromboses by observing changes in the flow characteristics of the Hemasite.
As with any internal fistula, progressive increases in venous pressure during
succeeding dialysis sessions should signal the need to study the venous anastomosis angiographically (figure 7 -10). Documentation of a narrowed segment
may allow elective revision to avoid thrombosis .
101
Figure 7 -10. Transeptal angiogram of Hemasite with low flow demonstrates occlusion of main
venous channel. Patency is maintained by retrograde flow through a small collateral branch to
the deeper venous system. This was successfully treated by transposing the venous end of the graft
to the larger vessel visualized.
The Hemasite device permits simpler and more accurate assessment of its
flow rate than is available for other fistulas. The fixed geometry of the flow
chamber leaves flow as the only variable for pressure differences observed
between inflow and outflow prongs. Flow is proportional to the square root of
the differential stop flow pressures by a proportionality constant determined
experimentally [13]. By sequentially recording Hemasite flows, one can anticipate thrombosis from arterial as well as venous stenoses.
Some thrombotic episodes develop in the absence of any stenotic lesions, as
a result of the hypercoagulability state or of low flow from hypotension. The
Hemasite design allows the thrombus to be removed in these situations without further skin incisions [7, 14]. The locking C ring has small holes in its tips
that allow it to be grasped, compressed, and removed from the well by a
special fine-tipped clamp. Once the C ring is gone, the pressure plate and
septum can also be removed to expose the flow tube. Two Fogarty balloontipped catheters are used for thrombectomy. One is inflated in one of the graft
limbs (B in figure 7-11) to maintain hemostasis, while the other (A in figure
7 -11) is used to retrieve the clot from the other limb. Once the flow is restored, the catheters are removed and the well is occluded by gentle pressure
from the operator's thumb (figure 7-11, inset). A septum replacement kit al-
102
Figure 7-11. Balloon embolectomy through the open well of the Hemasite. One balloon is
inflated in one of the graft limbs (B) to maintain hemostasis, while the other (A) is used to retrieve
the clot from the other limb. Inset: after thrombectomy, the operator's thumb is used to occlude
the open port while a new septum is positioned for insertion. Reprinted by permission from Reed
Wi>, Sadler JH: Experience with a needleless vascular access device (Hemasite) for hemodialysis.
SMJ 77:1501-1505,1984.
lows a premo un ted C ring, pressure plate, and septum to be seated in the well
with a single motion as the occluding thumb is withdrawn. With a little practice (a dummy arm with Hemasite is available), the whole procedure can be
performed with minimal (less than 50 ml) blood loss. Systemic heparinization
is not necessary but may help avert early recurrence of the thrombosis until
the underlying cause is corrected.
Transeptal thrombectomy may be carried out in the dialysis unit with proper attention to sterile technique, but asepsis is more certain in an operating
room setting. The arm should be scrubbed and draped as carefully as for a
surgical procedure, and the operator should wear a full-length sterile gown as
well as a cap, mask, and gloves. While this procedure provides a convenient
way to reestablish flow, it cannot be used to correct stenotic lesions and is contraindicated in the face of infections, particularly those where purulent drainage
is present about the exit site.
5.3. Excessive flow
The early experience with Hemasite grafts was complicated by excessive flows
that produced congestive heart failure. Operative constriction of the arterial
inflow graft was required to reduce flows to acceptable levels. This complications was particularly evident for grafts interposed between the femoral artery
and vein. With the introduction of the tapered arterial prosthesis and increased
reliance on the brachial vessels, this complication is seldom a problem any
longer.
103
Figure 7-12. The incision used for Hemasite removal extends through the length of the scar
marking the site of venous anastomosis (upper arrow), around each side of the exit port, then to a
point just proximal to the scar marking the site of arterial anastomosis (lower arrow). A small
ellipse of skin is left attached to the exit port.
5.4. Hemorrhage
Hemorrhage has been seen as a complication only with the graftless form of
the Hemasite. Consisting of the standard T piece without attached PTFE, the
graftless model was designed for insertion into an existing internal fistula that
was too deep to be reached by standard access needles. The idea was to make
veins not ordinarly useful for fistulas available for access. Unfortunately, the
titanium tips of the flow tubes erode through the vessel wall after 12 to 14
months of use, producing hemorrhage that can be sudden and severe. For this
reason, the graftless device is no longer available.
6. TECHNIQUE FOR REMOVAL
Infected or thrombosed grafts can be removed rather easily [12]. Since access
does not involve puncture of the PTFE, the firm attachments of the graft to
subcutaneous tissue usually seen with this type of material are lacking. Only
the Dacron forms a tight bond. At the time of removal, local anesthesia is infiltrated along the course of both limbs of PTFE and around the exit site. A
longitudinal incision is used to expose the graft from the point of venous anastomosis to a point just shy of the arterial one, leaving a small elipse of skin
104
Figure 7-13. The graft is detached from the vein, following which the venous limb and
Hemasite body can easily be elevated from its bed. The opening in the vein is only closed if
necessary for hemostasis. Reprinted from Reed WP, Moody MR, Newman KA, Light PD,
Costerton JW: Bacterial colonization of Hemasite access devices. Surgery 99:308-316, 1986,
with permission.
attached to the exit port (figure 7-12). The graft is detached from the vein,
which is closed with polypropylene glycol only if needed for hemostasis. The
venous limb is elevated out of the wound to permit the device to be dissected
from its bed to a point just short of the arterial anastomosis (figure 7-13).
Usually only the Dacron-covered portion of the device will give any difficulty
in this dissection. The PTFE is cross clamped as close as possible to the arterial
anastomosis without actually exposing the artery. This generally leaves a 1-2
cm stump of graft beyond the artery wall. The Hemasite is amputated, leaving
the clamp on the remnant. The remnant is closed with a basting suture of 5.0
polypropylene glycol and covered with a loose approximation of subcutaneous
tissue (figure 7-14). The skin edges are left open but not packed apart. Most
patients will heal completely and rapidly after graft removal. One patient in
three will develop persistent drainage from the arterial remnant that will require removal of the remaining PTFE. This should be performed under general
anesthesia, with a tourniquet available to provide hemostasis if proximal vessel
control is not possible. Usually this revision can be carried out as an elective
procedure at a time when most of inflammatory reaction from the Hemasite
infection has subsided.
105
Figure 7 -14. The graft has been removed and the opening in the vein has been closed. A small
stump of PTFE has been left attached to the artery to avoid arterial dissection and repair through
inflamed tissues. With subcutaneous tissue loosely approximated over this bed, most patients will
heal such wounds without the need for further revision. Reprinted from Reed WP, Moody MR,
Newman KA, Light PD, Costerton JW: Bacterial colonization of Hemasite access devices.
Surgery 99:308-316, 1986, with permission.
7. LONG-TERM FUNCTION
The first human implant of a Hemasite device was in July 1980. Since then
some 3000 devices have been used worldwide. Patient acceptance of the device
has been excellent because of its convenience and pain-free access [15]. The
simplicity of needle insertion and withdrawal has allowed previously reluctant
patients to convert to home dialysis programs. The cost of the device ($3000
per unit) has deterred wider application.
Long-term patency data has been maintained for nearly a third of the devices
used to date, 672 of which have been the grafted variety (figure 7-15). Overall
graft survival in this group has been 61 % at one year, 38% at two years, 23%
at three years, and 19% at four years. During the first two postimplant years,
24% of Hemasites have been removed for infection, 18% for unrelated patient
death or transplant, 14% for thrombosis, and 6.6% for miscellaneous reasons,
such as erosion-associated hemorrhage from the graftless device [8].
These survival rates seem poor when compared to the 80% to 88% one-year
and 72% to 86% two-year patency reported for autogenous vein fistulas [16,
106
HMl000 SURVIVAL
CUM SUR
'0
~
~
~
~
0
0
.
0
N
~
0
0
Days Post Implant
Figure 7-15. Overall survival of 672 grafted (graftless devices excluded) Hemasite devices
includes all sites of implantation. A 95% confidence interval is also plotted with cumulative
survival to 48 months.
17]. It should be noted, however, that 20% to 30% of such fistulas fail to
mature sufficiently to be useful clincially [17, 18]. These early failures are often
omitted from the survival curves, giving an inflated picture of success. Nevertheless, the direct arteriovenous fistula described by Brescia [19] is the most
durable access available for long-term hemodialysis when it is successfuL For
the fortunate patient, one or two forearm fistulas may satisfy a liftime of access
needs. Clearly, the expense of the Hemasite and its relatively high complication
rate make it an inappropriate choice for primary access when a standard vein
fistula will do.
Actually, except in the patient with a strong phobia for needles, the Hemasite
has not generally been used for primary access. It is the patients with poor
peripheral veins, such as the intravenous drug abuser, the obese patient or the
patient with mulitple prior access failures who have most often been considered
for Hemasite access because the device does not require adequate superficial
veins for implantation. Some patients have had as many as 20 failed access procedures prior to implantation of the Hemasite [20]. In our own series, fully one
third of the candidates were obese [7]. It is little wonder that the patency rates
of the Hemasite do not match those obtained with primary-access autogenous
vems.
The Hemasite survival looks better in comparison with bovine carotid
artery heterografts and standard PTFE grafts, the other major vein substitutes
used for secondary access [8]. With survival at 12 and 24 months in the range
of 79% and 64%, PTFE grafts provide somewhat better survival than the
Hemasite. Multiple operative revisions may be necessary to maintain this
degree offunction, however [21]. Bovine grafts seem to do a little worse, with
107
1.0
0.9
08
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0"--_-'-_-'-_--'-_--'-_--'_ _" ' - _ - ' - _ - "
100
200
300
400
500
600
700
800
Days Post Implant
Figure 7-16. Hemasite survival for nonobese (open circles) versus obese (open squares) patients.
The differences are significant, p = 0.009. Reprinted with permission from Reed WP, Sadler JH.
Experience with a needleless vascular access device (Hemasite) for hemodialysis. SMJ 77:15011505, 1984.
survivals at 12 and 24 months of 58% and 37%, respectively. Neither of these

conduits provides the comfort available with the Hemasite, and both require
maturation time before they can be used. Even though PTFE and bovine
heterografts have no skin exit site, infection rates as high as 20% have been
reported with each of these materials as well [22, 23].
The reported performance of Hemasites, PTFE, and bovine heterografts as
secondary access materials varies enormously from center to center [8], indicating that none is a panacea for the troublesome patient. While an average of
this variable experience suggests a Hemasite longevity that is less than that
seen with PTFE, under ideal circumstances the patency rates are pretty well
matched [8, 24]. The Hemasite does offer pain-free access, which requires less
skill to achieve, and transeptal declotting, which reduces the cost and discomfort of maintaining patency.
The Hemasite experience gathered to date suggests several approaches to
improving the results in the future. Obesity should be considered a relative
contraindication to Hemasite implantation. The presence of large amounts of
subcutaneous fat introduces laxity in the tissues, which interferes with stabilization of the exit port. Poor healing results, with early and repeated infections
[7]. When used in this setting, more than half of the devices have failed within
six months (figure 7-16). These patients are better served with another choice
of access, such as the long-term central venous catheter [25].
Reference has already been made to the problems inherent in the graftless
Hemasite. Longevity was so poor with this modification (figure 7 -17) that its
use has been discontinued. The best results have been obtained with the grafted
device in an upper-arm location (figures 7-18 and 7-19). Longevity for the
Hemasite in this location may be as high as 85% at 24 months, but careful
108
100 N _ 611
Days Post Implant
Figure 7-17. Survival of grafted versus graftless Hemasite devices. Survival is 19% greater
at 12 months and 26% greater at 24 months with the grafted device. Reprinted from Cosentino
LC: Hemasite Symposium Introduction. In Fischbach LJ (ed) 1984 Hemasite Symposium.
Minneapolis, MN: 1984, Renal Systems, p V, with permission.
0;
.~
::I
en
Q)
>
"5
::I
"$
20
360
Days Post Implant
Figure 7-18. The effects of antibiotic therapy on the survival of grafted Hemasites for all sites.
"All centers" represents the 24-month multicenter results for all sites using grafted devices only.
Improved survival is noted for "Center 1," the original implanting hospital, where an aggressive
policy of antibiotic treatment for Hemasite infections has been pursued. "Center 91" represents
the results that "Center 1" would have obtained if each first infection had resulted in graft loss.
Reprinted from Cosentino LC: Hemasite Symposium Introduction. In: Fischbach LJ (ed) 1984
Hemasite Symposium. Minneapolis, MN: Renal Systems, 1984, p XVI, with permission.
109
20
380
""
Days Post Implant
Figure 7-19. The effect of antibiotic therapy on grafted upper-arm Hemasite survival. "All
centers" represents the 24-month multicenter results for upper-arm Hemasite implants, using
grafted devices only. "Center 1," with an aggressive policy of antibiotic therapy for Hemasite
infection, demonstrates improved survival. "Center 91" represents the results that "Center 1,"
would have obtaiued if each first infection had resulted in Hemasite loss. Reprinted from
Cosentino LC: Hemasite Symposium Introduction. In: Fischbach LJ (ed) 1984 Hemasite
Symposium. Minneapolis, MN: Renal Systems, 1984, p XIX, with permission.
scrutiny and early agressive treatment of infection is required to achieve this

sort of result. Data from the center with the best reported results (figures 7 -18
and 7-19, Center 1) show that longevity is no better than average if the firstdevice infection is assumed to lead to Hemasite loss. When infections are treated
effectively, longevity becomes acceptable.
In summary, the Hemasite can, with appropriate care, provide access of
reasonable longevity. It offers greater comfort and convenience than other devices, but at greater expense and with greater susceptibility to infection (table
7-1). Limiting its use in the very obese and selecting a brachial implanatation
Table 7-1. Relative advantages and disadvantages of hemodialysis access devices
A V fistula
Needle pain
Maturation time
Access simple technically
Post dialysis bleeding
Longevity
Infection
Thrombosis
Cost
+
++
+
+
+++
Hemasite
+++
+
++
+
+++
PTFE
Bovine
++
+
+
+
+
+
+
+
++
+
+
+
+
++
+
110
site whenever possible should improve the overall performance of the device.
The Hemasite is inappropriate for primary access, except in cases when fear of
venipuncture may adversely affect the outcome.
REFERENCES
1. Ishihara AM: The current state-of-the-art for vascular access in hemodialysis. Contemp
Dialysis 1:29-36, 1980.
2. Thomas GI: Large vessel applique ateriovenous shunt for hemodialysis. Am J Surg
120:244-248, 1970.
3. Butt KMH, Friedmann EA, Kountz SL: Angioacess. In: Current Problems in Surgery, vol 13,
No 9. Chicago: Year Book Medical Publishers, 1980.
4. Shapiro FL, Keshaviah PR, Carlson LD, Martinez FJ, Amiot BP, Cracauer RF, Cosentino
LC: Blood access without percutaneous punctures. Proc Clin Dial Transplant Forum
10:130-137, 1980.
5. Collins AJ, Shapiro FL, Keshaviah P, Illstrup K, Andersen R, O'Brien T, Martinez FJ,
Cosentino LC: Blood access without skin puncture. Trans Am Soc Artif Intern Organs
27:308-313, 1981.
6. Mcintyre KE, Putnam CW: A new dialysis access device. Surg Gynecol Obstet 156:804-807,
1983.
7. Reed WP, Sadler JH: Experience with a needleless vascular access device (Hemasite) for
hemodialysis. South Med J 77: 1501-1505, 1984.
8. Cosentino LC: Hemasite Symposium Introduction. In: Fischbach LJ (ed) 1984 Hemasite
Symposium. Minneapolis, MN: Renal Systems, 1984.
9. Carter KH: Clinical experience with a traumatic vascular access for dialysis. Contemp Dialysis
3:24-30, 1982.
10. Dienst SG, Oh HK, Levin NW, Kallioinen S: A comparison of dialysis access grafts. Trans
Am Soc Artif Intern Organs 29:353-356, 1983
11. Kaplan AA, Grant J, Galler M, Galen MA, Longnecker RE: Regional experience with the
Hemasite no-needle access device. Trans Am Soc Artif Intern Organs 29:369-372, 1983.
12. Reed WP, Moody MR, Newman KA, Light PD, Costerton JW: Bacterial colonization of
Hemasite access grafts. Surgery 99:308-316, 1986.
13. Ilstrup K, Collins A, Hanson G. Keshaviah P: Repeatable access blood flow (ABF) measurement. Trans Am Soc Artif Intern Organs Soc 30:338-341, 1984.
14. Jain KM, Patil KD: Thrombectomy of a Hemasite graft. Am J Surg 167:696-697, 1984.
15. Levin NW, Donald LL, Edwards S, Zasuwa G: Comparing vascular access methods. Trans
Am Soc Artif Intern Organs 29:782- 784, 1983.
16. Aman LC, Levin NW, Smith DW: Hemodialysis access site morbidity. Proc Clin Dial
Transplant Forum 10:277-284, 1980.
17. Winsett OE, Wolma FJ: Complications of vascular access for hemodialysis. South Med J
78:513-517, 1985.
18. Corry RJ, Patel NP, West JC: Surgical management of complications of vascular access for
hemodialysis. Surg Gynecol Obstet 151:49-54, 1980.
19. Brescia MJ, Cimino JE, Appel K, Hurwich BJ: Chronic hemodialysis using venipuncture and
a surgically created arteriovenous fistula. N Engl J Med 275:1089-1092, 1966.
20. Kaplan AA, Sosler G, Longnecker RE: Use of the Hemasite device in patients with multiple
access failures. Dialysis and Transplantation 14:288-309, 1985.
21. Etheredge EE, Haid SD, Macser MN, Sicard GA, Anderson CB: Salvage operations for malfunctioning polytetrafluoroethylene hemodialysis access grafts. Surgery 94:464-470, 1983.
22. Bhat DJ, Tellis VA, Kohlberg WL, Driscoll B, Veith FJ: Management of sepsis involving
expanded polytetrafluoroethylene graft for hemodialysis access. Surgery 87:445-450, 1980.
23. Anderson CB, Sicard GA, Etheredge EE: Bovine carotid artery and expanded poly tetraflurosethylene grafts for hemodialysis vascular access. J Surg Research 29:184-188, 1980.
24. Collins AJ, Ilstrup K, Keshaviah P, Shapiro F: Multicenter clinical experience with the
Hemasite blood access device. Trans Am Soc Artif Intern Organs 29:789- 790, 1983.
25. Reed WP, Light PD, Sadler JH, Ramos E: Alternative vascular access in patients lacking veins
for standard arteriovenous fistulae. P Eur Dial 21:257-261, 1985.
8. ANGIOGRAPHY FOR STUDYING

HEMODIALYSIS VASCULAR ACCESS
ENRIQUE M. BURSZTYN
In the vascular access for hemodialysis, angiography is a prerequlSlte in

1) studying the patient's vascular bed to determine the choice of surgical
procedure, 2) determining the cause of a malfunctioning vascular access, and
3) selecting the appropriate treatment of the failing graft or arteriovenous
fistula. In addition to the traditional methods of venography and arteriography,
the most recent techniques of digital angiography and angioplasty will be
described in this chapter. Today there are basically two types of vascular access
used in chronic dialysis patients: the arteriovenous anastomosis initially described by Brescia et al. in 1966 [1] and the secondary or prosthetic graft using
autologous artificial or semi artificial material. The radiologic findings related
to failure of both types of vascular access will be illustrated.
1. VENOGRAPHY
This method was originally introduced by Staple in 1973 [2]. The access is
examined in a retrograde fashion from the venous side. The site of the fistula is
located by a thrill, and vein puncture is usually easy in the dilated forearm
veins, enlarged as a result of the created shunt. A total of 30 cc of contrast is
injected downstream from the anastomosis. Before the injection, the circulation
is stopped by a cuff inflated beyond the systolic pressure, as described by
Gilula et al. [3]. The pressure cuff is rapidly released during the injection and
filming is done at a rate of two exposures per second. This technique allows
111
112
Figure 8-1. Venography of an arteriovenous fistula. Simultaneous opacification of the vein and
artery (arrow). From Staple TW: Retrograde venography of subcutaneous arteriovenous fistulas
created surgically for hemodialysis. Radiology 106:224-225, 1973.
retrograde filling of the anastomosis and proximal artery (figure 8-1). This
method is simple and safe, however, the procedure is limited to the evaluation
of increased graft resistance or "graft hypertension," that is, the malfunction
of the graft or graft-venous anastomosis. Therefore, it presupposes that the
problem is localized to those areas that are impossible to determine prior to
angiography in many instances [4]. In addition, thrombosis has been reported
in a few instances related to the prolonged inflation of the cuff. The procedure
is now being used only in institutions where digital angiography is not available.
8. Angiography for studying hemodialysis
Signal
, level
Pixel
value
White
11000
Black
10
White
flO00
Black
' r ~oo
"
iii
~
-f...
}"~
f~ 500 t: :t - ::
"
,
"
'i'''
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~vesselS
ii~;
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113
- 500
0'
t\
::
I
:
/~
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iii
r- -~-r-~~
!! !
-=---~
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Figure 8-2. Schematic procedure for digital substraction angiography. a: Signal levels on the line
across the mask image. b: Injection of contrast medium gives reduced signal levels where blood
vessels cross the image line. c: After substraction of the two image lines, only the differences
representing the blood vessels are left. d: Enhancement makes the difference visible to the human
eye. From Winkels TGW: The Philips DVI system: Some specific features. In: Ludwig JW (ed)
Digital Substraction Angiography in Clinical Practice. Best, The Netherlands: Philips Medical
Systems, 1986, pp 33-49.
2. DIGITAL SUBSTRACTION ANGIOGRAPHY (DSA)
2.1. Introduction
Digital angiography was first applied in clinical practice in 1980 following the
investigations of Mistretta et al. [5,6]. The method is based in substraction and
enhancement. Substraction is the main processing procedure in DSA. An
image, the mask, made before the arrival of contrast medium in the blood
vessel and images obtained after the arrival of contrast are logarithmically substracted. The possibility of enhancement of the vessel contrast after substraction
is the most important feature of DSA. Figure 8-2A shows the signal level or
brightness of a line across a mask image. For optimum display, the whole
brightness range (from black to white) has to be used. The injection of contrast
material will result in a decreased signal level where the vessels cross the image
line (figure 8-2B). After substraction of the two image lines, only the differences, in this case the vessels, are left (figure 8-2C). Enhancement will now
114
Proc:es3Kog
~---------------------
Figure 8-3. Diagram of a digital angiogram suite. From Winkels TGW: The Philips DVI system:
some specific features. In: LudwigJW (ed) Digital Substraction Angiography in Clinical Practice.
Best, The Netherlands: Philips Medical Systems, 1986, pp 33-49.
make small contrast differences visible to the human eye (figure 8-2D). The
application of these principles requires a very sophisticated system where a
computer regulates the image acquisition process as well as the processing and
display functions. The computer is interfaced with the generator, image intensifier, TV camera tube, and digital substraction unit (figure 8-3). The x-ray
densities from the patient are converted into a light image by the image intensifier. The light image is then converted into a pattern of electrical changes
in the TV camera. The pattern of electrical charges is scanned, providing the
video signal. The analogue video signal is converted to numerical (digital)
values by the analogue-digital converter. After processing, each numerical
value is converted back into an analogue video signal by a digital-analogue
converter for display on a monitor. Hard copies can be made by the hard
copy unit. Storage of individual images is also provided for post examination
evaluation and processing.
2.2. Procedure
An antecubital vein opposite to the site of the fistula or graft is used and a 5
French pigtail catheter is introduced into the right atrium. Forty cubic centimeters of contrast are injected, at a rate of12 cc per second using a high-pressure
injector. The contrast is followed by 20 cc of 5% glucose solution to improve
the flow of the bolus of contrast. The images obtained include the arterial inflow, arterial and venous side of the fistula, or loop of the graft. Imaging is
115
Figure 8-4. Digital substraction angiography of an arteriovenous fistula. Severe stenosis of both
the arterial (arrow) and venous side (small arrow) is shown. From Bursztyn EM, ShanfK, Berger
ST: Digital intravenous angiography for the study of hemodialysis vascular access. Nephron
44:85-88,1986.
done on a 9 inch (or larger) image intensifier. The usual rate is one frame/
second. The injection mask delay is variable and is related to the location of the
area to be imaged. Exposure is started before the injection, and the number of
images is determined by visual monitoring. There are multiple advantages to
this procedure as compared to conventional angiography, as reported in our
previous publication [7]. The technique is extremely safe. The complications
reported in the early development of this procedure have been mild and are
now easily avoidable. The major problem found initially was the extravasation
of contrast medium (0.13% of cases) into the m ediastinum related to whipping
of a catheter with few or no side holes in the superior vena cava. This problem
is avoided by using a multi-side-hole pigtail catheter in the right atrium and by
setting a rise in the linear rates of the power injector [8, 9]. The cost of digital
angiography is considerably lower than conventional angiography [10, 11],
both in the North American [8] and European experience [10]. DSA doubles
throughout and reduces variable costs (film, contrast medium, catheters) to
less than 30% of those of conventional angiography. The overall cost of the
116
Figure 8-5. Digital substraction angiography of the subclavian vein. Complete occlusion of the
subclavian vein (arrow) with extensive collateral veins (cross-hatched arrow). From Bursztyn E,
Sharif K, Berger SJ: Digital intravenous angiography for the study of hemodialysis vascular
access. Nephron 44:85-88, 1986.
technique is about 50% of that of angiogra phy [11]. The procedure can be performed safely on an outpatient basis, and the radiation dose is considerably
lower than in conventional angiography.
2.3. Findings
A repeated and frustrating problem in regular dialysis therapy is the failure of

the dialysis fistula or graft as a result of thrombosis, which is usually preceded
by a period of diminished thrill and venous congestion [12, 13]. In most cases,
the underlying cause is stenosis of the proximal vein close to the anastomosis
site. [14, 15]. The etiology of the stenosis is unclear and may be related to
surgical trauma or the turbulence of arterial blood flowing in a low-resistance
vein, leading to fibrosis [16]. Stenosis may also occur due to progressive
pseudointimal hyperplasia. Others have suggested accelerated venous atherosclerosis in association with fistulas [17]. Although arterial stenosis is much
less common than venous stenosis (only 12% -15% of cases), it can sometimes
117
Figure 8-6. Digital substraction angiography of an arteriovenous fistula. Patient with direct
anastomosis of the radial artery (open white arrow) to a vein at the wrist (black arrow). The
proximal venous end of the fistula is occluded (closed white arrow). There are large venous
varicosities secondary to the proximal obstruction. From Glanz S, Bashist B , Gordon DH, Butt
KM, Adamsons R: Angiography of the upper extremity access fistulas for dialysis. Radiology
143:45-52, 1982.
be associated with venous stenosis (figure 8-4). Venous stenosis could occasionally occur far from the anastomotic site, as proximal as the axillary vein.
The cause is unclear, but a hypertrophic valve has been found as an unusual
cause [14]. DSA allows precise diagnosis by prolonged filming in the proximal
veins (figure 8-5). Prolonged venous hypertension as a result of stenosis can
result in incompetence of the venous valves and retrograde flow with distal
extremity varicosities (figure 8-6).
The most common approach for dialysis access is the Brescia-Cimino art-
118
119
Figure 8-8. Digital substraction angiography of an arteriovenous fistula. The fistula situated
above the elbow is open (arrow). The distal arterial flow is very poor (short arrow). From
Bursztyn E, Sharif K, Berger SJ: Digital intravenous angiography for the study of hemodialysis
vascular access. Nephron 44:85-88, 1986.
eriovenous fistula. This approach is preferred because of the longer survival

time, as well as a smaller incidence of thrombosis and infection than with artificial grafts [18, 19]. The usual surgery is a side-to-side fistula between the
radial artery and the cephalic vein in the forearm . If the anastomosis is larger
than 10 mm, excessive flow and high output failure may occur [20, 22].
Although high-output failure is usually multifactorial and causes such as fluid
overload should be ruled out, DSA frequently shows excessive shunting
(figures 8-7 A and 8-7B). Bandage of the fistula is the treatment of choice in
these cases. Excessive shunting can also produce poor distal arterial flow and
ischemia [23] (figure 8-8). As complications occur, revisions with more
Figure 8-7. Digital substraction angiography of an arteriovenous fistula. A: Shunting with

prominent collaterals (short arrow), cephalic (long arrow) vein, and specially basilic vein (crosshatched long arrow). B: There is poor arterial flow below the elbow (arrow). From Bursztyn E,
Sharif K, Berger SJ: Digital intravenous angiography for the study of hemodialysis vascular
access. Nephron 44:85-88, 1986.
120
Figure 8-9. Digital substraction angiography of an arteriovenous fistula. Stenosis of the venous
side (short arrow) and pseudoaneurysm next to it (arrow). From Bursztyn E, SharifK, Berger Sj:
Digital Intravenous angiography for the study of hemodialysis vascular access. Nephron 44:
85-88, 1986.
proximal fistula are created, with an increased incidence of motor and sensory
neuropathy.
Pseudoaneurysms are usually found at the site of the needle puncture, usually
related to poor compression technique postdialysis and hematoma formation.
Venous graft hypertension with narrowing of the venous side of the anastomosis is thought to be an important prerequisite for false aneurysm formation
(figure 8-9). Pseudoaneurysms also occur in the loop of PTFE grafts (figure
8-10). True venous aneurysms (figure 8-11) have been reported and are probably related to venous hypertension and proximal vein stenosis. These are
of no clinical significance unless they show progressive enlargement [14].
Thrombosis is the most serious complication of the access and accounts for
87% of the fistula failures [24]. The underlying cause is usually poor venous
runoff. Dissection of the intima by repeated puncture has been advocated as a
cause for obstruction leading to thrombosis [20] . If thrombosis is confirmed,
surgical thrombectomy is usually done under local anesthesia. Angiography
can then determine the cause of thrombosis as well as possible options, as will
be discussed in the next section.
121
Figure 8-10. Digital substraction angiography of a Gore-Tex (PTFE) graft. Two pseudoaneurysms are seen in the loop of the Gore-Tex graft (arrows). From Bursztyn E, Sharif K, Berger
SJ: Digital intravenous angiography for the study of hemodialysis vascular access. Nephron
44:85-88, 1986.
3. ROLE OF THE RADIOLOGIST IN THE TREATMENT OF

THE COMPLICATED HEMODIALYSIS ACCESS:
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY
3.1 Introduction
Percutaneous transluminal angioplasty (PTA) has become the procedure of

choice for the dilatation of a wide variety of vascular stenosis. Several recent
reports have focused on the application of this procedure to obstructed veins
and grafts [25-27] and also stenotic lesions in the dialysis access fistulas and
grafts [28-33].
3.2. Procedure
Dilatation is usually done with an oversized (8 or 10 mm in diameter), highpressure (8-10 atm) balloon. The large size and pressure needed is related to
the considerable hyperplasia and fibrosis usually found in the vascular access
[33]. Inflation and deflation of the balloon is done several times for about six
Figure 8-11. Digital substraction angiography of an arteriovenous fistula . Multiple venous

aneurysms (arrows) . From Bursztyn E, Sharif K, Berger SJ: Di gital intravenous angiography for
the study of hemodialysis vascular access. Nephron 44:85-88, 1986.
Cephalic
Ve in
Rad ial
Artery
Prox imal Artery
Distal Ve in
Catheter
D I.tal Artery
Figure 8-12. Side-to-side arteriovenous fistul a. The catheter is seen entering the distal vein.
From Hunter DW, Castaneda-Zuniga WR, Coleman CC, Young AT, Salomono witz E, Mercado
S, Amplatz K: Failing arteriovenous dialysis fistulas: Evaluation ana treatment. Radiology 152:
631-635,1984.
123
Figure 8-13. Conventional angiography of a graft. Left: Arterial injection of contrast

medium shows thrombosed graft anastomosis and the artery (white arrow) is patent. Right: After
infusion of streptokinase, the thrombus has partially lysed. The contrast medium extravasates into
the soft tissues (white arrow). Stenosis is seen at venous anastomosis (black arrows). From
Young AT, Castaneda-Zuniga WR, So SKS, Mercado S, Cardella JF, Amplatz K: Thrombosed
synthetic hemodialysis access fistulas: Failure of fibrinolytic therapy. Radiology 154:639-642,
1985.
minutes. Pressure gradients across the lesion are measured prior to the procedure. A gradient of 20 mmHg or greater is considered a good indication for
angioplasty. They are also measured after the procedure, and if the pressure
measurements indicate inadequate dilatation, Teflon dilators up to 12 French
size are passed through the lesion. In the case of radial artery-cephalic vein
anastomosis, the distal vein is used as the entry point in all cases of proximal
vein stenosis or occlusion (figure 8-12), and the entry is usually 2 em away
from the anastomotic site since stenosis [34, 35] too close to the puncture is difficult to negotiate [29]. Anastomotic occlusion is approached from the arterial
side since attempts through the venous side usually fail. The reason seems to
be that the occlusion is usually on the venous side and localization of the
anastomosis is very difficult with this approach. The distal artery is used in
these cases since damage to this vessel has no clinical consequences. The proximal artery is used when the distal artery is severely damaged or the distal artery
is difficult to negotiate. Arteriovenous fistulas occluded within a few days or
0(
124
...
N
\11
Figure 8-14. Angiogram of a dialysis graft. A: tight stenosis proximal to the venous anastomosis (open arrow); B: widening after angioplasty (closed
arrow); C: Three years later there is recurrent stenosis (arrowhead). 0: recurrent stenosis again responds nicely to dilatation (arrowhead). From Glanz S,
Gordon D, Butt KMH, Hoong J, Adamson R, Scalfani SJA: Dialysis access fistulas: Treatment of stenosis by trans luminal angioplasty. Radiology 152:
632-642. 1984.
126
weeks of their creation or those that have a weak thrill postoperatively are
usually not amenable to angioplasty and should undergo surgical revision [29].
In cases of extensive thrombosis, fibrinolytic therapy has been attempted with
the use of local infusion of streptokinase and heparin in arterial and venous
occlusions [36, 37]. In the case of dialysis access, although there are some
satisfactory results, the results have been disappointing, especially in PTFE
grafts, due to the high risk of bleeding at the site of puncture [38] (figure
8-13). Young et al. have abandoned the use of local fibrinolytic therapy and
have demonstrated that the failure of this treatment is due to the bleeding
around the graft caused by lysis of the blood clot that usually covers the
puncture site [39].
3.3. Results
The overall success rate of angioplasty is about 70% initially, with a patency
rate of over 50% after one year, as reported by Glanz et al. [35, 36]. The procedure can be performed on an outpatient basis and can be repeated in case of
restenosis (figures 8-14A through 8-14D). The patency three years after
angioplasty is only about 30%, but since these patients are usually subject to
numerous surgical procedures, prolongation of the fistula's life for a year or
longer makes it a worthwhile procedure. Complications of angioplasty are uncommon (less than 5%) and include intimal flap at the angioplasty site, thrombosis, pseudoaneurysm formation, hematoma, and infection. This type of
dilatation is usually very painful. X ylocaine is injected in the stenotic area to
control pain and vasospasm.
4. CONCLUSION
Digital substraction angiography (DSA) is the procedure of choice for studying

the failing hemodialysis vascular access. If thrombosis is confirmed, the patient
is usually taken to the operating room and thrombectomy can be performed
under local anesthesia. After thrombectomy, the digital angiogram is repeated
to evaluate the reason for the thrombosis and to determine if the patient is a
candidate for angioplasty. In the case of stenotic lesions, transluminal angioplasty guided by digital angiography is the procedure of choice. DSA and
angioplasty can be performed, if available, in the operating room immediately
after thrombectomy.
Close cooperation between the vascular surgeon and the radiologist is essential in the approach to the failing dialysis vascular access.
REFERENCES
1. Brescia NJ, Cimino JE, Appel K, Hurwich BJ: Chronic hemodialysis using venipuncture and
surgically created arteriovenous fistula. N Engl J Med 275: 1089-1092, 1966.
2. Staple TW: Retrograde venography of subcutaneous arteriovenous fistulas created surgically
for hemodialysis. Radiology 106:223-224, 1973.
3. Gilula LS, Staple TW, Anderson CB, Anderson LS: Venous angiography of hemodialysis
fistulas. Radiology 115:555-562, 1975.
127
4. Thomsen MB, Stenport G: Evaluation of clinical examination preceding surgical treatment of

A V-fistula problems. Is angiography necessary? Acta Chir Scand 151: 133-137, 1985.
5. Kruger R, Mistretta C: Digital image processor for real time x-ray substraction. Optical Eng
17:652-657, 1978.
6. Ort G, Mistretta C, Kelcz F: An improved technique for enhancing periodic changes in television fluoroscopy. Opital Eng 12:169-175, 1973.
7. Bursztyn EM, Sharif K, Berger SJ: Digital intravenous angiography for the study of hemodialysis vascular access. Nephron 44:85-88, 1986.
8. Pinto RS, Rosen RJ: Clinical applications of intravenous angiography. Applied Radiology
12:77-87, 1983.
9. Van Der Put TH: Cost/benefit calculations for digital substraction angiography. In: Ludwig
]W (cd) Digital Substraction Angiography in Clinical Practice. Best, The Netherlands: Philips
Medical Systems, 1986, pp 183-190.
10. Winkels TGW: The Philips DVI system: Some specific features. In: Ludwig]W (cd) Digital
Substraction Angiography in Clinical Practice. Best, The Netherlands: Philips Medical
Systems, 1986, pp 33-49.
11. Pinto RS, Manuell M, Kricheff II: Complications of digital intravenous angiography. Experience in 2,488 cervi co-cranial examinations. Am J Neuroradio 5:553-557, 1984.
12. O'Reilly RF, Hansen CC, Rosenthal ]]: Angiography of chronic hemodialysis arteriovenous
grafts. Am] Roentgen 130:1105-1113, 1978.
13. Gothlin J, Lindstedt E: Angiographic features of Cimino Brescia fistulas. Am] Roentgenol
125:582-589,1975.
14. Glanz S, Bashist B, Gordon DH, Butt KM, Adamsons R: Angiography of upper extremity
access fistulas for dialysis. Radiology 143:45-52, 1982.
15. Hughes K, Adams FG, Hamilton DNH: The radiology oflocal complications of hemodialysis
access devices. Clinical Radiology 31:489-496, 1980.
16. Graham LM, Bergen JJ: Expanded polytetrafluoroethylenc vascular grafts: Clinical and experimental observations. In: Stanley JC (ed) Biologic and Synthetic Vascular Prostheses. New
York: Grune and Stratton, 1982, pp 563-586.
17. Stebbens WE, Karmody AM: Venous atherosclerosis associated with arteriovenous fistulas
for hemodialysis. Arch Surg 110: 176-180, 1975.
18. Morgan A, Lazarus]M: Vascular access for dialysis. Am] Surg 129:432, 1975.
19. Hansen OK, Kraft 0, Mauritzen C: Biologic and semibiologic vascular grafts. Surg Gynecol
Obstet 138:940-942, 1974.
20. Butt KMD, Friedman EA, Kowitz SL: Angioaccess. Curr Probl Surg, 9:5-67, 1976.
21. Ahern DJ, Maher JF: Heart failure as a complication of hemodialysis arteriovenous fistulas.
Ann Int Med 72:201-203, 1972.
22. Andersen CB, Codd]R, GraffRA, Grace MA, Haster HR, Newton WT: Cardiac failure and
upper extremity arteriovenous fistula. Arch Int Med 136:292-297, 1976.
23. DePalma]R, Varnix R, BahuthJ, Abukurah A: "Steal" syndrome ischemia, congestive failure
and peripheral neuropathy. Proc Clin Dial Transplant Forum 3:9-11, 1973.
24. Kimnaert P, Vereerstraeten P, Toussaint C: Nine years experience with interval arteriovenous
fistulas for hemodialysis - a study of some factors influencing the results. Br ] Surg
64:242-246, 1977.
25. Zajko AB, McLean GK, Freiman DB: Percutaneous puncutre of venons bypss grafts for
transluminal angioplasty. Am] Roentgenol 137:799-802, 1981.
26. Cope C, Balloon dilatation of closed meso caval shunt. Am] Roentgenol 135:898-993, 1980.
27. Martin EC, Diamond NG, Casarella WJ: Percutaneous transluminal angioplasty in
non-atherosclerotic disease. Radiology 135:27-33, 1980.
28. Hunter DW, Castaneda-Zuniga WR, Coleman CC, Young AT, Salomonowitz E, Mercado
S, Amplatz K, Sutherland DER: Failing arteriovenous dialysis fistulas: Evaluation and
treatment. Radiology 152:631-635, 1984.
29. So SKS, Sutherland DER: Vascular access procedures. In: Najarian JS, Delaney]P (cds)
Advances in Vascular Surgery. Chicago: Year Book, 1983, pp 445-461.
30. Zeit RM, Cope C: Failed hemodialysis shunts - one year of experience with aggressive
treatment. Radiology 154:353-356, 1985.
31. Lawrence PF, Miller F], Mineau DE: Balloon catheter dilatation in patients with failing
arterovenous fistulas. Surgery 89:439-442, 1981.
128
32. Probst P, Mahler F, Krueta A, Descoeudres C: Percutaneous transluminal dilatation for

restoration of angio access in chronic hemodialysis patients. Cardiovasc Intervent Radiology
5:257-259, 1982.
33. Hunter DW, So SKS, Castaneda-Zuniga WR, Coleman CE, Sutherland DER, Amplatz K:
Failing or thrombosed Brescia-Cimino arteriovenous dialysis fistulas. Radiology 149:105109, 1983.
34. Gordon DH, Glanz S, Butt KM, Adamsons RJ, Koenig MA: Treatment of stenotic lesions in
dialysis access fistulas and shunts by transluminal angioplasty. Radiology 143:53-58, 1982.
35. Glanz S, Gordon DH, Butt KM, Joon H, Adamson R, Sclafani SA]: Dialysis access fistulas:
Treatment of stenosis by transluminal angioplasty. Radiology] 52:637-642, 1984.
36. Katzen BT, VanBreda A: Low dose streptokinase in the treatment of arterial occlusions. AmJ
Roentgenol 136:] 171-1178, 1981.
37. Dotter CT, Rosch J, Seaman A]: Selective clot lysis with low dose streptokinase. Radiology
111:31-37, 1974.
38. Rabe FE, Becker GJ, Richmond BD, Yone HY, Holden RW, Dilley RS, Katte EC: Contrast
extravasation through Dacron grafts: A sequelae of low dose streptokinase therapy. Am J
Roentgenol ]38:9] 7-920, ]982.
39. Young AT, Hunter DW, Castaneda-Zuniga WR, So SKS, Mercado S, CardellaJF, Amplatz
K: Thrombosed synthetic hemodialysis access fistulas: Failure of fibrinolytic therapy.
Radiology 154:639-642, 1985.
9. PERCUTANEOUS FEMORAL VESSEL CANNULATION

FOR HEMODIALYSIS
RA YMOND C. VANHOLDER and SEVERIN M. RINGOIR
Hemodialysis made it possible to keep uremic patients alive, and to improve

their quality of life. In order to perform hemodialysis, blood purification
technique access to the vascular bed is a must. Vascular access remains, however, the Achilles heel of modern dialysis.
In the early days of dialysis, access was obtained by arterial and venous
puncture or catheterization. Chronic maintenance hemodialysis on a large
scale only became possible after the introduction of the arteriovenous shunt by
Quinton and Scribner [1], but this access system had numerous problems.
Long-term dialysis without major pitfalls was enabled by the development of
the arteriovenous fistula by Cimino and Brescia in 1966 [2]. Maturation of a
Cimino-Brescia fistula, however, necessitates a waiting time of 3 to 8 weeks.
Therefore, this method is not suitable for acute situations, where a quick access
is needed. Central venous catheterization offers this possibility. The three
most obvious insertion sites are the subclavian, deep jugular, and femoral
veIns.
Femoral vein catheter dialysis was the first approach of this kind ever described and was introduced by Shaldon et al. in 1961 [3]. Since that time, it has
been used with varying success by numerous groups. It became a life-saving
procedure for acute patients in need of dialysis, but it remains difficult to find a
consistent view on this method in the literature; this appears essentially to be
due to methodological differences from unit to unit.
In the present chapter, the catheterization procedure, available catheter
129
130
types, indications, contraindications, complications and the complication profile, and the efficiency of femoral catheter dialysis will be reviewed and compared to other access methods.
1. PROCEDURE
1.1. Strategies
1.1.1. Two needle
Currently, the most frequently used access method in hemodialysis is the two
needle technique, in which a separate inlet and outlet blood access it created
with a continuous blood flow through the dialyzer. Historically, the first
femoral catheter dialyses took place in a two-needle setting. Two possibilities
were used: arteriovenous and venovenous.
1.1.1.1. ARTERIOVENOUS. A catheter is introduced in both the femoral artery
and vein or into a femoral artery and a brachial vein. Several early applications
of femoral catheter dialysis refer to an arteriovenous approach [3-4].
Nowadays, this method has largely been abandoned, except for continuous
arteriovenous hemofiltration (CA VH) [5].
1.1.1.2. VENOVENOUS. One catheter is introduced into the femoral vein.
The blood return catheter is introduced into the same [6-12] or contralateral
femoral vein [13-14], or into a peripheral vein (e.g., the antecubital vein)
[15-16].
1.1.2. Single needle
1.1.2.1. SINGLE LUMEN. The single-lumen, single-needle technique was introduced as an alternative to two-needle dialysis in 1972 by Kopp and Kolff
[17], and soon thereafter this approach was used for femoral vein catheter
dialysis [11-13,18]. The advantage of this technique is that only one vessel is
punctured, which reduces the puncture-related complication risk by 50%.
As shown by our group, the single-needle system, if carefully performed by
pressure-pressure monitoring, allows a dialysis efficiency that is comparable to
the current two-needle systems [19-20].
1.1.2.2. DOUBLE LUMEN. Double-lumen catheters allow the introduction of
one single catheter, together with a continuous blood flow, so that a conventional two-needle setup can be used [21]. Thus, the practical advantages of
a single catheter are combined with a two-needle device infrastructure. The
diameter of these catheters is markedly larger than in single-lumen, singleneedle dialysis. Double-lumen catheters may be coaxial or double-D shaped
(figure 9-1).
1.2. Catheters
The catheter types that are available for central vein catheter dialysis have
been reviewed recently [22]. The same catheters can be used for subclavian,
deep jugular, and femoral vein dialysis. Catheters of different sizes and
lengths, and composed of different biomaterials are available. Other important
9. Percutaneous vessel cannulation
131
f@\
Figure 9-1. Coaxial (left) and doublc-D-shaped structure (right) of double-lumen dialysis
catheter, with indications of inlet and outlet blood flow direction.
characteristics are radiopacity and the presence of side holes and of fixation
points.
1.2.1. Size
Catheters are available with an external diameter from 5 to 12 F (1.66 to 4 mm).

Currently used catheters for femoral vein dialysis in adults are 7 to 8 F (2.33 to
2.66 mm). In children and small adults, catheters with a smaller diameter can
be used. Double-lumen catheters have a larger diameter, in the range of 10 to
12 F (3.33 mm to 4 mm).
1.2.2. Length
A vailable catheters may vary in length from 9 to 25 cm. The longest catheters
are most currently used, except in children and small adults. If the catheter is
too short, this may result in inadequate blood flow and inefficient dialysis. The
longer the catheter, the more important recirculation is in single-lumen,
single-needle dialysis. This will be discussed more extensively at the end of
this chapter.
1.2.3. Biomaterials
A vailable materials are Teflon, polyurethane, and silicone rubber. It was

claimed that polyurethane is less thrombogenic than Teflon [23]. The thrombogenicity of different types of polyurethane may, however, be divergent,
depending on the composition [24]. An advantage of polyurethane is that it
softens when it is warmed to body temperature.
Silicone rubber is a highly flexible material with low thrombogenicity [25].
High flexibility might be a disadvantage for long-term positioning in the
groin. When important negative pressures are built up, inadequate flows may
result from collapse of the catheter. Some catheters are available with heparinbond polymers [22]. This may decrease thrombogenicity. Heparin is, however,
gradually lost from these biomaterials, so that thrombogenicity may increase
over time [26]. With low molecular weight heparin, release is even faster.
1.2.4. Sideholes
Most dialysis catheters are manufactured with side holes. This prevents the
sticking of the catheter to the vessel wall and the blocking of blood movement
132
when high blood flows are pursued. When a heparin lock is applied to catheters
that remain in place for a long time period, this substance may be lost through
the side holes if their number is too high, resulting in thrombus formation.
1.2.5. Radiopacity
Virtually all dialysis catheters that are manufactured nowadays are radiopaque.
This characteristic is of diagnostic importance in dislocation or in catheter
embolism. Nonradiopaque catheters can only be traced by ultrasonography.
1.2.6. Fixation points
Some catheters have specific fixation points that allow their suturing to the
skin. This prevents inadvertent withdrawal but may cause discomfort. Catheter
fixation is specifically indicated in excited, semiconscious, and comatose
patients.
1.3. Insertion
1.3.1. Material
1.3.1.1. GUIDE WIRE. The guide wire (b in figure 9-2), preferably made of
stainless steel, should have a flexible tip at one end. This tip should be
introduced first in order to avoid vessel perforation when the guide wire is
slipped along resistant obstacles such as valves or stenoses. Recently, guide
wires with a curved, J-shaped tip became available; this avoids the introduction
of the guide wire into small secondary vessels, which is a potential cause of
venous perforation. There may be some problems in slipping these J-shaped
guide wires through catheters that are already in position (e. g., in the case of
catheter replacement by the Seldinger technique). In this case, preference can
be given to a guide wire with a conventional, uncurved tip. Guide wires
should be substantially longer than the catheter that is to be introduced.
1.3.1.2. INSERTION NEEDLE. Insertion needles (c in figure 9-2) should preferably be made in one piece and of stainless steel. Plastic insertion needles
necessitate the additional use of an internal metal needle to avoid kinking. The
presence of this metal core makes needle insertion more difficult and is a cause
of inadvertent arterial puncture and vein perforation.
1.3.1.3. CAPS. Caps (a in Figure 9-2) are used to close the catheter after its
use. They are based on the Luer-Lock principle.
1.3.1.4. CONNECTORS. Connectors should allow connection of the catheter(s)
to the dialysis circuit. The connecting system should be Y -shaped in the case of
single-lumen, single-needle dialysis (d in figure 9-2).
1.3.1.5. VESSEL DILATOR. A vessel dilator is only currently used in dual or
double-lumen catheter dialysis.
1.3.1.6. CLAMPS. Clamps are used to close the connector after flushing the
catheter, to prevent blood rebound in the few seconds that precede the
application of the Luer-Lock caps. Connectors are most often delivered by the
manufacturer with clamps in position. If not, clamps should be used that have
133
e
Figure 9-2. Material for femoral catheter insertion. a, cap; b, J-shaped guide wire; c, insertion
needle (one piece - stainless steel); d, Y -shaped connector (for single-lumen, single-needle
dialysis); e, catheter with side holes, a plastic fixation system, and a clamp.
no damaging effect on the delicate plastic structures of the catheter and

connector systems.
1.3.2 . Insertion technique
The patient is placed in the recumbant pOsItiOn. He or she can be left in a

semierect position in the case of fluid overload and left heart decompensation.
The legs are hyperextended, abducted, and rotated outwards. Some authors
place one or two pillows under the buttocks. One or both sides of the groin are
shaved and scrubbed under the inguinal ligament. With the palpating fingers
still in place, local anesthesia is applied to a region, 1 to 2 cm medially from the
femoral artery, and 2 to 3 cm below the inguinal ligament (figure 9-4).
A 16- or 17-gauge needle with a 5 ml syringe is then advanced into the
femoral vein (figure 9-3A). For the insertion, the needle is positioned at an
angle of 30 to 45 to the skin surface. The needle is advanced until venous
blood is easily aspirated. When this is impossible on a first attempt, the needle
position is corrected minimally until the aspiration of blood becomes possible.
The use of a punction needle with a syringe and without a mandrin enables
the quick recognition of a succesful puncture after minimal changes in the
puncture direction.
When venous blood is obtained, further catheter insertion is realized by a
134
I. Va scular access for hemodialysis
135
136
Figure 9-3. Insertion technique of femoral catheters. After the application of local anaesthesia,
the vein is punctured with a metal needle (A). A guide wire is introduced through the needle, and
the needle is withdrawn (B). The catheter is then slipped over the guide wire (C), and the guide
wire is withdrawn (D). Finally, the catheter is threaded to the skin (E).
modification of the Scldinger technique. A guide wire is introduced into the

vein through the needle (figure 9-3). If a resistance is felt, the wire is
withdrawn and a new attempt is made. Resistance is provoked by the presence
of venous valves, stenoses or thromboses, or by the entry of the guide wire
into small secondary veins. If the guide wire is forced through these obstacles,
vessel perforation may ensue when the catheter is slipped over it [10]. When
the patient complains of pain in the back, the guide wire should also be withdrawn and repositioned.
The guide wire should be moved deep into the vessel, over a longer distance
than the length of the catheter. The needle is withdrawn. Then the catheter is
slipped over the guide wire (figure 9-3C), and, when the catheter is in
position, the guide wire is withdrawn (figure 9-3D). Catheters that are moved
forward without the presence of a guide wire, even over a short distance, are
more prone to provoke perforation [27]. Finally, the catheter is sewn onto the
skin (figure 9-3E). The catheter is then flushed with saline, and connected to
the dialysis circuit. The use of a single-needle system necessitates the interposition of a Y-piece (figure 9-5). It may be necessary to apply an additional
skin incision to allow the passage of the catheter through the skin, especially
137
ARTERY
\ VEil
Figure 9-4. Anatomic structures surrounding the femoral vein. The ideal insertion place for
femoral dialysis catheters is 1 to 2 cm medially from the femoral artery, 2 to 3 cm below the
inguinal ligament.
when double-lumen catheters are inserted. Alternatively, a dilator can be used.

When applied in an appropriate way, this use of a dilator may decrease the risk
of infection, compared to the application of a skin incision.
At the end of dialysis, the catheter is again flushed with saline. If the catheter
remains in situ on a continuous basis, intravenous fluids can be given in this
manner, although this carries a risk of infection and thrombosis. Otherwise,
the catheter can be flushed with 5 ml of saline and filled with 1- 2 ml pure
heparin, which remains in place. The catheter is then closed by a clamp and a
Luer-Lok cap. When the catheter remains in place for a longer period, the
insertion site should be disinfected and the dressings should be changed at
regular intervals (every 48 hours), as with subclavian catheters [28].
If the catheter is withdrawn at the end of the dialysis procedure, manual
compression is exerted for at least 10 minutes. In some centers, protamine
sulphate is occasionally administered [29]. Some authors advise further compression [19] and/or the application of a pressure bandage for the next eight
hours [10].
If a venovenous approach is followed, and if a second catheter is introduced
into the same femoral vein, then the two catheters should be advanced into the
138
Figure 9-5. Connection of the femoral catheter to the single-needle dialysis circuit after the
interposition of a Y -piece (arrow) .
vena cava at two different levels. The more advanced catheter is used as a venous
return line, and the more distal catheter is used as the outflow line from the
patient to the dialyzer in order to avoid mixing and recirculation [10].
If an arteriovenous approach is followed, an arterial catheter is inserted by
roughly the same method as described for venous catheterization. The insertion
of the needle in the femoral artery should be performed with necessary care.
The catheters that are used in this case are shorter than those in use for venous
catheterization. At the end of dialysis, compression should be longer than for
the venous approach.
1.4. Timing
1.4.1. Intermittent catheterization
The original concept of femoral catheter hemodialysis is based on an int~r

mittent use [3]; catheters are withdrawn after each dialysis and are reinserted
before the start of the next session. This method has the advantage that the
139
patient experiences no inconvenience from the catheter in the interdialytic

period, and patients have been described that underwent more than 100 consecutive hemodialyses by this method [11, 13-16]. Complications due to the
long-term maintenance of a catheter in the femoral vein are virtually excluded.
A practical inconvenience is caused by the necessity of the presence of a medical
staff member at each insertion. The insertion procedure before dialysis and the
necessary compression of the vascular structures thereafter prolong the duration
of the session by at least 30 minutes. After repeated punctures, the groin may
become infected or fibrosed [16].
1.4.2. Continuous catheterization
Shortly after the introduction of intermittent femoral catheterization for

dialysis, Shaldon et al. started to leave femoral catheters in place for prolonged
periods of time [6, 7]. This approach became less popular after the description
of a number of life-threatening complications with femoral vein catheters that
had been left in place for moderately prolonged periods [10]. Comparative
studies of the intermittent and the continuous femoral approach are, however,
lacking. The main advantage of continuous catheterizaton is, of course, that
the patient does not experience the inconvenience of the repeated puncture of
the femoral vein and that he or she is not at risk for the potential complications
of these repeated catheterizations. On the other hand, the risk of specific complications, due to the prolonged presence of a catheter in the vein, may increase.
2. INDICATIONS
The major advantage of femoral catheterization is that it allows a quick vascular access by the internist or nephrologist in emergency situations, such as
severe fluid overload, hyperkalemia, or intoxication. In contrast to other access methods, no surgical intervention is needed, nor an x-ray control of the
catheter position; thus dialysis, ultrafiltration, or hemoperfusion can be started
within 10 minutes after the medical decision on therapy.
Femoral catheter dialysis may be used as an access for hemodialysis in acute
renal failure. Other acute indications are hemoperfusion for intoxication or
hepatic coma, plasmapheresis, and pure ultrafiltration in diuretic resistant fluid
Table 9-1. Indications for femoral catheter dialysis

Absence of other vascular access
Emergency situations
pulmonary edema
hyperkalemia
intoxication
Subclavian and/ or deep jugular catheterization impossible
Major complications in subclavian and/or deep jugular position
Pulmonary insufficiency
140
Table 9-2. Contraindications for femoral catheter dialysis
Former inguinal or pelvic surgery

Thrombophlebitis/phlebothrombosis of femoral, iliac, or pelvic veins
Recent surgery of the lower abdominal vessels
Renal transplant
Transplantation candidate
(Infection of the abdominal cavity)
overload. If necessary, transition can be made later on to a deep jugular or

subclavian access.
Femoral catheter dialysis may also be used in chronic renal failure in the
absence of an A V fistula or in the presence of a fistula thrombosis, infection, or
hematoma formation. We use it when puncture in the subclavian or deep
jugular regions becomes impossible, when catheters in the latter positions are
withdrawn because of major complications, or when these catheter positions
are contraindicated. Puncture of the femoral region carries no risk of complications in the pulmonary region, such as hemothorax or pneumothorax.
Femoral catheter dialysis is the catheter method of preference in patients with
pulmonary insufficiency, chronic bronchitis, asthma, and restrictive syndrome,
or when the attending doctor has little or no experience or training in the
insertion of subclavian or jugular catheters.
3. CONTRAINDICA TIONS
Former inguinal or pelvic surgery may make femoral catheterization difficult

or impossible. Needle or guide wire insertion may be impeded by the presence
of scars, thromboses, or stenoses. Even if the guide wire can be introduced,
there is a substantial risk of perforation.
Thrombophlebitis or phlebothrombosis of the upper femoral, iliac, or pelvic
veins is an absolute contraindication, as well as recent surgery of the lower
abdominal vessels. The insertion may be difficult in a patient who previously
underwent renal transplantation, because of alterations of the anatomic structures in the inguinal region.
Femoral insertion in potential transplantation candidates is also a relative
contraindication, as complications of the catheter insertion may cause problems at the subsequent implantation of a renal kidney graft [10]. Some
authors indicate infectious processes in the abdominal cavity as a contraindication [30], but this point of view has been contested [13].
4. COMPLICATIONS
Complications can be subdivided in two major classes: those occurring at the

moment of insertion and those specific for a prolonged insertion period. It is
obvious that when an intermittent approach is followed, the risk of insertionrelated complications is substantially increased. Complications due to longterm catheterization are absent in this setting. If catheters are left in place, a
different complication profile ensues.
141
4.1. Local hematoma/bleeding
Local hematoma or bleeding at the puncture site are common complications;

they are aggravated by intradialytic heparinization. Inadvertent arterial puncture is an additional cause of bleeding [20]. Most of these problems are prevented by manual compression for 15 to 30 minutes. Sandbags may also be
used. If necessary, protamine sulphate can be administered as a heparin
antidote.
4.2. Retroperitoneal bleeding
Retroperitoneal bleeding, although rare, is certainly one of the most dramatic

complications of femoral catheter dialysis. It occurs after rupture of the vessel
wall, e. g., when the guide wire or catheter is forced against a resistance [10];
this is mostly due to the introduction in a thrombotic lesion or a secoundary
vessel. The initial picture may be insidious. Acute abdominal pain and
hypotension are characteristic. Shock may ensue if not recognized in time.
Bowel sounds may disappear. Hematocrit values decrease, but not necessarily
from the early start of the symptoms.
Improvement can be obrtained by the infusion of plasma expanders; if fluids
are administered through an incorrectly positioned femoral catheter, plasma
expanders do not appear in the blood but go directly to the abdominal cavity,
where they are of no use. Diagnosis can be made by plain abdominal x-rays,
where psoas shadows become invisible [10]. Other diagnostic means are ultrasonography and computer tomographic scans. Some authors describe a displacement of the bladder wall at cystography [14].
The treatment consists of the prompt arrest of dialysis, eventually combined
with protamine administration. If at the same time plasma expanders are administered correctly, improvement can occur without the need for surgical repair, but some cases necessitate intervention. It may be necessary to perform
further dialysis with locoregional heparinization or to start peritoneal dialysis.
The presence of a large retroperitoneal hematoma may render the blind introduction of a peritoneal catheter more difficult, so that the surgical insertion of a
Tenckhoff catheter becomes more appropriate. At least two fatalities have been
reported in relation to this type of complication [10, 31]. It might, in part, have
been avoided by a more careful catheter insertion. It should, however, be
stressed that spontaneous retroperitoneal bleeding without the presence of a
femoral catheter has also been reported in dialyzed patients [32-34].
4.3. Arterial puncture
Puncture of the femoral artery may be accidental, or intentional in the case of

an arteriovenous approach. Some authors leave the intraarterial catheter in
place in the case of inadvertent arterial puncture and perform dialysis by this
accidental access in a two needle setting before withdrawing the needle [35].
Arterial puncture carries an important risk of bleeding, and meticulous compression during a sufficient period of time should be performed at the
withdrawal of the catheter.
142
In some cases, the subsequent development of arteriovenous fistulae has

been described [36]. In rare cases arterial occlusion may ensue. Dislocation of
atheromatous plaques may cause cholesterol embolisms. Because of these
potential pitfalls, intentional arterial puncture for femoral dialysis is largely
abandoned, except for continuous arteriovenous hemofiltration.
4.4. Thrombophlebitis/phlebothrombosis
Venous occlusion is the consequence of the contact of blood with the foreign
catheter material. Thrombogenicity may be decreased by making the catheter
material more biocompatible andlor by the linking of heparin to the catheter
wall [26].
Thrombophlebitis may be considered as a typical pitfall when the catheter is
left in place continuously for a prolonged period of time. Nevertheless, repeated puncture of the femoral vein before each dialysis during a substantial
number of sessions may also cause local thrombosis. Thrombosis is treated by
the administration of anticoagulants.
4.5. Pulmonary embolism
Thrombosis of the femoral or the inferior caval vein may result in the development of pulmonary embolism. This is a rare but life-threatening complication.
At least one fatal case has been described [30]. It should, however, be taken
into account that many of the patients on femoral dialysis are in a poor general
condition and that they are at risk for pulmonary embolism for other reasons,
such as prolonged immobilization.
4.6. Infection
4.6.1. Local
Infection of the insertion site may occur, especially in the presence ofhematomas. This is a more frequent complication of the repeated predialysis puncture
procedure [11]. An abscess may develop. Surgical drainage is necessary in
some cases.
4.6.2. Catheter infection
The catheter may become infected when it is left in place for a prolonged
period of time. An episode of septicemia may develop. If no other potential
cause for the fever is found, the catheter should be withdrawn immediately,
which is often sufficient to overcome the infectious episode. The catheter tip
should be cultured; if a responsible organism is revealed, Staphylococcus aureus
is registered in more than 50% of infected dialysis catheters [37, 38]. Antibiotics may be administered additionally.
4.7. Peritoneal perforation
Peritoneal perforation could theoretically be the result of making a puncture
143
too close to the inguinal ligament. However, this complication has, as far as
we know, never been described.
4.8. Tears of the catheter wall
Tears of the catheter wall may occur when a catheter is left in place for a
prolonged period of time. Since the groin is submitted to repeated flexion,
tear formation can be frequent, dependent on the catheter material. This also
rna y be a source of bleeding and infection. The catheter should be replaced as
soon as possible. A new catheter can eventually be introduced via a Seldinger
technique.
4.9. Inconvenience
The presence of a continuous catheter in the groin may be a source of inconvenience, especially in ambulatory patients. In general, complaints are minimal.
It is appropriate to hospitalize patients on continuous femoral catheters, at least
during the first days to weeks after the catheter insertion. If thereafter no complications are observed, patients may be allowed to return home between the
dialysis sessions. Repeated puncture of the groin in the intermittent approach
may cause inconvenience as well.
4.10. Neuropathy
In rare cases, development of femoral neuropathy has been described after

puncture of the femoral nerve or after compression due to a hematoma, abscess,
or fibrous tissue [11]. Therapy is aspecific. The risk of this complication is increased when the femoral vein is repeatedly punctured.
4.11. Catheter embolism
As far as we know, catheter embolism has not been described for femoral
catheters, but it has been observed in subclavian catheters [27]. Catheter embolism is a frightening complication if non-radio opaque catheters are used,
because they cannot be traced on plain x-rays. Eventually, their position can be
recognized by ultrasonography. Withdrawal is necessary, in view of the permanent risk of infection when the catheter is left in situ.
4.12. Inadvertent withdrawal
Inadvertent withdrawal may occur in confused or excited patients. It can be

prevented by the fixation of the catheter. Some manufacturers offer catheters
with extra fixation points so that they can be threaded to the skin.
4.13. Inadequate flow
Inadequate flow is the result of the presence of clots in the catheter lumen, with
the catheter continuously in place. It is an epiphenomenon ofbioincompatibility.
It influences dialysis efficiency in a negative way. Replacement of the catheter
via the Seldinger technique most often resolves the problem. It is possible that
144
these occlusions are related to thromboses in the venous vascular access bed,
but clincial signs of phlebothrombosis are rarely found in these patients. If
such inadequate flow occurs frequently, this may be a reason for transition to
intermittent predialysis catheterization.
5. COMPLICATION PROFILE
5.1. Intermittent catheterization
There are at least ten papers in the literature that discuss the complication profile of intermittent femoral catheter dialysis and that are based on populations
of sufficient size. They cover the experience in 13,812 hemodialysis sessions
(table 9-3). Seventy-three major complications were reported (table 9-4).
Bleeding is the most frequent complication. It was registered 24 times, gave
rise to two fatalities, and necessitated surgery in one case. Retroperitioneal
bleeding was observed 11 times, gave. rise to two fatalities, and necessitated
Table 9-3. Complication profile of intermittent femoral catheterization -
studied populations
Authors
Reference
Year
Number of dialyses
Nidus et al:'
Kjellstrand et aL h
Von Klippers et aL
Schleifer et aL
Fuchs et aL
Friedman
Erben et aL
Nidus et aL
Boen ct aL
Sharp et aL
Total
29
10
30
39
11
35
31
16
40
14
1974
1975
1976
1076
1977
1979
1979
1981
1982
1983
600
700
540
139
2,949
1,822
2,367
2,344
1,704
647
13,812
Arteriovenous approach.
hCatheter left ill place up to 48 hours.
,I
Table 9-4. Complication profile of intermittent femoral catheterization (literature review)

Complication
Number
Fatalities
Surgery
Bleeding
Retroperitoneal bleeding
Pain
Arteriovenous fistula
Throm bophlebitis I phlebothrombosis
Pulmonary embolism
Infection
Catheter embolism
Intestinal perforation
Inguinal hematoma
Puncture urinary bladder
Lesion femoral nerve
Total
24
11
2
2
1
5
11
7
4
3
2
6
1
73
145
surgery in five cases. Pain occurred 11 times. Spontaneous formation of an

arteriovenous fistula was observed seven times, mostly in patients where the
arteriovenous approach was used. Three pulmonary embolisms were observed,
and one of them was fatal. Overall, five fatalities were registered. Surgery was
necessary In SIX cases.
5.2. Continuous catheterization
5.2.1. Literature data
Literature data on femoral dialysis catheters left in place are extremely scarce.
Two papers by Raja et al. cover the experience with about 255 and 358 dialysis
sessions [12, 41]. The number of catheter dialysis sessions per insertion were
2.26 and 1.95, respectively. Most frequent complications were arterial puncture, local bleeding, superficial infection, and catheter clotting.
5.2.2. Personal experience
In our dialysis unit in Ghent, femoral catheters have been studied as a possible
or alternative vascular access since 1977. Other catheter insertion sites are the
subclavian and the deep jugular position. All these femoral catheters were used
in a single-needle pressure-pressure setup.
In the ten-year period from 1977 to 1986, 274 patients were treated by
femoral catheterization: 153 presented in acute conditions and 121 were chronic
renal failure patients. The reasons for insertion in the acute group were: acute
renal failure, 94; intoxication, 37; fluid overload necessitating pure ultrafiltration, 13; plasmapheresis, 6; and hepatic coma necessitating haemoperfusion, 3.
The indications for the chronic patients were: lack of access, 72; fistula thrombosis, 28; fistula infection, 11; fistula hematoma, 8; and fistula aneurysm, 2.
In most of these patients, catheters were left in place for a certain period of
time; withdrawal after one dialysis occurred in only 50 cases. Overall, 354
catheters were used, remaining in place for 5.2 15.6 days (mean S.D.) per
patient. In 27 cases, a new catheter was introduced over a guide wire, after
withdrawal of the former one, so that no venous puncture was necessary at the
insertion of a second catheter.
The number of patients treated by femoral dialysis and the number of catheters inserted per year are displayed in figure 9-6. The insertion rate is relatively low in the period from 1979 to 1982, but the overall incidence of patients
treated by catheter dialysis was also low in that period. Femoral catheter dialysis was performed for three days or less in 110 patients. Forty-nine patients
were treated continuously for more than 20 days. More than half of them (n =
28) completed the full course without needing to have the original catheter replaced. In three other patients, the catheter was replaced by Seldinger technique
only, so that no second puncture was necessary. In one patient the catheter was
left in place without problems for 141 days. These data indicate that treatment courses are possible, even when femoral catheters are left in place for
prolonged periods of time. The reasons for withdrawal of the catheters are
146
n
120
Figure 9-6. Total number of patients treated with catheter dialysis in our center per year
(subclavian + deep jugular + femoral): 0; number of inserted femoral catheters: k1!I; number of
patients treated with femoral catheter dialysis: 1llI. Femoral catheter dialysis is used in to '/.
of the overall patient population treated by catheter dialysis.
',I,
illustrated in table 9-5. In a substantial number of cases, catheters were withdrawn for reasons related to the natural evolution of the renal condition (recuperation of renal function in acute renal failure, possible fistula puncture,
death, transition to other treatment). The main "complication" was inadequate
flow (n = 41). This was never related to clinical venous thrombosis. Fever
necessitated catheter extraction on 18 occasions. All other complications occurred less than ten times. One deconnection was followed by shock and death
of a patient.
5.3. Comparison ofintermittent versus continuous catheterization
It is difficult to compare different series, in view of the differences in therapeutic approach and the definition of the complications. If we compare our
personal experience with continuous catheterization (table 9-5) with a literature review of intermittent treatment (table 9-4), then it is clear that traumatic
complications (retroperitoneal hematoma, bleeding) are more frequent in the
Table 9-5. Reasons for withdrawal of femoral catheter (personal experience)

Cessation of treatment
Puncture fistula
Death
Inadequate flow
Infection
Total occlusion
Transition to CAPD
Inadvertent withdrawal
Transfer to other center
146
48
45
41
18
17
9
9
Torn catheter wall

Bleeding
Hematoma
Transition to Hickman a
Subclavia
CAVH b
Local infection
Pulmonary embolism
Kinking
4
4
2
I
I
I
I
I
I
'A Hickman catheter is a silicone catheter in subclavian or deep jugular position that is used for prolonged
vascular access.
hContinuous arteriovenous hemofiltration.
147
latter group. However, we also find complications like infection, thrombosis,

and pulmonary embolism in the group on intermittent catheterization. Our
experience with catheters left continuously in place points to infection as the
main complication of clinical importance. One nonfatal pulmonary embolism
was observed in this group, but no thrombophlebitis. When taking into account the number of dialyses in each group, the number of serious complications seems equally distributed in both conditions. Mortality was also
comparable in both groups (0.036% for intermittent catheterization, 0.053%
for continuous catheterization).
5.4. Comparison with other acute access methods
5.4.1. Theoretical refiections
5.4.1.1 SUBCLAVIAN CATHETERIZATION. The puncture site in subclavian catheterization is near to the lungs. The most dramatic complications of subclavian
catheters are related to events affecting pulmonary function and to traumatic
lesions of the heart and vascular bed [42]. The subclavian procedure is
contraindicated in patients with compromised pulmonary function: in this
case, femoral catheterization should be preferred. Before starting dialysis, a
chest x-ray is necessary after subclavian catheterization in order to check the
catheter position. This makes the subclavian procedure also less suitable in
hyperacute situations. Subclavian catheters necessitate insertion by a skilled
person [43].
Inadvertent arterial puncture makes it necessary to postpone dialysis for 24
hours, because of the risk of hemothorax during heparinization. Prolonged
subclavian catheterization may result in thrombosis or stenosis of the vena
cava, followed by local edema of the arm and/or fistula occlusion if an arteriovenous fistula is constructed at the ipsilateral side [44].
Subclavian catheters are, however, more comfortable than other forms of
catheter dialysis when left in place for a prolonged period of time in ambulatory patients.
5.4.1.2. DEEP JUGULAR CATHETERIZATION. Deep jugular catheterization carries virtually the same risks as subclavian catheterization [45]. Patient discomfort may be compared to that of femoral catheters, due to their positioning in
the flexible neck region.
5.4.1.3. ARTERIOVENOUS SHUNT. Arteriovenous shunts are inserted surgically, which may cause a substantial loss of time in hyperacute situations.
When occluding, they cause the loss of vessels that may be imporant for the
future creation of arteriovenous fistulas. They are, in our opinion, less suited
for acute access procedures than central vein dialysis catheters.
5.4.1.4. ARTERIOVENOUS FISTULA. There is no debate that endogenous arteriovenous fistulas are the most appropriate access in renal patients. They
necessitate surgical intervention. Their maturation over several weeks before
use makes them unsuitable for acute situations.
5.4.1.5. ACUTE PERITONEAL DIALYSIS. The catheter for acute peritoneal dia-
148
Table 9-6. Comparison complication profile for femoral

versus subclavian and deep jugular catheters (personal expcrience)
Femoral
(n = 354)
Flow problems
Systemic infection
Inadvertent withdrawal
Bleeding
Torn catheter wall
Hematoma
Disconnection
Local infection
Pulmonary embolism
Hemothorax
Deep venous thrombosis
Pneumothorax
Air cmbolism
58
18
9
16.4
5.1
2.5
1.1
1.1
0.6
0.3
0.3
0.3
4
4
2
1
0
0
0
0
Subclavian + deep jugular"

(n = 786)
n
%
60
40
44
11
7.6
5.1
5
6
2
0.6
0.8
0.3
4
3
2
1
0.5
0.4
0.3
0.2
5.6
1.4
L1
,IData extracted from Vanholder et a1. [45].
lysis can be positioned as fast as a femoral catheter. Blind positioning may

cause perforation of the intestine. The method is not suited for patients with
abdominal diseases and recent abdominal surgery. The presence of important
quantities of fluid in the abdominal cavity may decrease pulmonary function.
Peritonitis may be a troublesome complication.
5.4.2. Comparative studies
The only effective comparative data that are available relate femoral to subclavian catheter dialysis. A study of Raja et al. pointed to differences in the
number of dialyses per insertion, which were higher for subclavian dialysis
[12]. The number of access-related hospitalization was lower for subclavian
dialysis, whereas the number of outpatient dialyses was higher.
When we compare the complication profile of femoral dialysis in our own
hands to the experience in the same unit with subclavian/jugular dialysis (table
9-6), then it appears that the overall profile is fairly similar. Flow problems are
less frequent in the jugular/subclavian position. No fatalities were seen in subclavian dialysis, versus one in femoral dialysis. Erben et al. observed a similar
low incidence of fatalities with subclavian and femoral dialysis [31]. In general,
complication frequency is thus similar in subclavian and femoral dialysis.
6. EFFICIENCY
Two factors related to vascular access may influence dialysis efficiency: recirculation and dialyzer blood flow. Recirculation is influenced by the quality of
the vascular bed in which the access is positioned (eventual thromboses and
stenoses) [46] and by the common path that is followed by inlet and outlet
blood in the dialysis circuit. Recirculation is specifically inherent to the single-
149
Table 9-7. Efficiency offemoral catheter dialysis

(n = 8) - (m S.D.)
Dialyzer blood flow (QB)
Recirculation (R)
Dialyzer urea clearance" (C u )
<1
20 ml!min
18 8%
134 11 ml!min
257
Corrected for recirculation.
lumen, single-needle technique, although it also occurs in two-needle dialysis.

If the single-needle technique is performed in an appropriate way, recirculation
can be minimized. The length of the catheter, the flow in the caval vein, and
the compliance of the dialysis circuit all may influence recirculation. When a
two-needle technique is performed with two catheters in the same vein, catheter tips should be positioned at different levels to avoid recirculation [10].
Some authors try to obviate the recirculation problem by introducing doublelumen catheters, but the gain in efficiency is often counterbalanced by a loss in
blood flow [47].
Most femoral dialysis systems realize a sufficient blood flow to allow adequate
dialysis. Return of venous blood via a peripheral vein may create resistance and
may impede the creation of adequate blood flow.
Literature data on the efficiency of femoral catheter dialysis are extremely
scarce. A few authors report satisfactory small molecular extractions [12, 13].
Weinstein et al., making use of three, single-needle systems, obtained inadequate blood flow and clearance values [48]. These authors, however, used timetime-and pressure- time-monitored types of single-needle dialysis, and these
are known te be related to inadequate blood flows and clearances. The pressure-pressure, single-needle technique makes it possible to obtain much higher
blood flows and adequate dialysis. Satisfying clearances and blood flows have
been reported during catheter dialysis with this pressure-pres sure-monitored
technique [49]. Recirculation values of40% have been reported during femoral
single-needle dialysis [50]. Here also a time-time-monitored, single-needle system was used, however. Recirculation with the more efficient pressure-pressure,
single-needle catheter dialysis was reportedly in the range of 20% [49].
Limited efficiency data, obtained recently in our unit in eight patients on
femoral catheter dialysis, are reported in table 9-7. The patients were treated
by four hours of dialysis with 1 m 2 plate cuprophan dialyzers in a pressurepressure, single-needle setting. Dialyzer blood flows and urea clearances
(corrected for recirculation) in the range of 260 ml/min and 135 ml/min,
respectively, were obtained. Recirculation average 18 8%.
7. CONCLUSIONS
Femoral catheterization is a valuable alternative access method for hemodialysis,

especially in hyperacute situations. Specific indications are severe hyperkalemia,
pulmonary edema, and intoxication. It can also be used as an alternative to
150
subclavian or deep jugular catheter dialysis, especially when the latter approaches are difficult or impossible because of complications or lack of experience.Femoral catheters can be inserted intermittently at each hemodialysis
or can be maintained in place for several dialysis sessions. The intermittent
approach carries a greater risk for acute complications, whereas a continued
catheterization is characterized by more biocompatibility-related problems,
such as inadequate flow and infection. In general, however, the complication
and fatality risk is similar for both approaches. The complication profile of
femoral catheter dialysis is also fairly similar to that of other types of catheter
access, e.g., subclavian catheterization. The most frightening complications
are rupture of the vascular wall and thrombophlebitis. Many complications
can be avoided by the careful application of the technique. Femoral dialysis can
be performed in a single-or a two-needle setting. When two catheters are inserted, the acute, insertion-related complication risk is increased. If performed
properly, single-needle catheter dialysis with the pressure-pressure system can
result in an efficiency that is comparable to the two-needle technique.
Although perhaps not the type of catheter dialysis of first choice in all conditions, femoral dialysis appears to be a valuable alternative to other acute
access methods.
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femoral vessel cannulation. Nephron 13:416-420, 1974.
Von Klippers H, Risler T, Krian A, K6nigshausen T, Hofmann K, Schnurr E, Grabensee B:
Perkutaner zugang zu den femoralgef;issen mittels seldingertechnik bei der akutdialyse.
Nieren- und Hochdruckkrankheiten 1 :43-46, 1976.
Erbenj, Kvasnickaj, Bastecky j, Grohj, Zahradnikj, Rozsival V, Bastecka D, Fixa P, Kozak
j, Herout V: Long-term experience with the technique of subclavian and femoral vein cannulation in hemodialysis. Artif Organs 3:241-244, 1979.
Milutinovich j, Follette WC, Scribner BH: Spontaneous retroperitoneal bleeding in patients
on chronic hemodialysis. Ann Int Med 86:189-192, 1977.
Bhasin HK, Dana CL: Spontaneous retroperitoneal hemorrhage in chronically hemodialyzed
patients. Nephron 22:322-327, 1978.
Brautbar N, Menz CL, Winston MA, Shinanberger jH: Retroperitoneal bleeding in hemodialysis patients. A cause for morbidity and mortality. JAMA 239:1530-1531,1978.
Friedman EA: Vascular access update. Trans Am Soc ArtifIntern Organs 25:526-531,1979.
Kron j, Sutherland K, Rosch j, Morton Mj, McAnulty jH: Arteriovenous fistula: A rare
complication of arterial puncture for cardiac catheterization. Am j Cardiol 55:1445-1446,
1985.
Kozeny GA, Venezio FR, Bansal VK, Vertuno LL, HanojE: Incidence of subclavian dialysis
catheter-related infections. Arch Intern Med 144:1787-1789, 1984.
Feliciano DV, Mattox KL, Graham jM, Beall AC, jordan GL: Major complications of percutaneous subclavian vein catheters. Am j Surg 138:869-874, 1979.
Schleifer CR: Femoral catheter dialysis. Abstracts Am Soc Artifintern Organs XXII:71, 1976.
Boen ST, Haagsma-Schouten WAG, Birnie RJ: Percutaneous femoral vein catheterisation.
Proc EDTA 19:115-125,1982.
152
41. Raja RM, Kramer MS, Fernandes M, Rosebaum JL, Barber K: Subclavian vein and femoral
vein catheterization for hemodialysis - one year comparison. Trans Am Soc Artif Intern
Ogans 28:58-60, 1982.
42. Huffman KA, Sheretz RJ, Mattern WD: An appraisal of the subclavian dialysis catheter. IntJ
ArtifOrgans 6:176-177,1983.
43. Tapson JS, Uldall R: Avoiding deaths from subclavian cannulation for hemodialysis. Int J
Artif Organs 6: 227-230, 1983.
44. Van HerweghemJL, Yassine T, Goldman M, Vandenbosch G, Deleour C, StruyvenJ, Kinnaert P: Subclavian vein thrombosis: A frequent complication of subclavian vein cannulation
for hemodialysis. Clin Nephrol 26:235-238, 1986.
45. Vanholder R, Hoenich N, Ringoir S: Morbidity and mortality of central venous catheter
hemodialysis: A review of 10 years' experience. Nephron 47:274-279, 1987.
46. Vanholder R, Hoenich N, Ringoir S: Single needle hemodialysis. In: Maher JF (ed) Replacement of renal function by dialysis, third edition. Boston: Kluwer Academic Publishers, 1989,
pp 382-399.
47. Raja R, Kramer M, Alvis R, Goldstein S, De Los Angeles A: Comparison of double lumen
subclavian with single lumen catheter - one year experience. Trans Am Soc Artif Intern
Organs 30:508-510, 1984.
48. Weinstein Am, Frederick PM, Sullivan JF: Single-needle venous dialysis: A comparison of
three systems. Uremia Invest 8:69-77, 1984.
49. Vanholder R, Hoenich N, Ringoir S: Dialysis performance of single lumen subclavian
hemodialysis: A comparative study with single lumen fistual hemodialysis. Artif Organs
6:429-432, 1982.
50. Fried TA: Recirculation during single-needle femoral hemodialysis. Kidney Int 21:167,1982.
10. SUBCLAVIAN VEIN CANNULATION FOR HEMODIALYSIS
JEAN-LOUIS V ANHERWEGHEM
Nephrologists are often presented with the problem of the immediate need for
access to the circulation for hemodialysis. For this purpose, the use of the
Scribner shunt implies the possible loss of peripheral vessels, while femoral
vein cannulation before each dialysis is often painful for the patient and timeconsuming for medical and nursing staff, as well as difficult to manage in
ambulatory patients.
In contrast, the advantages of subclavian vein cannulation are rapid bedside
insertion by medical staff, no impairment of the patient's mobility and no
damage to blood vessels. This technique was first described by Erben et al. in
1969 [1] and is now being widely used all over the world [2-12].
1. INDICATIONS
The indications for the use of subclavian catheters are usually the need for a
temporary vascular access in the following cases [1-12]:
1. Acute renal failure requiring hemodialysis
2. End-stage renal failure not previously diagnosed
3. Sudden failure of an established vascular access In patients undergoing
maintenance hemodialysis
4. Temporary transfer from peritoneal dialysis to hemodialysis, for example,
when abdominal surgery is required
153
154
5. Acute renal failure in transplant recipients whose arteriovenous fistulae

have thrombosed
6. Kidney diseases requiring plasmapheresis
Moreover, the use of subclavian catheters for hemodialysis is proposed as a
definitive method for vascular access when all else fails and when peritoneal
dialysis is impossible [13].
2. TECHNIQUE
2.1. Insertion and management of the catheters
From the literature [1-4,6-8,11,12,14-16] and in order to avoid complications (see below), the following technique of catheter insertion and management is recommended:
1. Prefer, if possible, the right subclavian vein for cannulation.

2. Position the patient head-down (15 Trendelenbourg position) and ask
him/her to turn his/her head to the opposite side.
3. Widely shave the skin of the shoulder, chest, and neck; prepare it surgically with a 10% polyvidone-iodine solution and drape the surrounding
areas with sterile towels.
4. Wear mask, surgical gloves, and sterile overall.
5. Infiltrate subcutaneously with a local anaesthetic along the inferior border
of the clavicle.
6. With reference to the subclavian route described by Aubaniac [17] and the
Seldinger technique [18]:
Precisly advance the needle in a direction determined by the line connecting the midpoint between the acromion and the anterior axillary
fold to the upper margin of the sternoclavicular point, directing the tip
backward with a 15 angle from the frontal plane. Advance the needle
with a constant negative pressure on the syringe.
Introduce the soft end of the guide wire swiftly.
Insert the cannula over the guide into the subclavian vein.
7. Secure the external part of the catheter to the skin by suture fixation. A
subcutaneous tunnel does not help.
8. Confirm the intraluminal catheter-tip position by back bleeding.
9. Apply a 10% polyvidone-iodine solution to the insertion site before
dressing it with sterile compresses covered with a soft, elastic, airpermeable tape.
10. Confirm the correct catheter tip position by x-ray. The catheter tip must
be in the superior vena cava, no more than 3 cm below the sternomanubrial junction.
11. Use aseptic and antiseptic techniques for connecting and disconnecting the
catheter with the tubing at each dialysis session.
12. At the end of each dialysis session, fill the catheter with 1. 5 ml isotonic
10. Subclavian vein cannulation
155
saline solution containing 2500 IV heparin and close off the catheter with a
Luer-Lok cap.
13. Do not manipulate the catheter between dialysis seSSIons.
Supplementary recommendations are:
Limit the placement of the catheters to experienced operators or do it under
their close supervision.
Do not use the subclavian route for restless, uncooperative, or breathless
patients.
If a catheter slips partially out of the skin, never push it back without first
introducing a guide wire.
A void hemodialysis with heparin immediately after an accidental puncture
of a subclavian artery.
Do not manipulate the catheter without positioning the patient in the
Trendelenbourg position.
2.2. Type of catheters
Currently available types of hemodialysis subclavian catheters are listed in

table 10-1. The catheters are generally made of Teflon or polyurethane.
Table 10-1. Currently available hemodialysis subclavian catheters
Manufacturer
Type
Material
Size
Length (cm)
Argon Medical Corp.
SL
SL
DL
SL
DL
SL
DL
SL
DL
SL
SL
DL
DL
SL
DL
DL
SL
Teflon
Polyurethane
Polyurethane
Teflon
Polyurethane
Polyurethane
Polyurethane
Polyurethane
Polyurethane
Teflon
Polyurethane
Polyurethane
Polyurethane
Teflon
Teflon
Silicone
Teflon
SF
llF
llF
5F-7F
lOF-12F
SF
llF
7F-SF
9F-lOF-IIF
SF
SF
I1F
llF
SF
lOF-12F
12F
SF
SL
DL
DL
Polyurethane
Polyurethane
Teflon
SF
6,5F-IIF
12F
16.5-25
9-13-16-19-25
20
5-7-9-13
10-15-20
15-20-24
15-20
9-12
12-15-20
15
15-20
10-15-20
10-15-20
10-15
10-15
15
10-12,5-15-17,5
20-22,5-25
12,5-15
10-15-20-24
19
Cook, Inc.
Impra, Inc.
Medcomp
National Medical Care
Quinton Instrument Co.

Shiley, Inc.
Vas-Cath, Ltd.
The information provided in this table is from reference 19, in which the reader may find more details.
SL = single lumen; DL = double lumen.
156
DUAL LUMEN SUBCLAVIAN CATHETER
DOUBLE LUMEN SUBCLAVIAN CATHETER
Figure 10-1. Design of dual-lumen subclavian catheter (a) and double-lumen subclavian catheter
(b). From Tapson]S, Hoenich NA, Wilckinson R, Ward MK: Dual lumen subclavian catheter for
hemodialysis. Int] ArtifOrgans 8:195-200,1985, by permission.
Depending on the manufacturer and the type of the catheter, kit/tray, T

connector, inner introducer cannula, and rotating suture wing catheters are
available. Polyurethane material usually softens with body heat. Attainable
flows vary with size, length, and type from 75 mllmin to 500 mllmin. Some
Teflon catheters are available with a curved shape. Three types of hemodialysis
catheters are currently available for the percutaneous cannulation of the subclavian vein. The single-lumen subclavian catheter was described first [2-4] and
remains the most popular device in British renal units [20]. Single-lumen
cannulas require a reciprocating single-needle system. Such a system alternately cycles blood in and out of the patients by means of a time or pressure
system and requires adequate equipment as well as experienced operators in
order to obtain sufficient blood flow with minimized recirculation. Clinically
insignificant recirculation may ensue when inflow time is maintained between
3 to 5 seconds and when time-time, single-needle devices are used [21]. It is
also the case with double headpump systems (personal experience). Nevertheless, the difficulty of achieving efficient single-needle dialysis has led to the
development of double-lumen cannulas [22] of either a coaxial or septum
design (figure 10-1).
The coaxial, double-lumen subclavian cannula [9, 22, 24] (figure 1O-1b)
consists of two concentric cannulas, an outer "arterial" cannula and an inner
"venous" one. A disadvantage of this type of catheter is the need to remove
the inner cannula after dialysis and to replace it before the next dialysis,
increasing the risk of infection [10]. Another disavantage of the coaxial cannula
157
Its large size, which makes insertion difficult and necessitates the use of
a vessel dilatator. The septum-designed model (also called the dual-lumen
catheter) [23, 25, 26] (figure 10-h) consists of "arterial" and "venous"
lumens separated by an inner septum. Compared to the coaxial model, the
blood flow rate is significantly higher (250 mIl min vs. 227 mIl min) and the
venous resistance is significantly lower (128 mmHg vs. 190 mmHg) [24].
Because the "arterial" holes cover only half of the cannula surface, it is not
uncommon to find that blood flow is insufficient due to the fact that aspiration
of blood occludes the catheter by sucking the vessel wall into the holes. This
problem may be eliminated by turning the cannula but is sometimes insoluble
and is described as the most common cause of catheter failure [26]. Moreover,
manipulation of cannulas not only enhances the risk of vessel perforation or
catheter infection, but also results in expenditure of both physician and nursing
time.
Minimum hemodynamic performance standards for double-lumen subclavian cannulas at a blood flow of 200 mUmin are defined to be a maximum of
- 100 mmHg for the cannula inlet "arterial" pressure, less than 150 mmHg for
outlet "venous" pressure, and less than 5% for cannula recirculation [27]. The
efficacy and the safety of coaxial and side-by-side, double-lumen subclavian
catheters were compared with the single-lumen catheters [28]. Poor flow
problems were more frequent with left-sided, double-lumen catheters, while
infections and mechanical problems were more frequent with coaxial catheters.
For nephrologists experienced in sinlge-needle techniques, the single-lumen
catheters are thus recommended.
IS
3. COMPLICATIONS
A lot of case reports (see infra) and some reviews [15, 16, 29] were devoted to
the complications associated with the use of the subclavian vein for hemodialysis access. These complications range from technical complications without clinical consequence to life-threatening complications.
3.1. Technical complications
Cannulation of a subclavian vein is impossible in 5% of the cases [16], ranging

from 1.5% to 5.5% [2]. Puncture of the subclavian artery occurs in 4% of our
cases and ranges from 0.9% to 10.6% in other series [2, 7, 12, 16]. Malposition
of the catheter is described in about 2% of the cases [12, 29].
Poor blood flow (with or without kinking of the catheters) is observed in the
range of 1.5% [12] to 15% of the cases [29] and is more frequent with doublelumen, coaxial catheters than with single-lumen catheters (35.2% vs. 8.7%)
[10]. Clotting of the catheter ranges from 3.9% [12] to 8.0% [7]. Without
clinical consequences, disconnection of the catheter may occur in about 0.5%
of the cases [12, 29], inadvertent withdrawal in 1%-4% [12, 28], and local
bleeding in 1.3%-2.8% [7,8, 12].
158
3.2. Clinical complications

3.2.1. Immediate traumatic complications
Pneumothorax and hemothorax are classical complications of the subclavian

route. As shown in table 10-2, the rate of these complications ranges between
0.0% and 3.6%, with an average of 1.7% [1-3, 5-7, 9,12,15,29], which is
also the rate described when subclavian vein catheter are inserted for purposes
other than hemodialysis [30]. Operator inexperience was considered to be the
major factor that led to these traumatic complications [31]. Attention was
drawn to a delayed onset of massive hemothorax after three hours of hemodialysis with heparin due to accidental puncture of the subclavian artery [32],
leading to the recommendation to postpone hemodialysis for at least 24 hours
after any accidental subclavian artery puncture. Among the 15 deaths related to
subclavian catheters for hemodialysis reported from the British units, one was
due to a pneumothorax and two to hemothoraxes [20].
3.2.2. Airembolism
Venous air embolization is reported in 0.5% of the cases of subclavian vein

catheters for hemodialysis [16] and is responsible for one death in the British
experience [20]. This complication o<;curs when catheters are opened without
positioning the patient in the Trendelenbourg position.
3.2.3. Microangiopathic hemolytic anemia
Of a total of 75 patients, the cases of eight patients (11 %) who developed

symptomatic hemolytic anemia with red cell fragmentation associated with
the use of single-lumen subclavian catheters were reported [33]. This syndrome can be recognized by a sudden worsening of anemia and the presence of
schistocytes in the peripheral blood smear. The exact etiology of this phenomenon remains uncertain. It could be due to a shearing stress of the red cells by
Table 10-2. Immediate traumatic complications related to the subclavian route for hemodialysis
Authors
De Cubber et al. [3]
Dorner et al. [5]
Erben et al. [1]
Fornasieri et al. [12]
Lewinstein et al. [9]
Raja et al. [7]
Schwarz beck et al. [2J
Uldall [6]
Vanherweghem et al. [15]
Van Holder et al. [29].
Total
Number of catheter
insertions
83
103
101
155
41
87
160
200
200
313
1,443
Number of cases with

pneumothorax and/or
hemothorax
3
1
3
2
1
0
3
2
4
5
24
Incidence
(%)
3.6
1.0
3.0
1.3
2.4
0.0
1.9
1.0
2.0
1.6
1.7
159
the passage of 200-300 mIl min of blood through a reduced cross-sectional

area when some of the side openings and/or the tip of the catheter are blocked
by a thrombus. The fragmentation resolved in all cases on withdrawal of the
catheter.
3.2.4. IllfectiollS
When catheters are systematically cultured after removal according to the

technique ofMaki et al. [34], infection of the catheter was documented in 29 of
200 catheters in our cases [35], in 25 of116 cases of Dahlberg et al. [36], in 28 of
74 cases of Cheesbrough et al. [37], and in 10 of 60 cases of Sheretz et al. [38],
thus occuring in an average of 20.4% of the catheters. Table 10-3 shows that
sepsis related to subclavian vein catheters for hemodialysis occured in 9.9% of
the patients, 6.1 % of the catheters, and in 0.43 per 100 catheter days, when
cumulative data of 1815 catheters placed in 1124 patients for 25,918 days were
considered [2, 4, 7, 9, 10, 12, 29, 35-40].
When infected, catheters are the source of sepsis in about 50% of the cases
[35-38]. The microorganisms that are most often implicated in catheter infections are Staphylococcus epidermitis in 50% -85% of the cases and Staphylococcus
aureus in 20% -45% [35-38], but infections with Proteus mirabilis, Pseudomonas
aeruginosa, and Candida albicans have also been described [37, 38]. About 45%
of the catheters infected by Staphylococcus epidermitis cause sepsis, while up to
90% of the catheters infected by Staphylococcus aureus do so as well [35-38].
Various factors that may influence the incidence of subcla vian-dialysis, catheterrelated infections have been investigated. Figure 10-2 shows a life-table analysis depicting catheter survival free from sepsis or colonization [37]: Sepsis
occurred throughout the catheterization period; the slope did not vary significantly with time, a result suggesting a constant per day risk [37, 38], and thus
the fact that the organism introduced at the time of insertion rarely colonizes
the catheter. Indeed, catheter-related sepsis were more frequent when catheter
dressings were manipulated during hospitalization or by inexperienced nurses
[35]. This emphasizes the key role of postinsertion catheter care [35, 38, 39].
The need for more manipulations also explains the higher incidence of infections with double-lumen catheters than with single-lumen ones [10]. Three
studies suggest that patients receiving antibiotics have less catheter-related
infections [37, 38, 41]. This last point, nevertheless, requires further confirmation by prospective studies.
Patients with diabetes or receiving immunosuppressive drugs are theoretically at risk for infectious complications. Indeed, as compared with other
patients, the incidence of sepsis was greater in the group of patients with
diabetes (16.0% vs. 5.1 %) [35, 39], as well as in the group of patients receiving
immunosuppressive drugs (19.0% vs. 10.0%) [35, 37-39]. Nevertheless, it
must be emphasized that these differences do not reach a degree of statistical
significance, even by accumulating the data of different series.
The prospective randomized study of Dahlberg et al. [36] has shown that the
53
88
102
29
74
66
47 (DLC)
46 (SLC)
141
27
64
92
148
147
1.124
Cheesbrough et al. [37)

Dahlberg et al. [36)
Fornasieri et al. [12)
Lcwinstein et al. [9)
Kozeny et al. [39)
Raja et al. [7)
Raja et al. [10)
64
116
155
41
110
87
71
52
160
60
91
214 (?)
200
394
1.815
Number of
catheters
DLC = double-lumen catheters; SLC = single-lumen catheters.
Schwarzbeck et al. [2)

Sheretz et al. [38)
Uldall et al. [4)
Uldall et al. [40)
Vanherwheghem et al. [35)
Van Holder et al. [29)
Total
Patients
Authors
Table 10-3. Sepsis related to subclavian dialysis catheters
1.687
1.299
4.630
220 (?)
1.361
780 (?)
370 (?)
506 (?)
2.096
646
1.911
2.322
2.798
5.292
25.918
Catheter days
13
11
9
2
9
1
5
1
4
5
9
16
17
9
111
Number of
bacteremias
24.5
12.5
8.8
6.9
12.2
1.5
10.6
2.2
2.8
18.3
14.0
17.4
11.5
6.1
9.9
per patient
(%)
20.3
9.5
5.8
4.9
8.2
1.2
7.0
1.9
2.5
8.3
9.9
7.5
8.5
2.3
6.1
per catheter
(%)
0.77
0.95
0.19
0.91
0.66
0.13
1.35
0.20
0.19
0.77
0.47
0.68
0.61
0.17
0.43
per 100
ca thetcr da ys
Incidence of bacteremias
161
1110
80
c: 70
60
.~ SO
~
40
20
g 30
'c'"
c
.~
...
10
<5
OfL____~I____~I_____LI_____LI____~IL__
20
40
60
80
100
Ouration 01 catheterization period 'day,)

64
31
14
No. of catheters in situ at beginning 0' time inten:a l
Figure 10-2. Life-table analysis depicting catheter survival free from microbiologically confirmed sepsis or colonization on catheter removal for 64 fully processed catheters (e = sepsis;
o = colonization; <I> = SE; CP = catheterization period). From Cheesbrough )S, Finch RG,
Burdell RP: A prospective study of the mechanisms of infection associated with hemodialysis
catheters. ) Infect Dis 154:579-589, 1986, by permission.
creation of a subcutaneous tunnel did not influence the rate of catheter-related

sepsis (13% with tunnel, 11.5% without tunnel). Also, systematic replacement
of the subclavian dialysis catheters did not decrease the incidence of sepsis [40]
(17.8% with replacement, 17.0% without systematic replacement).
When catheters were properly replaced on a guide wire introduced by the
lumen of a previously inserted catheter, we [351, as well as Dahlberg et al. [36],
observed that this procedure did not increase the risk of infections.
Subclavian-dialysis catheter infections were once said to be easily managed
with antibiotics and removal of the catheter [39]. However, this statement
seems no longer valid since serious complications are now being reported.
Among 15 subclavian-catheter-related deaths in British units [20], two were
due to catheter-related sepsis and one to a mycotic pulmonary embolism.
Accumulating the data of six studies in which serious complications are
mentioned (9, 15,37-39,41), right-sided endocarditis occurred in eight cases
among 379 patients (2.0%) [9, 15,37,39,41], vertebral osteomyelitis in one
case [15], and a sepsis-related death in one case [38]. Endocarditis required
cardiac surgery at least in two cases [9, 15] and was the origin of death of
patients in three cases, either by associated sepsis [37], pulmonary embolism
[41], or late cardiac complications [37].
In summary, subclavian-dialysis, catheter-related infections are frequent and
are certainly not always benign. Measures that seem to decrease the risk of
162
infections are rigid aseptic techniques and a careful nurse training. Prophylaxis
with antibiotics could help, but this point deserves further studies.
3.2.5. Perforations of right atrium or superior vena cava
Perforations of the superior vena cava or of the right atrial wall by subclavian
dialysis catheters are classified among the causes of sudden death in hemo-.
dialysis patients [42], and this was actually the case in 7 of the 15 deaths reported
in British experience [20]. We have reviewed 16 cases [15] described in the
literature [4, 15, 43- 51]. Out of these 16 cases, death occurred in three cases
[43, 44, 49], and emergency surgery was required in five cases [15, 45, 46].
The catheters placed through the left subclavian vein led to superior vena
cava perforations with mediastinal hematoma in one case [50], contralateral
hemothorax in six cases [46-48, 51], or both in one case [15]; while catheters
placed through the right subclavian vein caused perforation of the right atrial
wall with pericardial tamponade in six cases [15, 43-46] and right hemothorax
in one case [49], due to the passage of the catheter from the right atrium into
the right pleural cavity.
The possible causes of these life-threatening complications were malposition
of the catheter tip in the right atrium in six cases [15, 43, 45, 46, 49]; pushing
back the catheter, which had slipped partially out of the skin in two cases [44,
49]; too rigid a material in one case [44]; and hypothetical direct injury to the
vessel wall during the course of catheter insertion in five cases [15, 43, 45, 46].
Nevertheless, in six cases [47, 48, 50, 51], perforations occurred after 2 to 26
dialysis sessions without problems and without further manipulations of the
catheters. These cases concerned the left subclavian route with right-sided
perforation of the superior vena cava. In this instance, the catheter tip just
pushed against the right lateral wall of the vessel and a progressive erosion of
the vascular wall may have resulted not only from a prolonged contact of a
rigid catheter against the wall, but also from the to-and-fro movement of the
catheter tip during dialysis sessions. This last hypothesis must be of importance, since later perforations after catheter insertion were not described with
subclavian catheters placed for reasons other than dialysis [52, 53]. In summary, dialysis teams must be warned of the posssible life-threatening, delayed
complications of the subclavian route and recommendations for decreasing
their incidence are included in the section on technique.
3.2.6. Subclavian vein stenosis or thrombosis
In 52 patients treated by chemotheraphy using the subclavian route, asymptomatic thrombosis of the subclavian vein was documented in 46.1 % of the
polyvinyl chloride catheters and in 11.5% of the silicone ones [54]. Moreover,
prospective phlebographies undergone after 60 central venous catheterizations
have shown sleeve thrombi in 42% of the cases and mural veno occlusive
thrombi in 8% [55]. Thus, we may speculate that phlebothrombosis of the
subclavian vein or the superior vena cava is a potential complication of the use
lO. Subclavian vein cannulation
163
of the subclavian route for hemodialysis. Indeed, several such cases were
reported [1, 2, 4, 5, 9, 15, 29, 56-68]. At the beginning of the use of the
subclavian route for hemodialysis, the rate of subclavian vein thrombosis
appeared to be low: 8 cases among 400 patients [57]. Later, systematic studies
revealed more numerous cases of asymptomatic subclavian vein thrombosis or
stenosis. Zingraff et al. [58] carried out venograms in 15 patients a week or
longer after removal of the catheter and found two patients with complete
thrombosis and two with partial stenosis. Ratcliffe and Oliver [56] studied
eight consecutive patients with venograms performed for poor flow or at the
conclusion of the temporary vascular access and found large amounts of
thrombus in seven patients. Van Holder et al. [29], by systematic investigation,
either at necropsy or using venograms, found subclavian vein or superior vena
cava thrombosis in 16 out of 32 patients; finally, our group [65] performed
systematic venograms in 42 patients selected on the basis of a history of
previous subclavian vein cannulation. The venograms were done 15.7 8.9
months after the removal of the last catheter. Eight patients (19%) had complete thrombosis or severe stenosis (figure 10-3), while six patients (14%) had
minimal luminal defects. Comparing the patients with subclavian vein thrombosis or severe stenosis to the others patients, we observed no difference
between the two groups in the number of catheter infections, the number of
catheters with poor blood flow or obstruction, the coagulation screening of the
patients, and the length of time between the removal of the last catheter and
the venogram study. On the other hand, in the group of patients with thrombosis or stenosis, there were more females (64% vs. 32%), more cannulations
per vein (1.87 vs. 1.32), and more cumulative days of cannulation per vein
(35.1 vs. 24.4). Despite this observation that subclavian vein thrombosis
occurred more frequently after prolonged catheter insertion, it must be emphasized that thrombosis may be observed after only two days of cannulation [59,
65]. Thrombosis occurred with polyurethane material as well as with Teflon
material [60, 65], and with single-lumen catheters as well as with doublelumen catheters [61, 62]. The clinical relevance of subclavian vein thrombosis
after the use of indwelling catheters for parenteral nutrition was minimized,
since all the patients were asymptomatic [54]. In another study, five cases
of pulmonary embolism were nevertheless reported [69]. Moreover, the problem is substantially different in chronic uremic patients: The subclavian vein
obstruction usually remains silent but may become symptomatic when the
venous return is greatly increased by the ipsiside creation of an arteriovenous
fistula [62-66, 68]; a painful swelling of the arm occurs and sometimes
requires the closure of the fistula. Balloon dilatation of the stenotic subclavian
vein segment is sometimes successful in relieving the symptoms [64]. One case
of surgical bypass of the stenotic area has been reported [70]. Benign intracranial hypertension was also been as a complication of hemodialysis, catheterrelated vein thrombosis associated with the creation of an arteriovenous fistula
[71]. In our series [65], subclavian vein thrombosis or stenosis caused clinical
164
Figure 10-3. Severe stenosis of a left subclavian vein as seen in an asymptomatic dialysis patient
having received subclavian vein cannulation for hemodialysis three months earlier. From VanhcrweghemJL, Yassinc T, Goldman M, Vandenbosch G, Delcour C, StruyvenJ, Kinnaert P: Subclavian vein thrombosis: A frequ ent complication of subclavian vein cannulation for hemodialysis.
Clin Nephrol 26:235-238, 1986, by permission.
problems in 6.4% of the chronic uremic patients who received subclavian vein
cannulation for hemodialysis and compromized chronic vascular access in
4.5% . The use of the subclavian route for hemodialysis may thus lead to the
exclusion of a large part of the vascular bed available for future chronic and
even temporary vascular access in some patients. This complication may
obviously have late dramatic implications. Prior to the creation of an arteriovenous fistula in patients who have undergone previous subclavian vein cannulation, the control of subclavian vein permeability by Doppler ultrasound or
by venogram is recommended.
4. CONCLUSION
Bed side rapid insertion and protection of the mobility of the patient are
important advantages of the subclavian route of hemodialysis. Nevertheless, it
must be made clear that the insertion of a subclavian catheter for hemodialysis
is not a single intervention and that this technique requires experienced staff
and careful handling in order to prevent traumatic and infectious complications. Following the recommendations described in the section on technique,
the incidence of these complications can be maintained at an acceptable level.
By contrast, subclavian vein catheterization may no longer be considered as a
165
procedure that causes no damage to the blood vessels. The potential long-term
consequences of subclavian vein thrombosis should prompt all nephrologists
to limit, as much as possible, the use of the subclavian route as a temporary
vascular access for hemodialysis in chronic uremic patients.
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34. Maki DG, Weise CE, Sarafin HW: A semi-quantitative culture method for identifying
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subclavian Uldall catheters. Arch Intern Med 143:52-56, 1983.
39. Kozeny GA, Venezio FR, Bansal VK, Vertuno LL, Hano JE: Incidence of subclavian dialysis
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40. Uldall PR, Merchant N, Woods F, Yarworski U, Vas S: Changing subclavian hemodialysis
cannulas to reduce infections. Lancet 1:1373, 1981.
41. Pezzarosi HE, Ponce De Leon S, Calva JJ, Lazo De La Vega SA, Ruiz-Palacios GM: High
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42. Cohle SD, Graham MA: Sudden death in hemodialysis patients. Forensic Sci 30:158-166,
1985.
43. Fine A, Churchill D, Gault H, Mathieson G: Fatality due to subclavian dialysis catheter.
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malpositioned subclavian dialysis catheter. Nephron 32:363-364, 1982.
46. Barton BR, Hermann G, Weil R: Cardiothoracic emergencies associated with subclavian
hemodialysis catheters. JAMA 250:2660-2662, 1983.
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50. Vaziri ND, Maksy M, Lewis M, Martin D, Edwards K: Massive mediastinal hematoma
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53. Peters JL: Current problems in central venous catheter systems. Intensive Care Med 8:
205-208, 1982.
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Parenteral Enteral Nutr 7:560-562, 1983.
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after prolonged central venous catheterization. Ann Surg 194:779- 783, 1981.
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of subclavian dialysis. Jama 252:3403-3406, 1984.
60. El Nachef MW, Rashad E, Ricanati ES: Occlusion of the subclavian vein: A complication of
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for hemodialysis. Clin Nephrol 25:54, 1986.
(,3. Fant GF, Dennis VW, Quarles, LD: Late vascular complications of the subclavian dialysis
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catheter injury. Surgery 100:924-927, 1986.
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Kinnaert P: Snbclavian vein thrombosis: A frequent complication of subclavian vein cannulation for hemodialysis. Clin Nephrol 26:235-238, 1986.
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obstruction following creation of arteriovenous fistulae for hemodialysis. A problem following subclavian line dialysis? Nephrol Dial Transplant 1:258-260, 1987.
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Subclavian vein stenosis as a complication of subclavian catheterization for hemodialysis.
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11. INTERNAL JUGULAR VEIN

CANNULATION FOR HEMODIALYSIS
BERNARD JEAN-MARIE CANAUD
Temporary vascular access for hemodialysis is a frequent requirement for

nephrologists. It plays a pivotal role in the management of uremia by giving
more flexibility in the organization of a treatment program [1, 2]. All renal
units utilize temporary vascular access in the treatment of acute renal failure,
when end-stage renal failure occurs before fistula maturation or after a sudden
loss of an internal fistula in a dialyzed patient. The need also exists in patients
under long-term continuous peritoneal dialysis who require substitute hemodialysis or for some transplanted patients requiring temporary hemodialysis.
Current habits of nephrologists regarding the temporary vascular access
sites for hemodialysis are summarized in a recent British multicenter study
[3]. Percutaneous angioaccess was preferred to the arteriovenous shunt as the
first-choice method in the majority of cases (94%). Single-lumen subclavian
catheterization has become the most popular access device used in all units,
(83% of cases), compared to 7% and 4%, respectively, for femoral and
internal jugular vein catheterization. However, its use was restricted to the
single-needle, double-pump machine, which complicated the hemodialysis
procedure and was associated with a 28% incidence of fatality.
Despite the great advance permitted by subclavian cannulation, both due to
the improvement in catheter design [4-7] and to the optimization of dialysis
performance of the single-needle hemodialysis module [8-10], temporary
angioaccess is still problematic for most physicians. The double (or dual)lumen catheters designed to overcome this problem have not been generally
169
170
accepted by clinicans, since they are associated with a higher risk and/or
technical difficulties of insertion due to their size [3, 11-13].
Indeed, subclavian cannulation is still associated with a significant prevalence of morbidity and/or mortality [14-28]. Accordingly, there is still a
need for a method meeting with the criteria of an ideal temporary access:
easy insertion at bedside, a low risk of complications providing high blood
flow rate with low recirculation using standard hemodialysis apparatus, immediately usable, allowing mobility of the patient, and sparing blood vessel
capital.
Until recently, the internal jugular vein was not routinely used for hemodialysis, being considered uncomfortable for the patient and/or exposing
the patient to a higher risk of infection. The recent development of silastic
catheters derived conceptually from those used in total parenteral nutrition or
chemotherapy in cancer patients [29, 30] renewed the interest in internal
jugular vein catheterization, providing a new and convenient alternative to
conventional temporary vascular access for hemodialysis [31-47].
These methods of internal jugular vein catheterization are suitable for
short-, mid- or long-term vascular access for hemodialysis with the technique
of insertion. The results reported in the literature and the author's experience
with them are described in the following chapter. Moreover, the interest and
potential usefulness of cannulation with silicone rubber material are emphasized.
1. CATHETER DESCRIPTION
1.1. Percutaneous internal jugular vein catheters
Although shorter, percutaneous internal jugular vein (IJV) catheters have the
same general design as the subclavian catheter. They basically consist of a
single piece made up of two parts: a distal intravascular semirigid tubing and a
proximal extension and connecting tubing (figure 11-1).
The intravascular segment is usually made of radiopaque Teflon or polyurethane, 10 to 15 cm long, with an inside/outside diameter of 1.5-2.0 mm
for the single-lumen catheter and 1-3.7 mm for the double-lumen catheter,
with a conic extremity facilitating both skin and vein penetration. Functional
specificity is given by the size number and the disposition of the lumen.
Single-lumen catheters have an axial end hole and 5 to 6 holes disposed
spirally. The tip of dual-lumen catheters have two separate holes disposed
laterally, 3 to 5 cm apart, while the two end holes of double-lumen catheters
are coaxially disposed and 3 cm apart.
The extension tubing fits tightly over the proximal part of the intravascular
segment. It consists of a larger bore silicone rubber tubing,S to 7 cm long,
adapted to multiple clamping and ending in a female Luer-Lock adapter. In
the single-lumen catheter, a removable "Y" with silicone rubber arterial and
venous extension lines is attached to the proximal segment.
Percutaneous IJV catheters are supplied in sterile prepacked kits containing
all the equipment necessary for insertion by Seldinger's method: metallic
11. Jugular vein cannulation
A~
171
o
o
Figure 11-1. Different types of catheters usable for IJV catheterization (on the right-hand side
section of the catheters). A: double-lumen catheter (polyurethane) used for percutaneous insertion;
B: single-lumen silastic right atrial catheter with a Dacron cuff (Raaf Catheter, Quinton); C:
double-lumen silas tic right atrial catheter with a Dacron cuff (Perm-Cath, Quinton); D: double
silas tic right atrial catheter with two removable parts used for percutaneous IJV catheterization
(Canaud Cath, Vygon).
flexible guide wire, introducer needle, introducer dilator catheter, 10 ml

syringe, Luer Lock caps, and adhesive dressings.
1.2. Silastic or right atrial catheters
The right atrial catheters have three main common points: soft and flexible
silicone-rubber, catheter tips located in the right atrium, and protection by a
long subcutaneous tunnel. Depending on the insertion procedure, the IJV cannulae may be classified either as surgical or percutaneous implantable catheters
(figure 11-1).
1.2.1. Surgical implantable IJV silastic catheters
The main characteristics of surgically implantable IJV catheters presently available are presented in table 11-1. The common feature is that they consist of a
single piece with two different parts: an intravascular radiopaque silicone
tubing fitted with an extravascular extension and a larger bore silicone tubing
ending in a Luer-Lock connection.
Length
(cm)
2.0/(3.8
30
Canaud Cath (Vygon)
30
2.0/(3.2
1.8/4.5
40
3.2)
5.5)
1.6/ (2.8/4.9)
40
1.00/(2.2
40
1.50
2.65/4.88
40
2.00
1.57/3.18
30
1.5
2.6/4.9
32
No. oflumens
1.50
1.25
2.6/3.2
26
3.7)
1.30
Dead space
(ml)
1.6/3.2
Diameter in/ out

(mm)
90
PERCUTANEOUSL Y IMPLANTABLE CATHETERS
Hickman Cath
(Evermed, Quinton)
Hickman Cath
(Evermed, Quinton)
Ped Tenckhoff Cath
(Quinton)
WBWCath
(Original)
WBWCath
(Original)
RaafCath
(Quinton)
RaafCath
(Quinton)
Raaf Cath
(Quinton)
Permcath
(Quinton)
SURGICALL Y IMPLANTABLE CATHETERS
Catheter
manufacturer
Table 11-1. Main characteristics of silas tic right atrial catheters for hemodialysis reported in the literature
suture
suture
ring
Dacron
cuff
296 10
236 5
217 27
188 26
230
150
190
300
100
QB
mllmn
7.7 0.7
10.7 5
12 3
7.1 3
12
15
15
Recirculation
(%)
0;;.
-r
Q..
:;;.
"3
::r
,..,
,..,
if
.,
::
r,
<
f;:
.......
173
Their specificity depends on the disposition and number of lumen and end
holes (single-, double-, or dual-lumen catheters), the length and inside/outside
diameters of the tubing, and the presence or lack of a Dacron cuff. Some
IJV catheters have been adapted from existing peritoneal or vascular access
devices, while others have been specifically designed and manufactured for
hemodialysis.
1.2.2. Percutaneous implalltable IJV silas tic catheters
In keeping with the same concept as described above, these catheters

(Vygon) are made of two removable parts joined tightly during the insertion
time (figure 11-1). The intravascular cannula is made of radiopaque siliconerubber tubing and is 30.0 em long, with six side holes disposed spirally along
the three distal centimeters. Their internal and external diameters are 2.0 and
3.2 em, respectively.
The extension or connecting device is made of a 7-cm silicone-rubber tubing
fitted onto the proximal side with a 5-cm polyvinyl tubing segment, which
is attached to the intravascular cannula, and on the distal side with a nylon
female Luer-Lock connection for attachment to the hemodialysis blood lines.
The internal jugular catheter kit is supplied in a sterile prepacked tray with all
the equipment necessary for insertion: two identical silicone cannulae with
their plastic stylets; two extension devices; two straight and curved, safe-J,
double, flexible trip guide wires with a straightener; one introducer needle; one
sheath vein introducer (Desilet), two Luer-Lock caps; and one transparent
plastic dressing.
2. INTERNAL JUGULAR VEIN ACCESS SITE
The different methods oflocating the internal jugular vein have been updated
by Rosen et al. [48]. In figure 11-2 the two main approaches to IJV catheterization have been schematized. According to the position of the IJ vein,
"high methods" are suitable for percutaneous IJV catheterization with a
semirigid catheter, and "low methods" are most suitable for silicone right
atrial catheters that require subcutaneous tunneling.
3. CATHETER INSERTION
The IJV catheters are inserted into the superior vena cava or right atrium
through the internal jugular vein (mostly right IJV for anatomical reasons)
under local or light general anesthesia. The procedure must be performed in
aseptic conditions in an operating room or at a patient's bedside by confirmed
and trained physicians.
3.1. Pre-insertion care
Before catheterization, the patient lies comfortably flat on a bed, with the
head turned to the opposite side and protected by a cradle. Patient consent is
obtained after giving all information concerning the procedure. For anxious
174
Figure 11-2. Main routes for locating the internal jugular vein defined by Rosen 148]. A: "high
methods" above the internal part of the stcrnocleido muscle; B: "low methods" in the Sedillot
triangle.
patients, a light general anesthesia (atropine, ethylloflazepate) is administered

30 minutes before operating. The skin of the neck and of the anterior chest
wall are shaved, meticulously toweled, and disinfected with polyvidone-iodine
solution (Betadine) 10 minutes before insertion and at the time of insertion,
and is draped with sterile towels. Skin landmarks of IJV are then drawn.
3.2. Insertion
3.2.1. Percutalleous I]V catheterization (Seldillger method)
After adequate local anesthesia, the IJ vein is located with a fine needle,
which is removed and replaced by a larger introducer needle. A guide wire is
introduced into the vein through the introducer needle. The needle is then
withdrawn, maintaining the guide in place. The skin puncture hole is enlarged
with the tip of a scalpel blade by 2 or 3 mm. The IJV catheter is introduced
with a twisting motion to facilitate its penetration into the vessel over the
guide wire.
For large catheters (double or dual-lumen catheters), an intermediate step
may be necessary, a vein dilator introducer catheter being used to facilitate the
introduction of the IJV catheter. The guide is pulled out, the IJV catheter is
flushed with normal saline, and the external part of the catheter is clamped.
The IJV catheter is fixed securely to the skin with a suture. If required, a
second IJV catheter may be introduced 2 to 3 em higher into the ipsiinternal
jugular vein by the same method. Catheters are then filled with standard
heparin (1 to 1.5 ml) and closed with Luer-Lock caps. Wound dressing is
applied to protect and secure catheters.
175
Figure 11-3. Main steps of surgical implantation ofa double-lumen silas tic right ' atrial catheter
(Perm-Cath). A: dissection and isolation of IJ vein through a transverse cervical skin incision
above the internal part of the clavicle; B: control of IJ vein by means of vascular slings; C:
subcutaneous tunneling of the catheters by means of a fine forceps dissector; D: internal jugular
venotomy through a purse-string suture and insertion of the cannula into the vessel; E: vessel and
skin suture.
3.2.2. Implantation ofsilicolle illternaljugular vein cannula
3.2.2.1. SURGICAL INTERNAL JUGULAR VEIN CANNULA IMPLANTATION. Local

anesthesia (2% xylocalne) of the region of the cervical Sedillot triangle, prolonged down the anterior chest wall, is carried out. The insertion of the IJV
catheter is carried out in six main steps [49] (figures 11-3 and 11-4):
1. The internal jugular vein is exposed after a 3 to 5 cm transverse cervical skin
incision (A in figure 11-3) just above the internal part of the clavicle,
through the clavicular head of the sternocleidomastoid muscle and dissection
in depth. The vein is easily found and cannulated.
176
Figure 11-4. Final aspect of a double-lumen right catheter (Perm-Cath) with a Dacron cuff
inserted in a patient. A: intravascular segment; B: subcutaneous segment fixed with the Dacron
cuff; C: extension and connecting segment.
2. The internal jugular vern is controlled by mean of vascular slings (B in

figure 11-3).
3. In the case of double or dual-lumen catheterization, subcutaneous tunneling
is performed at this stage. The cannula is flushed and filled with saline and
clamped atraumatically. Starting from the distal skin exit located 10 em
below the clavicle, a blunt, fine, forcep dissector is tunneled towards the
cervical incision. The forcep is then removed and introduced downward
through the cervical incision. The distal end of the cannula is connected to
the forcep dissector and pulled out in the I]V exposure area (C in figure
11-3). The Dacron cuff, if present, is located 1 em inside the skin exit.
4. Internal jugular venotomy is then performed in the center of a purse-string
suture (5 dec Prolene). The distal vascular segment of the cannula is inserted
through the venotomy (D in figure 11-3), and pushed down approximately 15 em until the tip is located in the right atrium E in figure 11-3,
figure 11-4). A purse-string suture is tied firmly around the catheter to
ensure blood-tightness. Note that a peel-away sheath introducer may be
used at this stage to facilitate the insertion of the cannula into the vessel [50].
5. In the case of a single-lumen or two-removable-part catheter, subcutaneous
tunneling is performed in the caudal direction, as described in step 3.
6. Free blood flow is confirmed by aspirating and flushing with normal saline.
Each side is filled with standard heparin (1 to 1.5 ml). Skin suture of the
cervical incision is done with flexocrin.
3.2.2.2. PERCUTANEOUS INTERNAL JUGULAR VEIN CANNULA IMPLANTATION.
Adequate local anesthesia using 2% xylocai"ne is performed within the Sedillot
177
Figure 11-5. Main steps of percutaneous implantation of a double silastic right atrial catheter
(Canaud Cath, Vygon). A: IJ vein locating with a fine needle; Band C: introduction of the two
guide wires into the vein; D: introduction of the sheath vein dilator (Desilet) over the first guide
wire; E: insertion of the first silas tic cannula into the vessel through the sheath introducer; pro cede
in the same manner to insert the second cannula; F: subcutaneous tunneling of the cannula in a
caudal and internal direction using a long metallic tunneler needle; G: extension tubing adaptation
over each cannula; H: catheter fixation and skin suture.
triangle, prolonged subcutaneouly down the anterior chest wall. Cannulae are
flushed with normal saline.
Catheter insertion consists of five main steps (figures 11-5 and 11-6):
1. Internal jugular vein location. The internal jugular vein is located with an
introducer thin-wall needle and a 10 ml syringe (A in figure 11-5). The
straightened J portion of the first guide wire is passed through the needle
and advanced 10 to 15 cm into the vessel. The entry needle is again used to
introduce the second guide wire through the same skin puncture (B and C
in figure 11-5). When difficulties in locating the internal jugular vein are
met, it is more advisable to pass the two guide wires through a larger bore
needle or an adequate small introducer catheter at the same time.
178
Figure 11-6. Final aspect of a double silastic right atrial catheter inserted in a patient. A:
intravascular segment; B: subcutaneous segment; C: extension segment with connecting devices
and skin suture fixation.
2. Introduction oj the two silicone cannulae into the internal jugular vein. To
facilitate the movement of the sheath vein introducer, a 0.5 cm transverse
cervical skin incision is made to enlarge the needle skin puncture by a 1 cm
deep downward cut. The sheath vein introducer (Desilet) is introduced 5 to
7 cm into the vessel with a twisting motion over the first guide wire. (D in
figure 11-5). Stabilizing the vein introducer, the sheath is pushed 4 to 5 cm
into the vessel. The vein introducer and the guide wire are then removed,
leaving the sheath in place. The first silicone cannula with its plastic stylet is
then rapidly introduced through the sheath (E in figure 11-5). Holding the
cannula, both the sheath and plastic stylet are withdrawn carefully. The
cannula is aspirated, flushed with normal saline, and clamped with an
atraumatic vascular clamp. Using the same Desilet, the second cannula
is introduced into the vessel over the second guide wire following the
same procedure.
3. Subcutaneous cannula tunneling. The extravascular segment of the cannula is
tunneled subcutaneously in a caudal and internal direction, using a 15 cm
metallic tunneler needle (F in figure 11-5). The skin exit is located usually
10 cm below the internal part of the clavicle on the chest wall. The internal
cannula is shortened by 3 to 4 cm. Each cannula is tied firmly over the
tunneler and pulled downwards with its suture through two separate subcutaneous tunnels. Careful attention is paid to preventing catheter kinking
or damage during this maneuver.
4. Extension tubing adaptation. The emerging part of the silas tic cannula is
179
Figure 11-7. Usual aspect of the emerging parts of a double silastic right atrial catheter.
soaked in an ether solution for one minute to soften and expand the tip. The
polyethylene tip of the extension tubing is pushed 5 cm into the cannula
with its straightener, and allowed to dry and form a tight fit over the
cannula. Each cannula is then fitted with its extension device and a suture
is tied firmly around the overlapping tubing segments (G in figure 11-5).
The catheters are aspirated, flushed with normal saline, and clamped. Each
cannula is then pushed back into the vessel using the metallic guide wire.
5. Catheter fixation and skin suture (H in figure 11-5 and figure 11-6). There
are two means of catheter fixation. Initially, each catheter is tightly fixed to
the skin with separate sutures (Flexidene; dec 4). Recently, we found that
attaching the two sutures emerging from the neck incision together offered
a more convenient means of making an internal subcutaneous "U" stitch,
suppressing the need for skin suture fixation. The neck skin inclSlon is
closed with two independent fine sutures (Felxocrin; dec 2.).
The mean time of IJV catheter implantation is 45 minutes, which can be
reduced to 30 minutes when done by trained physicians. The catheters are
flushed with saline to check their permeability and to test the inflow/outflow
resistance, filled with 7500 IU (1.5 ml) of standard heparin, and closed with
Luer-Lok caps. The final aspect of IJV catheters is given in figure 11-7.
180
Figure 11-8. Chest x-ray to check the correct positioning of a radiopaque silas tic catheter tip in
the right atrium.
3.3. Immediate post insertion care
After post insertion, the catheters are protected by a small transparent plastic
dressing. To prevent the occurrence of hematoma or hemorrhage, an elastic
compressive bandage is maintained for one hour over the neck and the
supraclavicular fossa on the seated patient.
4. CANNULA POSITIONING
If possible, the radiopaque cannula posltlon is checked during insertion by

fluoroscopy or by a standard chest x-ray film immediately after insertion and
before the first hemodialysis session. The suitable position for catheter tips
appears to be the right atrium for the silicone catheters (figure 11-8) or the
superior vena cava for the semirigid catheters.
5. CATHETER USE AND LONG-TERM MAINTENANCE
Internal jugular vein catheterization is currently used in extracorporeal circulation, but can be extended to IV fluid or drug administration. IJV catheters
are manipulated by trained nurses of the dialysis staff in strictly aseptic conditions, using disposable and sterile gloves, masks, gowns, and drapes. Povidoneiodine solution is usually employed to disinfect the skin and emerging parts of
the catheters.
181
Before each hemodialysis, the catheters are aspirated to remove the distal
clot if present, and the first 2 ml of blood are discarded; the catheters are then
flushed with saline to test permeability and free flow. Blood lines are attached
to the catheters. By convention, the internal or shorter line is utilized as the
"out" catheter and the external line is used as the "in" catheter.
With IJV catheters, dialysis is performed as usual, either in the single-needle
or in the double-pathway configuration, according to the hemodialysis system.
Blood flow rate is maintained in the optimal range of 200 to 300 mIl min
for adults.
After each dialysis, the catheters are flushed back with saline and filled
with 5000 to 7500 IU of standard heparin, closed with a Luer-Loek cap, and
protected with a small waterproof dressing (Op'site).
Between dialysis sessions, the catheters remain in situ and require no special
care, except that the integrity of the dressing has to be carefully maintained.
The patient does not have to alter his or her way oflife and may take a shower
after the first week if an adequate waterproof dressing is used.
6. CATHETER EVALUATION
Catheter evaluation may be performed in three ways.

6.1. Functional evaluation
Although a rough evaluation of catheter function may be obtained during

hemodialysis, it is necessary to periodically evaluate effective IJV catheter
performance by measuring the effective blood flow rate according to the
"bubble transit time" method, the return venous pressure recirculation rate,
and the clearance of urea and creatinine under standard operational conditions.
6.2. Phlebography evaluation
A chest x-ray is normally sufficient to check positioning of the radiopaque

catheter tips. However, angiography may be indicated to explore unusual symptoms: poor blood flow rate, unexplained fever, and acute dyspnea. Depending
on the patient's superficial venous system, either cannula angiography or
bilateral forearm phlebography with cavography will be selected. In cannula
angiography, each cannula lumen is examined separately by rapid automatic
injection of 20 ml of iodinated contrast medium (Hexabrix), with serial
radiographs at the rate of two per second for 10 to 15 seconds. Phlebocavography is performed by injecting 30 to 45 ml of iodinated contrast medium, at
the rate 15 mllsec, into the catheters placed on each forearm (figure 11-9).
Digitalized bilateral forearm phlebocavography provides an excellent and less
aggressive means of exploring the superior vena cava.
6.3. Microbiological evaluation
Skin-exit and tunnel examination, and temperature measurement before each

hemodialysis connection, remain the best means of detecting early catheter
182
Figure 11-9. Usual aspect of superior phlebocavography performed through a double-forearm

angiography confirming the integity of the 1J vein and the superior vena cava.
infection. Catheter blood culture performed periodically and culture of the

distal clot are used to identify bacteremia related to catheter infection. Finally,
a tip-catheter culture performed systematically at the time of catheter removal, or in the case of proven or suspected bacteremia, should confirm and
contribute to a rapid cure of the problem.
7. CATHETER REMOVAL
Catheter removal must be performed aseptically. The skin suture and Dacron
cuff are removed, freeing the cannula. The catheter is pulled out gently under
firm digital compression of the jugular access site over 10 minutes. A small
dressing is then fixed onto the skin exit.
8. INDICATIONS
Hemodialysis is an optimal clinical setup for internal jugular vein cannulation. However, analysis of the literature data show that the reasons for IJV
cannulation depend on the method of insertion (table 11-2).
Surgically implantable IJV catheters are considered mainly for long-term
vascular access. In adults, IJV cannulation was the ultimate choice in chronic
patients whose vascular access was exhausted [31, 35-38]. In children, IJV
28
4
15
9
1
24
27
129
153
43
4
10
72
26
4
15
9
1
27
27
138
165
47
4
9
72
J.D. Mahan [34]

D. Francis [31]
C. Reed [36]
D. Francis [35]
R.S. Arze [37]
A.R. Watson [41]
H. Schanzer [45]
B. Canaud [43]
B. Canaud [44]
A.H. Moss [46]
R.J. Caruana [58]
D. T. Domoto [59]
G. Buller [47]
hsuperior vena cava.
ad = days; w = weeks; m = months.
No. catheters
No. patients
Author
1-6w
6-2w
118 d
14.4m
12m
35d
37d
54d
57.3 d
I-14m
5w/22m
66d
Time a
0
0
0
I
0
0
0
2
2
0
2
3
0
3/1
013
010
1/0
010
011
010
3/2
4/3
6/0
1/10
6/0
Thrombosis
SVC b
Infection
skin I sepsis
1
0
0
0
0
0
0
0
0
0
0
0
Emboli
2
3
6
1
0
3
0
0
0
2
3
7
Incorrect
flow
0
0
0
0
0
0
0
0
0
0
0
0
Trauma
Table 11- 2. Clinical experience and complications of the silas tic right atrial cannulation for hemodialysis reported in the literature
1
0
0
0
0
0
0
7
0
2
2
0
Self-withdrawal
'"
00
...
;:l
0'
fr
t:
;:l
;:l
()
.,
:;"
<:
.,...
t:
aq
t:
'-
184
cannulation was indicated either in acute or chronic cases as an alternative to

conventional vascular access (34, 41).
The easily inserted percutaneous silicone IJV catheters are more widely
used, and their potential usefulness is now better known [33, 42-44]. We have
performed 381 IJV catheterizations in our department (table 11-3).
End-stage renal failure is the most frequent reason for IJV cannulation (74%
of patients). This group is made up of four main subgroups: 1) patients in
whom hemodialysis is initiated in the absence of a functioning fistula (62.6%),
2) patients receiving long-term hemodialysis but whose regular access cannot
be used (19.2%), 3) patients maintained on long-term peritoneal dialysis
requiring transfer to hemodialysis after peritoneal catheter removal because of
severe peritonitis or loss of peritoneal membrane transfer capacities (17.4%),
and 4) a means of starting hemodialysis in graft kidney failure without fistula
(0.71 %). In most cases IJV catheters were used as temporary vascular access
for immediate hemodialysis while waiting for the arteriovenous fistula to
occur. However, in some patients IJV cannulation was used on a mid- or
long-term basis, either because of patient preference or in patients with limited
prognosis, or again in patients whose peripheral vascular access site capital was
exhausted. Forty-five patients were trained in ambulatory home dialysis with
IJVC while their fistula was maturing; six end-stage renal disease patients were
transplanted with IJVC as the sale blood vascular access. It is interesting to
point out that patients with a "high risk" of infection, patients with diabetes
[18], systemic lupus erythematosus [5], chronic skin bacteria [5], and those
receiving immunosuppressive drugs [8], were included.
Acute renal failure represents the second reason (24% of patients) for IJV
cannulation. This group is made up of five subgroups according to the origin
of the acute renal failure. The majority of patients (51 %) had iatrogenic or
Table 11-3. Main indications for placement of a double-silastic
right atrial catheters using the percutaneous internal jugular vein cannulation
Indication
n'
END-STAGE RENAL FAILURE
281
176
54
49
2
100
62.6
19.2
17.4
0.71
Toxic nephropathies
Postoperative
Transplant with temporary failure
Traumatism
Obstetric
100
51
33
8
7
1
100
51.0
33.0
8.0
7.0
1.0
TOTAL
381
lOO.O
Without vascular access

Failed vascular access in chronic patient
Transfer from CAPD program
Chronic rejection of transplant
ACUTE RENAL FAILURE
'Number of percutaneous fJY cannulations performed in the Nephrology Department ofMontpellier.
185
toxic tubular necrosis. A postoperative cause was found in 33% of cases

(vascular surgery, 39.4%; abdominal surgery, 30.3%; urinary tract surgery,
30.3%). Acute kidney graft failure represented 8% of the cases. Traumatic
rhabdomyolyses or an obstetrical origin were found in 7% and 1 %, respectively. In ten cases, ARF associated with multiple organ failure was treated by
means of continuous, pump-assisted venovenous hemofiltration. In all other
cases, patients were dialyzed in the intensive care unit using standard hemodialysis with bicarbonate-containing dialysate. Ventilatory assistance was
performed concomittently in five patients with tracheotomy and in six patients
with nasotracheal tubing.
9. RESULTS
Surgically implantable IJV catheters have been used successfully on a mid- or

long-term basis in chronic dialysis patients. However, the number of patients
and/ or catheters implanted is so limited that it is impossible to draw any
definite conclusions about this procedure.
Percutaneously implantable IJV catheters have been used in a larger group of
patients. We have implantated 381 double, internal jugular-vein catheters
between December 1982 and September 1987 (227 males, 154 females, mean
age 54.7 1. 7). The right internal jugular vein was used preferentially (237
patients) because this approach provides a direct course into the right atrium.
The left internal jugular vein (44 patients) was used only when the right side of
the neck or of the chest was already in use for parenteral nutrition. During
this period, more than 10,000 dialysis sessions, averaging 25 per patient
(range 1 to 467), were performed in a double-pathway configuration. Dialysis
prescription (KT/V) was done according to individual patient requirements.
Anticoagulation with standard heparin was not modified for the IJV cannula.
The cumulative duration ofIJV catheter use reached 104 years, with an average
of 121.2 and 40.6 days/patient in chronic and acute renal failure patients,
respectively.
10. PITFALLS AND COMPLICATIONS
OF INTERNAL JUGULAR VEIN CANNULATION
10.1. Technical difficulties
Difficulties in inserting IJV catheters may occur, mostly with the percutaneous method, due to anatomy or due to surgical cervical sequelae. Left IJV
cannulation is subject to more problems. Multiple cannulations of the same
vein are possible, but fibrotic sequelae increase the difficulty of vein catheterization. A short or bull neck, thyroid goiter, parathyroidectomy sequelae,
and tracheotomy were the main difficulties met in IJV cannulation. In one
patient, who had a pacemaker implanted on the same side three months earlier,
IJV cannulation was impossible. The surgical incision of the IJ vein found a
thrombosed and fibrosed IJ vein.
Accidental arterial puncture may occur. In our experience this happened
186
five times, but remained uneventful after removing the introducer needle and
compressing the puncture exit site for five minutes.
10.2. Minor complications
Cervical pain is usually experienced within hours following the insertion but
may be relieved easily by analgesics.
Bleeding and/or cervical hematomas may occur in the immediate postinsertion
period, particularly in severe uremic patients or in patients with coagulation
abnormalities. Such problems could be due to vein puncture leak, to faulty
vein catheter tightness, or to rupture of a subcutaneous vessel during tunneling. This happened in four patients. Treatment consisted of sitting the
patient up and compressing the cervical incision and the subcutaneous tunnel with an elastic bandage. The catheter was not removed. Any bleeding
tendency was corrected by dialysis.
Pulsatile back pain during dialysis, related to blood flow, is an uncommon
complication. It is mostly seen in right atrial catheters. This was observed on
two occasions during the first hemodialysis session. Catheter angiography
showed a selective opacification of the azygos lymphatic drainage system. It
was speculated that the blood pump flow created a high pressure in the lumbar
venous system, responsible for back pain during dialysis. This hypothesis was
confirmed, since shortening the catheters solved the problem.
Skin-exit inflammation may be observed within days or weeks following
catheter insertion. It usually results from an irritating effect, both of catheter
movement during connecting procedures and/or disinfecting agents. This
problem can be solved by applying local antiinflammatory unguents.
Poor bloodflow and/or high venous pressure are the most frequent complications
of IJV catheters reported in the literature that require catheter revision (see
table 11-2). Inadequate blood flow may be due to four main causes: malposition of the catheter tip confirmed by x-ray, necessitating cannula repositioning
using a guide wire; tube kinking in the subcutaneous tunnel, necessitating
cannula revision; partial thrombosis of the catheter due to insufficient flushing
before connection or to inadequate heparinization during the dialysis session;
and development of a lumen fibrin sleeve, which has a partial obstructive
effect. The two last problems can be solved by fibrinolytic agents (streptokinase, urokinase) infused or maintained in the cannula for one or two hours.
However, catheter angiography is necessary to eliminate vein thrombosis.
10.3. Major complications (Table 11-4)
Traumatic complications (pneumothorax, hemothorax, compressive cervical hematoma, etc.) are sometimes encountered, particularly when the IJV catheter
is placed in a low position or when semi rigid material is implanted. This
risk is identical to that observed in subclavian cannulation and is extensively
reported in the literature [14, 17, 20]. However, when a silicone cannula is
inserted, this risk exists only at the time of implantation, since the softness and
187
Table 11-4. Major complications observed with the use of381 consecutive
double-silicone internal jugular vein catheters in the Nephrology Department ofMontpellier
Complication
No.
None
Skin infection
Septicemia
Staph. aur.
Pseudo maltop.
Acinetobacter
Withdrawal
Superior vena cava thrombosis
Air embolism
Allergy
Catheter embolism
336
17
13
10
2
1
9
5
3
2
1
88.22
4.45
3.41
2.36
1.30
0.78
0.52
0.26
flexibility of the material eliminates all mid- or long-term risks. These complications were never observed in our hands, suggesting that traumatic complications due to percutaneous venous access procedures are negatively correlated
with the training and experience of operators [3].
Anaphylactoid reactions at the time of insertion due to allergy to ethylene
oxyde or other materials is possible, particularly in atopic patients. In our
hands, two patients suffered from allergic reactions: one had severe Quincke
edema that resolved within a few minutes after catheter removal and symptomatic treatment, the other had an acute attack of asthma that responded to
symptomatic treatment and that did not necessitate catheter removal.
Arrhythmia (ventricular fibrillation, extraventricular beats) may result from
the introduction of the guide wire or the tip of the cannula into the atrium
or, in some cases, into the ventricle and may be solved instantaneously by
withdrawing the guide or cannula by a few centimeters.
Catheter self-withdrawal is also possible, especially when it is not firmly fixed
to the skin. This accident happened rarely. The risk can be estimated at 2.4%.
In one occasion it was complicated by air embolism.
Air embolism is a common risk of the intrathoracic central vein catheters. The
risk increases with the diameter of the catheter and can be prevented by patient
position (Trendelembourg) and an appropriate clamping measure during the
insertion time or connecting procedure. It may sometimes occur late after
catheter removal [51]. In our experience, this never happened during the
insertion time but was observed later in three patients: two were on ambulatory hemodialysis, one of whom had a small accidental plastic crack on the
connecting device, and the other committed suicide by opening the catheters.
In the third case, a delirious patient disconnected the blood lines during a
dialysis session.
Catheter embolism into the circulation or heart represents a potential hazard
of IJV cannulation. This complication has been described with central vein
188
Figure 11-10. Massive mural thrombosis (arrows) of the superior vena cava entrapping the tips
of the IJV catheter revealed by cannula angiography.
catheters [7] but has not been reported with I]V catheters used for hemodialysis. This risk appears particularly high during the insertion time of
removable IJV catheters. It happened in one of our severely ill patients, in
whom IJV catheters were used both for hemodialysis and parenteral nutrition. An accidental disconnection of the two pieces of cannula during the
continuous IV administration resulted in a cannula migrating into the right
ventricule. The cannula was easily brought back by a basket probe (Dormia
probe), passed through the femoral vein, and guided by fluoroscopy [52].
Vein thrombosis, a major and common risk of central venous catheters [18,
19, 27, 28, 53-55], also occurs with silicone I]V catheters [56-60]. Ten cases
are reported in the literature [43,56-60]. In our study, 80 phlebographies were
performed retrospectively: 50 were asymptomatic at the time of catheter
removal and 30 had clinical symptoms. In five cases, partial mural thrombosis
of the superior vena cava was discovered (figure 11-10). No catheter sleeve
189
thrombosis coating was noted. Interestingly, thrombosis was never observed

within the internal jugular vein itself, thus confirming a low overall incidence
(1. 3%) of vein thrombosis related to IJV cannulation when silas tic material is
used. Such massive mural thrombosis was never complicated by pulmonary
embolism. On the basis of these observations, three important points must be
made: 1) Symptoms of massive thrombosis of the superior vena cava are poor
(intermittent poor blood flow, fever) if not asymptomatic. 2) Thrombosis was
noted in an inflammatory clinical setup ( severe peritonitis in four cases, five
cases with high fibrinogen level and platelet number) 3) The mural clot was
large and sticky, with little migration tendency, and was easily lysed by
medical means. Compared to data reported concerning the subclavian route,
this low prevalence of thrombosis or of stenosis sequellae [18, 19, 27, 28] can
possibly be explained both by the insertion method, which prevents catheter
tip damage and resulting endothelium trauma, and by the nature of the
cannulae [56, 57], two factors known to initiate local thrombosis.
To our knowledge, vein stenosis, although a potential risk of long-term
indwelling catheters - either due to permanent vein irritation or to the sequellae of thrombosis - was never reported with IJV cannulation using silas tic
material. Acute or subacute superior vena cava symptoms may be observed
when IJV catheters are passed through a narrow segment of the superior vena
cava or after creating an arteriovenous fistula unmasking a vein obstruction
[281. Immediate IJV catheter withdrawal and adequate anticoagulation solve
the problem.
lt~fection, a permanent risk of indwelling catheters, was rarely encountered
with this vascular access device. A few cases are reported in the literature
mainly due to Staphylococcus aureus. Interestingly, most of them were cured by
appropriate antibiotic therapy without removing the catheters. In our experience, the overall infection rate with IJV cannulation, including skin exit, tunnel
injection, and bacteremia, was evaluated at 3.7%, which is lower than that
reported by Hickman [30] and for subclavian catheters (range between 4.8%
and 20.6% with a mean of 14% [15, 21-23]. This observation becomes even
more significant when the number and/or the lifespan of the vascular access are
considered. Two major factors may explain such a low infection rate. First, the
IJV cannulation method itself combines the use of silicon cannulae carrying a
low infectious risk and a long subcutaneous tunnel, which protects and
stabilizes the catheters [56, 61]. Second, a key role is played by staff nurses
who manipulate IJV cannulation for hemodialysis in strictly aseptic conditions
[61, 62]. Results are probably improved when a Dacron cuff is used to fix the
catheters, but that remains speculative since the number of patients is small
[35-40, 46, 47], or when patients are selected [63]. Although it seems possible
to cure catheter infection in situ [39], that does not seem to be a reasonable
attitude. In our experience, a proven or suspected catheter-related infection
was accompanied by immediate IJV catheter removal and adequate antibiotic
therapy was given. That was a key to the success of the percutaneous method.
190
If needed, IJV cannulae can be implanted on the opposite side a few days after
apyrexia is obtained.
11. INTERNAL JUGULAR VEIN CANNULATION COMPARED TO
OTHER TEMPORARY VASCULAR ACCESS METHODS FOR HEMODIALYSIS
IJV cannulation has been underused over the past. It is complementary to subclavian or femoral temporary venous access. Among the different methods
ofIJV catheterization, in our opinion the percutaneous method using semirigid
material should be considered as an emergency high-risk procedure that
cannot be safely recommended, even for a short time period.
On the contrary, IJV cannulation methods using silicone cannulae with
a long subcutaneous tunnel appear safer and more promising for short- or
long-term vascular access than the subclavian method.
The common advantages of silicone ljV cannulation are threefold: the large
diameter of the IJ vein permits introduction of larger bore catheters with less
risk of obstruction and reduced shear stress for blood elements [26] than the
subclavian vein; silicone rubber cannulae with improved hemocompatibility
minimize the risks of thrombosis or infection; and the flexibility and softness
of IJV catheters preclude the risk of having a vein or cardiac traumatism,
particularly on a long-term basis.
Percutaneous ljV cannulation with a silicone catheter is a new approach. It allows
mid- or long-term temporary vascular access for hemodialysis and is the best
compromise today between conventional percutaneous catheterization with
poorly biocompatible material and a surgically implantable silicone rubber
cannula. IJV catheters keep the advantages of percutaneous subclavian
cannulation. The IJV cannula is inserted in a "clean" area, limiting the
infectious risk. IJV cannulation does not restrict patient mobility or activity,
permitting most chronic patients to be ambulatory on the day of implantation. This fact is economically important, since it substantially shortens the
hospitalization period.
ljV cannulation is not a particularly difficult task for a nephrologist familiar with
the venous percutaneous catheterization method to perform. The time of IJV
cannula insertion averages 45 minutes and is identical to subclavian cannulation
with subcutaneous tunneling. Traumatic complications resulting from insertion or long-term use of IJV cannulation are rarely encountered, confirming
that in trained hands the method is very safe. Finally, IJV cannulas appear
easier to handle than the surgically implantable right atrial silas tic catheters,
which necessitate a delicate vascular surgical approach, with the non-negligible
risk of sacrificing the vessel.
In addition the ljV cannula offers specific advantages over the subclavian catheter.
The IJV cannula permits, by means of a virtually unlimited blood flow rate
with low recirculation, optimization of the dialysis prescription required for
an individual patient. Chronic or stable acute renal failure patients may be
treated with standard hemodialysis equipment, while patients presenting with
191
multiple-organ failure may benefit from a continous low efficiency method

such as continuous, pump-assisted hemofiltration. Technical maintenance of
the IJV cannula appears to be simpler than subclavian catheters, since it does
not necessitate manipulation between hemodialysis sessions. Comfort and
safety provided by the IJV cannula permit home dialysis to be performed in
selected patients. The relatively low morbidity associated with the IJV cannula
also permits its use on a mid- or long-term basis. Consequently, chronic
vascular access need no longer be performed urgently. This aspect is particularly interesting in patients having a poor nutritional status leading to
healing difficulties (e.g., a peritoneal dialysis patient after a severe peritonitis
episode). Dacron cuffs were not used routinely in our initial experience,
because peel-away sheath vein introducers were not available. Indeed, their
presence around the cannula may improve their safety. This measure should
reduce the infection rate and increase patient comfort, as already shown in
small series.
12. CONCLUSION
Double or dual IJV cannulation using silas tic catheters provides a safe and
reliable temporary vascular access for all extra corporeal treatments (hemodialysis, hemofiltration, hemodiafiltration). Percutaneous IJV cannulation
with silicone catheters should be considered as a "hybrid" method designed
for mid- or long-term angioaccess. The high biocompatibity of the silicone
cannula may be one contributing factor to the low morbidity rate. Possible
improvements in cannula design could make IJV cannulation the first choice
for temporary vascular access in uremic patients. Although further studies are
required to define its exact place in angioaccess, IJV cannulation seems to be a
promising and attractive method for temporary vascular access.
ACKNOWLEDGMENTS
The author wishes to thank Fran~oise Buchet for drawing the figures and
Dr. Cyril Bouloux for his invaluable advice in reviewing the manuscript.
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1982.
12. VASCULAR ACCESS FOR HEMODIALYSIS IN CHILDREN
WOLF D. BRITTINGER, WOLF D. TWITTENHOFF and GOTTFRIED WALKER
Regular dialysis therapy (RDT) in children with end-stage renal failure was
still a matter of controversial discussion long after the establishment of this
form of treatment in adults. It is only since the mid-1970s that RDT in this age
group has been a therapeutic method accepted worldwide until the dawn of
successful kidney transplantation. This primary goal in pediatric nephrology
can be reached by either continuous ambulatory peritoneal dialysis (CAPD) or
hemodialysis. In our opinion, CAPD is the treatment of choice for infants up
to the age of four years. Chronic hemodialysis is a life-saving therapy for
thousands of older children throughout the world.
In pediatric patients on hemodialysis, a variety of specific problems are encountered, resulting from having to treat chronic illness at this age. Very often
emotional and psychosocial disturbances exist or emerge. Technical problems
may also complicate the treatment of children with the artificial kidney.
We now know that such technical problems have been over-estimated in the
past and are statistically far less serious than was assumed several years ago.
Nevertheless, they can make RDT difficult in individual cases. Most often
these difficulties are related to obtaining or maintaining the permanent
vascular access necessary for hemodialysis and its practical long-term use
[1-13]. The approach to these problems is controversial. In this context it
should be mentioned that in the literature, pediatric nephrologists recommend
totally different vascular access types as suitable or even ideal, depending on
their own experience [9, 10, 13-24]. In contrast, the authors emphasize from
195
196
the beginning that there is no special pediatric access type and that all forms
relevant for adults may also be of significance for children. The vascular
surgeon therefore can rely on the entire spectrum of proven access types and
choose the one most suitable. Despite this fact, it cannot be denied that
vascular access for regular dialysis will be a major problem for a growing
number of patients - adults and children as well. This especially refers to
those patients who have been on dialysis for many years. In these patients,
most access sites are often exhausted or remaining vessels cannot be used
without the risk of peripheral ischemia. Table 12-1 illustrates this development, showing our own experience from 1977 to 1985 in children and adults.
Analyzing the statistics for each year, it is evident that the percentage of
patients with more than five previous operations rises from 10% in the first
year to 42% in 1985. The change is comparable in the group with more than
ten operations: The number grew from 3% to 14%.
With respect to this development, the vascular surgeon should take into
account the following considerations, especially when operating on children:
1. Life expectancy on RDT tends to be many years, even if transplantation
replaces dialysis in some cases, for periods of different duration.
2. The function of each access type is statistically always time limited.
Therefore, one necessary surgical intervention must be part of a general
concept, integrating the need for consequent operations. The use of access
types, such as the Teflon-silastic shunt, or of surgical techniques, such as the
end-to-end anastomosis of an arteriovenous fistula, must have a strong indication, because they always have unfavorable hemodynamic consequences.
This also applies to grafts implanted centrally as an initial access.
In access surgery, attention has to be paid not only to such "economic" considerations but also to individual situations. Two factors are most important:
1. The medical history of each child. If a child is suffering from a vascular
disease, e. g., diabetes, only access variants are applicable without negative
influence on peripheral circulation. On the other hand, access types with
low shunt volumes will be chosen in the presence of cardiopulmonary
insufficiency.
2. The vascular state. Checking for patency of the arteries, arterial occlusion
after previous operations, and/or overt peripheral circulatory dysfunction is
obligatory. Evaluating the state of the veins must include recording their
distance from the artery, their caliber under a normal condition and after
applying venostasis, the elasticity of the vessel walls, the length of the
venous segments suitable for cannulation, and signs of obstruction such as
cutaneous collaterals.
Only upon consideration of all these factors can a decision be made as to the
type, site, and technique of access recommendable for the child.
1977
1978
1979
1980
1981
1982
1983
1984
1985
1977/11985/12
Leg
63
26
62
78
119
121
161
150
184
894 964
35
32
61
82
63
110
105
195
211
2
1
2
1
2
273
37
52
47
64
28
6
21
18
132
1
16
1
25
40
29
13
Leg
PTFE
446
2
18
10
55
123
146
25
67
9
12
8
12
11
5
1
6
3
2935
171
167
234
264
304
433
481
410
471
323 (- 11 %)
> 10 previous
op. s
820(-28%) 2115(-72%) 956(-33%)
> 5 previous
op. s
5(-3%)
9 (- 5%)
14 (- 6%)
21 (-7%)
33 (- 10%)
58 (- 13%)
77 (-16%)
42 (-10%)
64 (- 14%)
141 (- 83%)
126 (- 75%)
181 (- 77%)
215(-81%)
253 (- 83%)
351 (- 81%)
377(-78%)
249 (- 61 %)
222 (- 48%)
Multiple
operations
Number of patients with
18 (-10%)
28 (- 16%)
43 (- 18%)
62 (- 23%)
106 (- 34%)
163 (- 37%)
198(-4]%)
141 (- 34%)
197 (- 42%)
30 (-17%)
41 (- 24%)
53 (- 22%)
49(-18%)
51 (- 16%)
82 (-18%)
104(-21%)
161 (- 39%)
249 (- 53%)
Other Total
First
access number operations
types
144 67
7
4
19
64
31
14
5
Arm Leg
Grafts
Bovine graft
Left Right Left Right Arm
Arm
Arteriovenous fistulas
Table 12-1. Statistical survey of the procedures for vascular access between
1977 and 1985 - Department of Nephrology , Rehabilitationsklinik Neckargemund
-..J
....
-0
::l
(I)
Er
0:
,..,
1S
0;.
0..
(I)
:r:
ao
tv
198
Prerequisites for vascular access surgery in the pediatric age group are
adequate instruments, preferably microsurgical ones. Small-pointed forceps,
small straight and angled scissors, suitable needle holders, and miniaturized
bulldog clamps are indispensable utensils.
Suture size should be 7-0 or 8-0 (6-0 with grafts). The use of monofilament or braided sutures is determined by the potential complications the
surgeon wishes to avoid. Surgeons prefer the smoother but less flexible monofilament suture if they are afraid of retracting the adventitia. They choose
the supple, braided material if they prefer a tight suture without traction.
We exclusively use braided material for the aforementioned reasons and
because we often see adverse tissue reactions when using the monofilament
sutures due to their rough ends. Whether the suturing of children's small
vessels should be done under a magnifying glass or not depends upon the
individual surgeon's visual capabilities.
1. EXTERNAL ARTERIOVENOUS SHUNTS
Quinton and Scribner's external Teflon-silastic shunt [25] and its modifications
should be mentioned first. Although we respect the importance of this invention in medical history, we will not describe this access form in further
detail because its use is no longer justified, in our opinion, due to the advent of
other access types and the alternative, CAPD.
Its many disadvantages must be stressed: frequent clotting episodes, early
irreversible thrombosis, infections, hemorrhages, frequent hospitalizations of
shunt patients, restriction of physical activities by being forced to take care of
an external device, and, last but not least, the loss of an artery and thereby of a
potential site for permanent access. These disadvantages of the external shunt
far outweigh its positive aspects, notably the avoidance of needle punctures.
We do not deny the problem of repeated punctures for dialysis in children.
However, we do not agree with other authors' recommendations of the shunt
for infants [3, 5, 9, 20], because we know this problem usually subsides with
time. Most children get used to the painful procedure or don't even notice the
pain after a while [26-28]. We have confirmed this by questioning 75 children
with an average age of 11. 8 years (range 3 to 17 years). The patients were being
dialyzed via subcutaneous arteriovenous fistulas or via heterografts (PTFE and
bovine grafts) for longer periods. All had former experience with the external
shunt or knew it well from fellow patients. The relevant questions on the
questionnaire were:
Question
1. How do you judge
the puncture stress?
2. Would you prefer the
external shunt?
Answer
none at all minor
major
no
yes
no comment -
29
29
17
70
3
2
(39%)
(39%)
(22%)
(92%)
( 4%)
( 3%)
12. Hemodialysis in children
199
In only a minority of small children, access types that necessitate puncturing

have to be abandoned due to anxiety or stress [15, 22, 29]. Not even in these
cases do we believe that the shunt is a good alternative with respect to other
possible procedures (CAPD, long-term central venous catheter).
2. SUBCUTANEOUS ARTERIOVENOUS FISTULA
(BRESCIA-CIMINO FISTULA)
2.1. Radial-cephalic arteriovenous fistula
Figures 12-1 and 12-2 show an arteriovenous fistula (A VF) between the radial
artery and the cephalic vein at the wrist. It is now the predominantly used
angioaccess, even in children [30]. A longitudinal skin incision, about 3 cm
long, is made between the tendon of the flexor carpi muscle and the cephalic
vein, beginning 2 cm above the processus styloideus radii and extending to the
elbow. Even very small vessels can be used in children because of their great
elasticity, despite an inner diameter ofless than 2 mm. Careful dilating with a
small Fogarty catheter may facilitate the handling of the vessels. The vessels
should be flushed with heparinized saline prior to suturing. Figure 12-1
schematically illustrates the hemodynamics of a side-of-artery to end-of-vein
anastomosis. A frequent consequence of this fistula form is a high shunt
volume caused by deriving blood from the ulnar artery via the palmar arch, in
addition to the antegrade flow from the proximal radial artery. This retrograde
blood flow can be as high as 50% of the total volume, without influencing
fistula function. Despite its high shunt volume and its possible consequences
for peripheral and cardiac hemodynamics, we favor the side-to-end anastomosis over the fistula in the end-of-artery to end-of-vein fashion, which exerts
less burden on the heart. The reason is that this method preserves the artery in
case of irreversible occlusion of the fistula. Followup surgery can then be
performed on the same limb, with lower risk of insufficient perfusion of the
hand. Moreover, it has been proven that the majority of patients tolerate the
slightly greater shunt volume well.
We choose the end-to-end technique only for those patients with manifest
heart failure in which angioaccess with the lowest shunt volume is mandatory.
This can be achieved in two fashions:
1. Conversion from side-to-end to "functional" end-to-end anastomosis by
ligating the distal part of the artery. Proceeding in this way alleviates
creating fistulas with vessels of diameters less than 2 mm. In doing so,
arteriotomy and venotomy can be made as long as necessary and as convenient as possible for suturing. On the other hand, this method sometimes leads to diverticulumlike eversion of the anastomosis, causing great
turbulence of the blood and potentially initiating fistula thrombosis.
2. The direct end-to-end anastomosis. We prefer this technique to the
"functional" one because of better flow dynamics. Bridging the two vessels
should be in the form of a gentle loop. The ends of both an artery and a vein
200
C
(
Figure 12-1. Flow dynamics of radio cephalic fistula -
side-to-cnd technique.
Figure 12-2. Radiocephalic side-to-end fistula in a 14-year-old girl. Extreme ectasia of the fistula
vein after five years.
201
Figure 12-3. End-to-end anastomosis of small-caliber vessels using a patch.
are dissected in a correspondingly oblique manner (at an angle of about

50). When the vessels arc of small caliber (outer diameter less than 2 mm),
interposition of a venous patch is helpful (figure 12-3). Usually the vein is
long enough to take such a patch from its distal end. Otherwise, any other
vein found in the operating area may be used. Inevitable postoperative
stenoses of the suture line can be compensated by this artifical aneurysmatic
enlargement of the anastomosis.
We predominantly use the side-to-end technique, aiming at a length of 10 to
15 mm in the anastomosis. The closer the vein and the artery are to each other,
and the sharper the angle at which the vein is brought to the artery, the longer
the anastomosis must be.
Several precautions should be observed in performing this procedure:
1. The arteriovenous connection has to be free of tension. Exposure of the
vein must be extensive enough so that the artery is not pulled out of its
original position.
2. Kinking of the vein has to be avoided by adjusting the length of the
anastomosis and by variation of the vein's dissection.
3. Circular retractions of the mobilized vein caused by adventitial bands are
often seen, especially in infants, even if dissection has been performed with
the most possible care for the adventitia. The vein must be scrutinized for
such bands, which must be carefully removed with a microforceps. The
operation should be brought to an end only when the characteristic thrill is
present over the vein just above the anastomosis as proof of an adequate
blood flow.
2.2. Ulnar-basilic AVF
In older children, the basilic vein quite often (in about 10% of cases) is better
developed than the cephalic vein. In these cases, the primary method should be
the construction of a side-to-end anastomosis between the ulnar artery and the
basilic vein (figure 12-4). A 4-cm skin incision is made at the lateral edge of
202
Figure 12-4. Ulnobasilic fistula (side-to-end technique) in a 16-year-child after two years .
the tendon of the ulnar flexor carpi muscle, beginning 3 cm above the styloid
process and extending to the elbow. More proximal anastomosing is not
possible because the ulnar artery becomes inaccessible there due to being
covered by the tendon of the flexor carpi muscle. This fistula type has been as
successful as the radio cephalic fistula in our experience.
2.3. Radiocephalic A VF at the upper forearm
If peripheral forearm vessels have been destroyed or are no longer available, a

radio cephalic fistula at the upper forearm is feasable, insofar as suitable veins
are present (figure 12-5). A skin incision, 4 cm long, is made following the
course of the radial artery, beginning at the transition of the middle section to
the upper part of the forearm, extending to the wrist. The distal end of the
incision is at the crossing of the pronator teres and the brachioradial muscle.
This fistula form always induces good dilation of the median antecubital
veins, continuing to the two proximal cubital veins. Despite the short segments available for cannulation, it can be a durable access when handled
carefully. In case the bifurcation of the radial and ulnar arteries is located rather
distally, a brachiocephalic fistula may be created.
2.4. Upper arm A VF
Another fistula type in the arm may be important for older children: the upper
arm fistula with subcuticularization of the basilic vein (figure 12-6). This
Figure 12-5. Arteriovenous fistula in the upper forearm artery and the cephalic vein.
203
end-to-end anastomosis of the radial
comes into consideration when only the vena mediana basilica or basilica
brachii are patent after occlusion of the vena mediana cephalica. If these veins
are patent, it can be presumed that the vena profunda cubiti opening into
them is also intact. In this case, anastomosing should be done between the
latter vein and the proximal part of the radial artery or the brachial artery in an
end-to-side fashion [31] via a 4-cm skin incision, beginning at the elbow and
extending to the hand along the course of the median cubital vein.
If only the vena basilica brachii is suitable for anastomosis, it must be
connected with the brachial artery in an end-to-side manner. A 3-cm skin
incision is made beginning at the upper end of the bicipital aponeurosis and
extending to the axilla, following the course of the brachial artery. High shunt
volume and potential cardiac stress must be accepted and taken into account.
The subcutaneous fixation of the basilic vein is performed some time after
anastomosing, when the vessel is dilated and stabilized under arterial pressure.
A skin incision is made following the whole length of the sulcus bicipitalis
medialis between the elbow and axilla. The brachial fascia is split as far as
possible, and the mobilized vein is embedded into the subcutaneous tissue
while resuturing the fascia. Skin closure is performed in one layer.
204
Figure 12-6. Brachiobasilic fistula (side-to-end technique) with subcuticularization of the vein in
a 16-year-old girl. Massive dilation of the basilic vein after seven years.
The vein, being taken from the natural anatomical site is unfortunately
prone to degenerative reactions of its wall. Fibriointimal hyperplasia leads to
progressive thickening of the vessel and ultimate failure of the fistula after
about 1112 years. But the opposite development, which is positive in respect to
fistula function, can also occur: Figure 12-6 shows extreme ectasia of the
basilic vein in a 16-year-old girl.
2.5. A VF at the lower leg
A rather unusual access type is the arteriovenous fistula in the lower leg,
shown in figure 12-7. In thinner, older children and in adolescents, the course
of the great saphenous vein in the shank and in the lower part of the thigh is so
superficial that it can easily be used for cannulation. In cases of end-to-side
fistula with the posterior tibial artery, we found it to be a safe and durable
hemoaccess. A slightly curved 6-cm skin incision was made, beginning about
2 cm above the upper border of the inner ankle and extending distally to
surround the medial malleolus.
3. SUBCUTANEOUS GRAFTS FOR VASCULAR ACCESS
The interposition graft is a good alternative for children on dialysis in whom

the access types outlined before have failed. Two materials have gained
12. Hemodial ysis in children
205
Figure 12-7. Arteriovenous fistula in the lower leg (posterior tibial artery/saphenous vein).
the foremost widespread acceptance for this purpose: expanded poly tetrafluoroethylene (PTFE) and processed bovine carotid arteries (BCA) [32-34].
Umbilical vein grafts and homografts of saphenous veins are seldom used
anymore because of their high complication rates.
Both the bovine and PTFE grafts have specific advantages and disadvantages
in relation to the individual condition of the recipients. If the vessels or the
limbs for implantation are small, we prefer the BCA graft for the following
reasons: The smooth collagenous material can be more easily anastomosed
to small and thin-walled veins and arteries, and it can be placed into the
subcutaneous tissue without extensive dissection and more easily than the
more rigid Teflon prosthesis. Hence we regularly choose this graft in little
children when there is a slim chance of constructing a fistula. In contrast,
PTFE grafts are favored when their special properties do not negatively
influence implantation; they are therefore suitable for older children and adults
with bigger vessels and well-developed subcutaneous tissue.
Many authors are convinced that BCA grafts are more prone to infections
and therefore function for a much shorter time than PTFE grafts, a statement
we cannot confirm.
Table 12-2 is a compilation of our experience from 1977 to 1983 and
demonstrates that BCA grafts had a 74% patency rate of more than one year
206
Table 12-2. Grafts for angioaccess - Comparison between

bovine and PTFE grafts. Experience in children and adults (1977 -1983)
PTFE
Bovine graft
N
Patency rate> 1 year
Thrombosis
Infection
With loss of graft
Perforation by infection
or aneurysm
Arm
Leg
Total number
Arm
Leg
Total number
255
184
(72%)
123
(48%)
61
(23%)
43
7
131
103
(78%)
84
(64%)
4
(3%)
3
2
386
287
(74%)
207
(53%)
65
(16%)
46 (71 %)
9
354
226
(63%)
214
(59%)
72
(20%)
19
125
89
(71%)
91
(71%)
3
(2%)
0
479
315
(65%)
305
(63%)
75
(15%)
19 (25%)
0
without any complications, whereas with PTFE grafts it was only 65%. The
infection rates were almost equal, 15% vs. 16%. With both graft materials,
infections in the thigh were less frequent than in the arm (3% and 2% vs.
23% and 20%). However, one significant difference exists: The BCA graft
is more often lost in case of infection (71 %), occasionally under dramatic
circumstances, than the PTFE graft (25 %).
We prefer insertion of heterologous conduits in a loop configuration (as
shown in figure 12-8) in the arm. The graft is placed into the subcutaneous
tissue of the forearm in a loop that is as wide as possible, while anastomosing it
with the brachial artery and the basilic (sometimes the brachial) vein in an endto-side fashion above the elbow. The main skin incision is 5 cm in length,
beginning in the sulcus bicipitalis medialis at the transition of the middle to
the lower third of the upper arm and extending anterodistally in a slight
curve. In addition, two or three incisions of about 1.5 cm in length are made
at the volar aspect of the forearm, marking the proposed loop.
The loop should be long enough for easy cannulation: Its apex should be in a
central volar position of the middle forearm. The parts of the loop crossing the
joint should also be used for needle punctures. We think less of stabilizing
those parts by, e. g., several reinforcing rings, because there is no substantial
danger of kinking in the flexion crease of the elbow. Graft occlusion for
this reason has never been observed. Some authors propagate the straight
interposition graft between the brachial artery above the elbow and an axillary
vein in children [9]. They report a disappointing experience with the loop
graft, showing a high incidence of thrombosis, and they consider childrens'
extremities to be too small for this procedure. We do not agree with that
opinion. If the subcutaneous loop is placed in such a way that its straight parts
follow the medial and lateral edge of the forearm's volar aspect, it can be
successfully used in small children. We believe it superior to the straight,
207
Figure 12-8. PTFE graft in loop configuration in the arm, two weeks p.o. with superficial
defects of the skin.
upper-arm graft. Even in infants to whom the mentioned argument may

apply, the upper arm is also too short for insertion of straight grafts sufficient
for repeated cannulation.
In infants, therefore, the favorite method is a loop in the thigh (figure 12-9).
Graft implantation should be done in the most superficial subcutaneous plane
in a gentle loop configuration. End-to-side anastomoses are created with the
femoral artery, below its bifurcation with the profound artery of the thigh,
and the great saphenous vein. The skin incisions are 1) an incision that is
almost 6 em in length, beginning about 4 em below the inguinal ligament and
extending to the knee along the inner border of the sartorius muscle; 2) three
additional incisions that are about 1.5 em in length in the middle of the anterior
aspect of the thigh, which permits almost circular placement of the graft.
No matter what site is chosen, it is essential to use large-bore prosthetic
conduits in order to prophylactically counter the inevitable fibrointimal hyperplasia, which often leads to inadequate venous outflow. We almost exclusively
utilize 7 mm (rarely 6 mm) grafts, even in small children. The arterial
anastomosis is limited to a 6 mm width in order to diminish the shunt volume
and to prevent the steal syndrome.
Because there are no specific indications for the different angioaccess types
208
I. Va scular access for hemodialysis
Figure 12-9. Bovine graft loop in the thigh in a four-year-old child.
mentioned thus far in children, information in the literature regarding the

frequency of each method and their implantation varies widely.
Regarding the initial general considerations, we come to the distribution of
the various access forms in our clientele shown in table 12-3.
Another type of vascular access for hemodialysis, indicated mainly for
children, is shown in figure 12-10. It is a type of button that exits through a
small hole in the skin. The device, available in two technologically different
Table 12-3. Distribution of the various types of access (n = 161)
among our pediatric patients (mean age 11.8 years; range 3-17 years) during 1978 to 1985
Access type
Radiocephalic fistula , wrist

Radiocephalic fi stula , upper for earm
Brachiocephalic fistula
Ulnobasilic fistula
Bovine graft - straight, arm
Bovine graft -loop, arm
Bovine graft -loop, thigh
PTFE - strai ght, arm
PTFE -loop, arm
PTFE -loop, thigh
Quinton-Scribner shunt
118
6
1
5
2
4
14
1
4
4
(73.3%)
(3.7%)
(0.6%)
(3.1%)
(1.2%)
(2.5%)
(8.7%)
(0.6%)
(2.5%)
(2.5%)
(1.2%)
209
Figure 12-10. DiaT Ap in the upper arm in a 16-year-old girl.
models (DiaT AP, Hemasite8), has two channels, which provide a pathway
for extracorporeal blood flow via a special double-cannula access set [35-39].
It is attached to a PTFE prosthesis that is anastomosed to an artery and a vein.
Sites of implantation can be the thigh (femoral artery I great saphenous vein) or
the upper arm (figure 12-10) (brachial artery Ibasilic, brachial or axillary vein).
Although six years of experience with many cases attests to the good function
of this device, we do not consider it a real alternative to the subcutaneous
arteriovenous fistula [40]. Numerous disadvantages, similar to those involved
with the Teflon-silastic shunt, may complicate its use. Furthermore, when a
button is inserted, BCA or PTFE grafts can also be implanted, and they are
superior in every respect, except for the need for needle punctures. Until now
we have seen only one child who has had no problems with the device, and in
this case it was implanted four years ago because of severe articular contractures caused by rheumatoid arthritis and extreme puncture neurosis (figure
12-10).
4. COMPLICATIONS OF SUBCUTANEOUS ACCESS PROCEDURES
Table 12-4 summarizes the etiology of access failures in our pediatric patients
from 1978 to 1985. The most frequent cause - found in about 70% of the
cases - was thrombotic occlusion.
In fistulas, thrombosis is often preceded by a progressive proliferation of
210
Table 12-4. Rate and etiology of failure of 161 access procedures in children (1978-1985)
Total number
Thrombosis
Infection
Hemorrhage
Insufficient blood flow
Other causes
47
33
4
4
4
(70.2%)
(8.5%)
(8.5%)
(8.5%)
(4.3%)
An additional 50 reversible con1plications were observed in this period.
the vein's intima a few centimeters proximal to the anastomosis, almost completely obstructing the lumen in a year's time. We observe this proliferation in
both side-to-end and in end-to-end anastomoses. It is most likely an adverse
reaction of the vessel wall to the arterial pressure as it is independent of
exogenous factors and not influenced by any means. The reason why this
phenomenon occurs in some patients is still obscure. A similar filiform narrowing often develops at the venous outflow in grafts at about the same time
postoperatively. Intimal hyperplasia is also responsible for these stenoses. In
both cases, surgical revision is necessary. In fistulas, a new anastomosis has to
be created proximal to the stenotic lesion. In grafts, a reimplantation at the
venous side has to be made above the hyperplastic segment. Dilation of the
stenoses is seldom successful in the long run; it should only be tried when
the stenosis is very short.
Another frequent but indirect cause of irreversible thrombosis is inadequate
puncturing. Repetitive cannulations of only a small segment of the vessels
lead to traumatic ectasias of the wall and to stenoses below and above these
aneurysms, initiating thrombosis. While false handling only impairs and limits
fistula function, repetitive cannulations of the same segments in heterografts
may cause severe and life-threatening complications. Consequentially, true
aneurysms develop in BCA grafts, and pulsating hematomas develop in
PTFE grafts that require surgery. Unless secondary infections necessitate the
removal of the entire graft, partial replacement of the aneurysmatic section
is possible.
Infection is a rare cause of failure. In autologous access types, it is seldom
and, as a rule, easily conservatively treated. In grafts, infection is a grave
complication and is difficult to manage, both in BCA and PTFE grafts. Conservative treatment, as in fistulas, seldom succeeds. Despite antibiotics, the
infection frequently spreads and precipitates septicemia with its deleterious
sequelae. Extensive graft interposition bypassing the affected segment has to
be performed. However, very often the infected graft has be totally removed.
Meticulous precautions preventing bacterial infection are of the utmost
importance. Aseptic techniques are mandatory, particularly in grafts. After
thorough disinfection of the skin, sterile gloves should be used for cannulation. The puncture sites should be covered by sterile dressings during dialysis
sessions. Digital compression of the puncture sites after removal of the
211
cannulas should also be performed under aseptic conditions. After hemostasis

is achieved, a sterile dressing has to be applied and kept in place for at least
24 hours.
Finally, abacterial forms of infection that occur frequently when implanting
grafts must be mentioned. In these cases, severe inflammatory reactions of the
perivascular tissue caused by extravasation of plasma are found and may last
for many weeks [41, 42]. Secretion can be extensive enough to necessitate
drainage for prolonged periods. Consequently, "lymphatic fistulas" are often
cited in the literature and may be explained by plasma extravasation.
5. VENOUS CATHETERS FOR VASCULAR ACCESS
Percutaneously inserted catheters were introduced in 1961 to perform hemodialysis [43, 44]. By 1965, several special hemodialysis catheters were already
on the market, all for percutaneous insertion by the Seldinger technique.
Initially, the femoral veins had been used for catheterization. Since 1969,
the subclavian and internal jugular veins have been favored for this purpose
[45-51]. (The technique witl k.4esa:iOOct in detail in another chapter).
Since 1969 we have become familiar with this method for hemodialysis in
acute renal failure and in the temporary dialysis treatment of chronic renal
insufficiency. Therefore, we have been able to manage without the Teflonsilas tic shunt for many years, with few exceptions. Percutaneous catheterization has proven to be indispensable, particularly in children. Special pediatric
catheters are marketed in different sizes and materials. In the meantime, we
have chosen this temporary access to circulation in 134 children, aged 9
months to 16 years. Insertion sites were: the subclavian vein (foremost at the
right side) in 160 cases; the right internal jugular vein in eight cases; and the
femoral vein, especially in small children, in ten cases. The catheters were
left in place an average of 14 days and for a maximum of three months
when necessary.
The following complications were encountered:
1. Difficulties in locating the vein, necessitating several attempts at insertion
of the catheters (in about 10% of catheterizations of the subclavian vein, in a
minor percentage of the jugular vein)
2. Accidental puncture of the artery and consequent hematoma formation (in
about 5%)
3. Deviation of the catheter, e. g., into the jugular vein while cannulating the
subclavian vein (in about 10%). The malposition can be often corrected
under x-ray
4. Insufficient blood flow by kinking or clotting of the catheter
5. Partial pneumothorax (one case)
6. Local infection of the exit site preventable in the majority of cases by careful
aseptic and antiseptic (povidone-iodine) technique, requiring removal of
the catheter in only about 5%
7. Septicemia (three cases)
212
In addition to these rather rigid catheters that are percutaneously inserted

for temporary access, another type of soft indwelling catheter for long-term
treatment has become increasingly popular in recent years. After surgical
exposure of either the external jugular or the cephalic veins at the sulcus
deltoideo-pectoralis, the catheter is inserted into the vena cava superior or into
the right atrium. In infants, the internal jugular vein may also be used. The
catheter exits about 6 cm below the clavicle after being secured by a ligature or
purse-string suture and after tunneling under the skin. A Dacron cuff on the
catheter is positioned in the tunneled segment for stabilization and for
protection against ascending infection.
The surgically placed flexible silas tic catheter, first described by Broviac
and Hickman for parenteral nutrition [52-56], has also proven to be highly
functional for maintenance hemodialysis [57]. There are single- and doublelumen catheters of different lengths and diameters. Small single-lumen catheters offer the best long-term treatment of newborns and infants. In older
children and adults, the indwelling catheters should be the last resort, only
when fistulas and grafts have failed.
6. CONCLUSION
Vascular access surgery for maintenance hemodialysis in children must follow

an overall concept, integrating as many options as possible for repeated access.
All access types successful in adults are feasible in children. The prerequisite is,
therefore, that the surgeon be familiar with the whole spectrum of access
types.
The method most often used in children, as well as in adults, is Brescia and
Cimino's subcutaneous arteriovenous fistula and its modifications. In order
to preserve the artery, a side-to-end anastomosis is the preferred technique.
Although the vessels are small, the fistula can be frequently created, even in
small children, due to the great elasticity of the vessels. If fistulas cannot be
constructed or have failed, heterografts (BCA or PTFE) in the arm or thigh are
good alternatives. Long-term treatment via surgically placed central venous
silas tic catheters of the Broviac-Hickman type or by CAPD is recommended
in newborns and infants, since heterografts often cannot be implanted due to
their size.
ACKNOWLEDGMENT
Dedicated to Prof. Strauch on his 60th birthday.

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du catheter de Hickman en nephrologie pediatrique. La Presse Medicale 15:429-432, 1986.
II. PERITONEAL ACCESS FOR PERITONEAL DIALYSIS
13. THE USE OF THE DISPOSABLE, STYLET CATHETER
STEFANO FEDERICO, GIORGIO FUIANO and VITTORIO E. ANDREUCCI
1. HISTORY
The catheters initially used for peritoneal dialysis were tubings that were
commonly utilized for different purposes and were adapted for peritoneal
access. Thus, regular gall-bladder trocars [1], rubber catheters or perforated
stainless steel tubes [2], polyvinyl chloride tubes with small holes in the distal
part
4], polyethylene plastic tubes [5], brass fenestrated tubes [6], rubber
gastric tubings with side holes [7, 8], plastic gastric and nasal gastric tubes
with additional holes [9], and stainless steel sump drains similar to the metal
perforated suction tubes used in operating rooms [10] have been employed.
In 1959 a technique was suggested that utilized a single peritoneal nylon
catheter, 17.5 cm long, with multiple small holes at its distal 7.5 cm segment,
slightly curved at its end, and with a rounded tip. This catheter was inserted
via a trocar through the linea alba of the abdomen [11]. This technique was
widely used for many years. However, from 1964 on a stylet catheter has
been employed [12].
r3,
2. THE STYLET CATHETER
Today, a stylet catheter is usually employed for the manual method of

peritoneal dialysis due to its safety and simplicity. The stylet catheter has the
advantage of being easily introduced into the peritoneal cavity without the
need of a trocar.
It is a plastic catheter (figure 13-1) approximately 3 mm in overall diameter
Copyright 19R9 by Kluwer Academic Publishers. All rights reserved.
217
218
II. Peritoneal access for dialysis
J
Figure 13-1. The disposable stylet catheter. The plastic catheter (in the top of the figure) an
overall diameter of approximately 3 mm and is 28 cmlong. Its distal part (12 cm long) has multiple
small holes (see also figure 13-2). When the m etal stylet (in the middle of the figure) is inserted
into the pl astic catheter, its tip protrudes from the end of the catheter, thereby providing a sharp
cutting tip useful for pcnetratin g the abdominal wall (see also fi g ure 13-2). A short connection
tube (in the botto m of the fi g ure) is provided w ith the catheter for making the connection between
the cath etcr and administration set once th e catheter has been positioned and the stylet has
been remo ved .
Figure 13-2. The disposable stylet catheter. This figure shows the distal part (12 cm long) of the
plastic catheter with the inserted metal stylet. T his part of the plastic catheter has multiple small
holes. Note that the tip of the stylet protrudes from the end of the catheter.
219
and 28 cm long. It is equipped with a metal stylet, the tip of which protrudes
from the end of the catheter (figure 13-2), thereby providing a sharp cutting
tip useful for penetrating the abdominal wall. The distal 12 cm of the catheter
has multiple small holes (figure 13-2).
The use of disposable catheters (such as the stylet catheter) rather than a
permanent catheter is indicated when only one or a few dialysis sessions arc
contemplated, as may occur in the following conditions: 1) acute emergencies
(e.g., pulmonary edema) when stylet catheter insertion at the bedside may be
life-saving [13]; 2) loss of (or awaiting) the vascular access for extra corporeal
dialysis therapy; 3) severe extracellular volume expansion (e. g., congestive
heart failure); and 4) the need for drainage of dialysate in patients on peritoneal
dialysis therapy because of one-way obstruction of the permanent catheter
and abdominal distension.
3. PREPARATION OF THE PATIENT
The patient's abdomen should be examined very carefully to decide about

the suitability for the insertion. Previous abdominal surgery may represent a
contraindication to stylet catheter insertion because of intraabdominal adhesions. Organomegaly or skin infection may suggest a different location of the
stylet catheter through the abdominal wall.
Catheter implantation usually requires mild sedation (e.g., Diazepam, 10
mg i.m.) the local anesthesia (e.g., 1% procaine). General anesthesia becomes necessary in children, in obese patients, and in patients with previous
abdominal surgery [14].
Conscious patients are usually very worried, particularly because they do
not know the procedure. Thus, it is very important that the operator describes
in advance to patients what will be done and keeps them continuously informed of the whole procedure while performing it. This reduces patients'
tensions and anxieties and increases their cooperation [14].
4. PROCEDURE
The stylet catheter is usually inserted at the bedside, but under sterile
conditions. Bacterial contamination of the peritoneum may be fatal and must
be prevented. Thus, aseptic procedures are mandatory.
Before the insertion of the catheter, the bladder should be emptied to avoid
puncture of a distended bladder. The patient is therefore invited to void.
Should the patient have difficulty in voiding, catheterization becomes necessary. Should the patient be constipated, an enema has to be given. Bowel
movement is important to avoid punture of the gut.
The abdominal wall is then prepared for catheter insertion. This includes
shaving a large area between the xyphoid and symphysis pubica. Careful
disinfection of the abdominal wall (with particular attention to the umbilicus)
is then performed with povidone-iodine solution: Betadine is commonly
used because of its good skin tolerance. Betadine is repeatedly spread over the
220
area of the abdominal wall previously shaved. This procedure requires several
minutes to ensure effective contact disinfection [14].
The operator should wear a sterile gown, cap, mask, and gloves. All
assistants should wear caps and masks. The abdomen of the patient is covered
with sterile cloths, except a small area around the insertion site.
The insertion site of the catheter is usually on the midline, an inch or so
(about 3 cm up to 6 cm) below the umbilicus. Sometimes, however, the iliac
fossa (either one) is used. The insertion site is infiltrated deeply with a local
anesthetic (1 % procaine) down to the peritoneum.
In order to minimize the risk of perforating an abdominal organ, most
operators introduce prewarmed dialysis solution into the peritoneal cavity in a
quantity large enough to distend the peritoneum before the insertion of the
catheter. This is performed via a large-bore (14- or 15-gauge), short-bevel,
spinal needle, 8-10 cm long. The volume of priming varies with the abdomen's size and distensibility, being careful to avoid causing discomfort to the
patient; it usually ranges between one and three liters of dialysate solution.
Some operators, however, prefer priming the abdomen during the catheter
insertion, as soon as the perforated segment of the catheter has reached the
peritoneal cavity.
A small (2 mm long) skin incision is made by using a N.ll blade; the size of
the incision is very important: The catheter, in fact, should fit snugly into the
orifice of the incision wound to prevent leakage and infection [14]. Nicking the
fascia of the linea alba with the blade is also suggested; it helps in carrying the
catheter through the abdominal wall [14]. The stylet catheter (stylet in place) is
then inserted through the skin and underlying tissues, perpendicular to the
abdominal wall, by applying pressure with a twisting motion. Cooperation of
the patient is very important, particularly during insertion of the catheter
through the peritoneum. The patient, in fact, should be invited to distend his
abdominal wall, by blowing it up or coughing, while the operator is applying
a firm pressure on the stylet catheter. The entrance of the tip of the stylet
catheter through the parietal peritoneum into the peritoneal cavity is felt by
the hand of the operator as a sudden decrease in resistance. If the procedure is
performed after priming the abdomen, dialysis fluid will now appear in the
catheter. The stylet is then withdrawn 1-2 cm in order to sheathe its tip. The
stylet catheter is then advanced at 45 toward the true pelvis. The operator
should seek the deepest placement of the catheter that is consistent with patient
comfort, since this position will provide the best drainage. Once the catheter is
positioned, the stylet is removed, the administration set is connected to the
catheter through a short connection tube (figure 13-1), and the dialysate is
allowed to drain out of the abdomen, thereby testing the feasibility of dialysis.
Careful positioning of the catheter is very important for adequate drainage and
for the patient's comfort.
If the patient complains of pain within the abdomen, which is localized
in the area of the rectum or the vagina, this may be due to the trauma of
221
the catheter tip and may be relieved by withdrawing the catheter by a few
centimeters. If drainage of dialysate is unsatisfactory, changing the patient's
position may solve the problem; otherwise, the catheter has to be repositioned.
Repositioning of a badly draining catheter is best done with the stylet
partially reintroduced: The catheter is withdrawn for most of its length,
leaving the tip within the peritoneal cavity; the stylet is reintroduced and the
stylet catheter is then advanced again in a new direction. All these maneuvers
should be carried out in aseptic conditions, since whenever manipulation of the
catheter is required, the risk of infection increases. If drainage is still unsatisfactory, the catheter should be replaced, either through the same incision in
the abdominal wall or through a new incision.
When finally placed, the catheter is fixed to the abdominal wall by surgical
tape. The area around the catheter is again disinfected with Betadine and
covered with several dry, sterile, lO-cm gauze squares, which are fitted around
the catheter and taped to the abdominal wall to prevent contamination of the
catheter entry site.
At the end of the dialysis session, after the last drainage, the catheter is
gently withdrawn under strict aseptic conditions. Sometimes this procedure is
painful to the patient because of incarceration of omental fringes into the holes
of the catheter; a slow axial rotation of the catheter, after the infusion of 2 ml of
1% procaine into its lumen, may help in making the catheter withdrawal less
uncomfortable [14]. Once the catheter has been removed, the wound is closed
by surgical tape strips; then, the area is dressed for 48 hours.
5. COMPLICATIONS
Most complications with the use of the stylet catheter are related to the
inexperience of the operator and the operator's lack of care in following the
correct procedure of catheter insertion. Others may occur even with expert
operators and even when correctly following the implantation procedure.
5.1. Perforation of the bladder
Perforation of the bladder may occur, usually when the bladder has not been
emptied before the insertion of the catheter. When it occurs, the patient feels
the urgency to urinate. Removal of the catheter and reinsertion of a new stylet
catheter, once the bladder has been emptied (by spontaneous voiding or by
bladder catheterization) will solve the problem.
5.2. Perforation of the bowel
Perforation of the bowel is a rare complication; the incidence may range

between 0.1 % [15] and 1.3% [16]. It is prevented both by introducing dialysis
solution into the peritoneal cavity in order to distend the peritoneum before
the insertion of the catheter and by giving an enema to constipated patients
prior to catheter implantation (bowel movement will prevent its puncture). In
222
any case, the catheter should never be forced into the abdomen during its
insertion when intraabdominal resistance is felt.
Bowel perforation is suspected when there is severe pain, watery diarrhea,
poor drainage of dialysate, cloudy and malodorous dialysate with fecal material, and signs of peritoneal irritation. The perforation may occur in the
cecum if the catheter if inserted into the right iliac fossa, in the sogmoid colon
if the insertion is into the left iliac fossa, and in the small bowel if the catheter
is placed in the midline [16]. Treatment may be conservative and consists of
replacement of the stylet catheter and the use of local (in the dialysate) and
systemic antibiotics [15-181. Others suggest a laparatomy with surgical repair
of the perforation [19, 20), followed by continuous lavage of the peritoneal cavity with antibiotics to prevent intra abdominal adhesions [20]. This
complication may be fatal [16].
Unconscious patients, cachectic patients, and patients who have previously
undergone abdominal surgery (with resulting intraabdominal adhesions) are
predisposed to bowel perforation. Thus, such conditions may represent a
contraindication to peritoneal dialysis. In any case, the peritoneal catheter
should not be inserted close to abdominal surgical scars.
5.3. Perforation of polycystic kidney
Many clinicians do not perform peritoneal dialysis in patients with polycystic

kidneys because of the abdominal distention from the large cystic kidneys, fear
of puncturing renal cysts, and the inability of the peritoneal cavity to hold two
additional liters of dialysis fluid. Other methods are used to perform dialysis in
these patients [15].
Should a renal cyst be inadvertently punctured, the catheter has to be
withdrawn and repositioned [15].
5.4. Bleeding
Skin bleeding from the abdominal wound, around the catheter, is sometimes
observed, but it is easily resolved by compression and pressure dressing.
During the first few exchanges, after the insertion of the stylet catheter, the
dialysate is frequently blood stained; but it usually clears up spontaneously
after two to three exchanges. The addition of heparin to the dialysis solution, during the first few dialysate exchanges, is usually recommended for
preventing early catheter plugging by blood clots.
Major bleeding, however, may sometimes occur, with a grossly bloody
dialysate. In these cases, the dialysate hematocrit may be greater than 5%.
Frequently the site of bleeding is the abdominal wall, at the entry of the
catheter in the peritoneal cavity, with the blood entering the peritoneal cavity
and mixing with the dialysate. Under such circumstances, the following
attempts should be made: compression around the catheter, pressure dressing;
a deep purse-string suture around the catheter, epinephrine injection into the
tissues surrounding the catheter, and discontinuation of heparin in the dialysate
223
(this, however, may cause catheter clotting) [14], Exceptionally, laparatomy

becomes necessary.
5.5. Leakage of dialysate
Leakage of dialysate around the catheter is usually due to too large an incision
of the skin and/or of the peritoneum. This complication should be prevented
by a correct implantation technique, since it causes edema of the abdominal
wall, wetting 0 the sterile gauzes around the catheter, and risk of infections.
These leaks may be stopped by a purse-string suture around the catheter and
a decrease of the amount of dialysate introduced into the peritoneal cavity
at each exchange (in order to avoid abdominal overdistension). if this procedure is unsuccessful, the catheter should be reinserted through a new, but
small, incision.
Recent abdominal surgery is not necessarily a contraindication to peritoneal
dialysis, even though it may cause leakage of the dialysate through the surgical
wound or form drainage tubes.
5.6. Inadequate drainage of dialysate
Inadequate drainage of dialysate may occur because of inaccurate positioning

of the catheter, blockage of the catheter holes by omental fringes, obstruction
of the catheter by fibrin or blood clots, peritoneal sequestration of fluid
because of intra abdominal adhesions (due to previous abdominal surgery or
peritonitis), or presence of air in the peritoneal cavity with consequent
disruption of the syphon effect [14]. Inadequate drainage results in intraabdominal retention of fluid, a grossly distended abdomen, a high diaphragm,
and consequent patient discomfort.
Manipulation of the catheter may restore drainage. In the case of catheter
obstruction by fibrin or blood clots, it has been suggested to instill the
fibrinolytic agent streptokinase (250,000 IU) within the catheter and wait
about one hour before doing a new exchange [21]. This method has been
successful in some reported cases [21, 22]. Should all these procedures be
unsuccessful, the catheter has to be replaced.
Sometimes the inadequate drainage of dialysate is due to improper insertion
of the catheter. Thus, if the catheter is not inserted into the peritoneal cavity,
but is inserted between the layers of the abdominal wall, dialysate will collect
between the layers of the abdominal walls rather than in the peritoneal cavity.
This will make drainage incomplete or even absent. Under such circumstances,
obviously, the catheter should be replaced.
5.7. Pain
Peritoneal dialysis may cause abdominal pain. Sometimes persistent pain

may be due to continuous pressure of the catheter's tip on the bladder, rectum,
or posterior parietal peritoneum. Frequently, the patient complains of pain
only at the end of the drainage phase; this is again due to the catheter tip
224
touching the bladder, rectum, or posterior parietal peritoneum. Under both

circumstances, the pain may be relieved by withdrawing the catheter by
1-2 cm.
Pain is particularly frequent when there are peritoneal adhesions. It may be
relieved by the addition of 5-10 ml of 1-2% procaine into the dialysate.
REFERENCES
1. Wear JB. Sisk lR, Trinkle AJ: Peritoneal lavage in the treatment of uremia. J Urol 39:53-62,
1938.
2. Fine J, Frank H, Seligman AM: The treatment of acute renal failure by peritoneal irrigation.
Ann Surg 124:857-875, 1946.
3. Derot M, Tanzet P, Roussillon J, Bernier JJ: La dialyse peritonealc dans Ie traitement de
l'uremie aigue. J Urol 55:113-121, 1949.
4. Legrain M, Merrill JP: Short term continuous transperitoneal dialysis. N Eng J Med 248:
125-129, 1953.
5. Grollman A, Tuner LB, McLean JA: Intermittent peritoneal lavage in nephrectomized dogs
and its application to the human being. Arch Intern Med 87:379-390, 1951.
6. Bassett SH, Brown HR, Keutmann EH, Holler J, Van Alstine HE, Mocejunas 0, Schantz H:
Nitrogen and fluid balance in treatment of acute uremia by peritoneal lavage. Arch Intern Med
80:616-636, 1947.
7. Boen ST: Kinetics of peritoneal dialysis. Medicine 40:243-287, 1961.
8. Boen ST: Peritoneal dialysis in clinical medicine. Springfield, Illinois: Charles C. Thomas,
1964.
9. Doolan PD, Murphy WP, Wiggins RA, Carter NW, Cooper WC, Watten RH, Alpen EL: An
evaluation of intermittent peritoneal lavage. Am J Med 26:831-844, 1959.
10. Boen ST: Review of the clinical use of peritoneal dialysis. In: Nolph KD (cd) Peritoneal
Dialysis. Boston: Martinus Nijhoff, 1981, pp 1-20.
11. Maxwell MH, Rockney RE, Kleeman CR, Twiss MR: Peritoneal dialysis: I. Technique and
applications. JAMA 170:917-924, 1959.
12. Weston RE, Roberts M: Clinical use of stylet-catheter for peritoneal dialysis. Arch Intern Med
115:659-662, 1965.
13. Mion CM, BeraudJ-J. Treatment of acute renal failure by peritoneal dialysis. In: Andreucci
VE (cd) Acute Renal Failure. Boston: Martinus Nijhoff, 1984, pp 463-479.
14. Mion CM: Practical usc of peritoneal dialysis. In: Drukker W, PersollS FM, Maher JF (cds)
Replacement of Renal Function by Dialysis. Boston: Martinus Nijhoff, 1983, pp 457-492.
15. Henderson LW: Peritoneal dialysis. in: Massry SG, Sellers AL (eds) Clinical Aspects of
Uremia and Dialysis, Springfield, Illinois: Charles C. Thomas 1976, pp 555-582.
16. Simkin EP, Wright FK: Perforating injuries of the bowel complicating peritoneal catheter
insertion. Lancet 1:64-67, 1968.
17. RubinJ, Oreoponlos DG, Lio TT, Mathews R, deVeber GA: Management of peritonitis and
bowel perforation during chronic peritoneal dialysis Nephron 16:220-225, 1976.
18. Oreopoulos DG: Peritoneal dialysis. In: Massry SG, Glassock RJ (eds) Textbook of
Nephrology. Baltimore: Williams & Wilkins, 1983, pp 830-841.
19. Dnnea G: Peritoneal dialysis and hemodialysis. Med Clin N Am 55: 155-175, 1971.
20. Tenckhoff H: Chronic peritoneal dialysis manual. University of Washington, School of
Medicine, Seattle, W A, 1974.
21. Thompson N, Uldall R: A problem in peritoneal dialysis (letter). Lancet II:602, 1969.
22. Ladefoged J, Steiness I: Intra-abdominal bleeding complicating peritoneal dialysis (letter).
Lancet 1:190, 1970.
14. THE PERMANENT TENCKHOFF CATHETERS
ALAIN SLINGENEYER
Between September 1973 and March 1988, our team implanted 768 catheters
in 621 patients, 715 of which were for chronic treatment of567 end-stage renal
disease patients. Catheters used were 675 double-Dacron felt cuff Tenckhoff
(Cobe), 74 Column Disc (Bernas), and 19 Gore-Tex (Gore) catheters.
1. TENCKHOFF CATHETERS
The basic catheter for chronic treatment was originally described by

Tenckhoff in 1968 [1]. The model we use is slightly different (Cobe) (figure
14-1): A 30-cm long medical grade silas tic tubing of 5 mm external diameter
is divided in three segments by two 1-cm long Dacron cuffs. The 16-cm long
intraperitoneal segment is perforated along its distal 7.5 cm to avoid flapping
of the intraperitoneal organs against the tip of the catheter, due to the low
negative pressure occurring during drainage. To avoid trauma, a blunt tip is
preferable to a right-angle edge. Frustum cone holes of 0.9 mm external and
0.5 mm internal diameters prevent omentum aspiration. The 7-cm median
segment, known as subcutaneous, lies between the two Dacron cuffs. The
third segment (external segment), apparent through the exit site, is intended
to be adapted to the tubing or to a cap via a connector.
Silastic tubing is well tolerated by surrounding tissues without any adhesion
to the material [2]. After a few weeks, the channel is lined by a squamous
epithelial layer. The cuffs enable the catheter to be fixed by promoting fibroblast proliferation within the Dacron itself [1]. At the same time, bacteria
225
226
Figure 14-1. The Tenckhoff catheter manufactured by Cobe Laboratories was packed in a tray,
forcing a gentle bend between the two Dacron cuffs.
migration along the catheter tunnel is prevented. The Dacron cloth is glued
directly to the silas tic tubing or onto a supplementary ring of silastic, itself
glued to the tubing (Cobe).
To facilitate positioning and removal when used for acute treatment, the
chronic Tenckhoff catheter was modified by the removal of the distal cuff [3,
4]. Several authors use this catheter for chronic peritoneal dialysis, but it is not
always easy to decide where to position the single cuff. Smith sutures it into
the fascia at the midline [5], and Diaz-Buxo leaves it free 1-1.5 em from the
exit site on the subcutaneous channel [6], as recommended by Tenckhoff [3].
These different cuff locations make comparison between one- and two-cuff
catheters difficult, but double-cuff catheters seem to give better results [5, 6].
Becker proposed the replacement of the subcutaneous Dacron cuffby a disc
of Dacron velvet (1.5 em diameter, 1 mm thick) lying 0.5 em below the skin.
A double bend helps to reduce stress during the percutaneous introduction
(Berlin catheter) (Fresenius) [7].
Modifications of the intraperitoneal segment were proposed: a curled segment [8], adjunction of an external perforated silastic balloon (Valli catheter)
[9], and a short segment [10].
The Column Disc catheter (Bernas) designed by Ash [11] has completely
modified the intraperitoneal segment. Two silas tic discs of 5 em diameter are
maintained separated by 40 pillars of the same material. Dialysate flows
between the pillars from or to a centrally located tube fixed in the abdominal
14. Permanent Tenckhoff catheters
227
wall by an inner Dacron cuff. The transabdominal segment is bent into a right
angle with an outer Dacron cuff at the level of the skin exit. The prosthesis is
fixed 3-4 em above the pubis against the anterior peritoneum, thus avoiding
possible migration and minimizing the velocity of dialysate flow during
injection or drainage. Other catheters are described in other chapters.
Barium impregnated silastic tubing allows easy x-ray control of catheter tip
position, avoiding the need for contrast material. Totally opaque catheters are
available, but catheters with only one radiopaque stripe are preferable [12].
2. CATHETER IMPLANTATION
The facilities available within the department (easy access to operating room)
and the patient's condition (necessitating intensive care or artificial ventilation)
determine whether both blind or surgical techniques will be performed at the
bedside or in the operating room.
2.1. Preparation of the patient
Psychological preparation of the patient is mandatory. A thorough clinical

examination must be carried out by the manipulator (surgeon or nephrologist),
who must pay particular attention to previous abdominal scars or to organomegaly. The skin exit site must be determined on a sitting patient to find the
most comfortable place likely to not interfere with the wearing of clothes. For
easy self-care and prevention of infection, the exit site must not be located in
the deep part of an abdominal skin fold.
An enema is given before the operation. The abdominal skin is shaved from
the xyphoid to symphisis pubis, washed with an antiseptic solution (Betadine)
(Sarget), and wrapped in a sterile drape. The patient is asked to void. Urethral
catheterization may be necessary. Some physicians recommend i.v. or i.m.
injections of cephalosporin or aminoside as prophylactic therapy. All participants must wear a mask, cap, sterile gown, and gloves [13].
2.2. Blind implantation (bedside implantation)
Tenckhoff very precisely described bedside implantation of his catheter with a

special trocar (figure 14-2) [3]. After mild sedation, the peritoneal cavity is
filled with 2-3 liters of prewarmed dialysate through a 12-gauge, 8-10 em
long needle (a spinal needle, for example). Dialysate should flow very freely
(10-15 minutes for a 2-liters injection), ensuring that the needle is in the
peritoneal cavity and not in the preperitoneal fat tissues. When the abdomen is
sufficiently distended, the needle is removed and a 2-cm blade incision is
made on the midline 7 em above the symphysis pubis under local anesthesia.
Blunt dissection is performed on the fibrous sheath of the linea alba, which
appears as a pearly whitish membrane made of decussating fibers. The complet~ trocar, with its four pieces, is then pushed through the linea alba and the
peritoneum, while the patient is asked to tighten his abdominal musculature.
A sudden decrease in resistance occurs when the trocar penetrates into the
228
Figure 14-2. Trocar designed by Tenckhoff for blind implantation of the peritoneal catheter. Its
two valves are maintained together by a steel cylinder. During implantation the sharp trocar is
itself inserted inside the three other parts to penetrate into the peritoneum and then is removed to
allow insertion of the catheter. The inner Dacron cuff rests against the sma1ler inner diameter of
the two valves.
peritoneal cavity. The trocar is then removed. Good positioning is confirmed

by a free outflow of dialysate between the two valves. A guide wire is inserted
down into the catheter to 2 em from the perforated tip and secured in this
position, either with a nontraumatic bulldog clamp or a screw (screw-adjusted
mandrin) (Fresenius). The catheter is then introduced between the two valves
into the left lower abdominal quadrant. The guide wire is removed. The
catheter is checked for patency by producing a free jet outflow. The cylinder
holding the two valves together is removed. The two valves arc removed, care
being taken to maintain the inner cuff positioned on the fibrous layer. The
subcutaneous channel is created with a flexible uterine sound or with a curled
clamp towards the predetermined exit site. The catheter is then threaded
through the stab wound, the outer Dacron cuff lying 1-2 em from the skin
exit site. The procedure is completed by suturing the midline incision but not
the exit site.
Di Paolo et al. [14] modified the original trocar into a steel instrument
consisting of two elongated semicones with round tips (similar to a rhinoscope). The abdomen is prefilled with 2 liters of dialysis solution or CO 2
through an is-gauge needle. A metal guide wire is then passed through this
229
introducer needle. The needle is removed. The exit site is enlarged with a blade
incision, and the two closed semicones are introduced down the peritoneal
cavity along the guide wire. After withdrawing the guide wire, the semicones
are opened and the catheter is introduced inside the semicones, leaving the
Dacron cuff between the anterior peritoneum and the fascia transversa. All
other procedures remain identical to those recommended by Tenckhoff [3].
2.3. Surgical implantation
2.3.1. Midline implantation
The site of incision is located 10 cm above the symphysis pubis below the
umbilicus or above it in obese patients. A 5-cm skin incision (blade number 23)
is sufficient in normal patients. Dissection is performed down to the decussating fibers of the linea alba (anterior sheath of the rectus muscle). Careful hemostasis, either by electrocoagulation (operating theater) or clamps (bedside
implantation), is mandatory. With a sharp blade (blade number 11), the linea
alba is opened from the peritoneum to the subcutaneous fat tissues. The
incision is extended to 5 cm with scissors. Both edges are suspended with
retractors.
At this stage of implantation, two difficulties may be encountered: 1) the
opening of the linea alba is not exactly on the decussating point. In this case, it
may be necessary to successively a) open the ant.erior aponevrosis of the rectus
muscle, b) recline the muscle with retractors, and c) open the posterior
aponevrosis. 2) When the skin access is low under the umbilicus, the manipulator must know that the posterior fibrous layer is thinner and sticks to the
peritoneum under the linea arcuata.
Identification of the middle umbilical fold is helpful in marking the fatty
preperitoneal space. Blunt dissection is performed through the preperitoneal
fat tissues to the peritoneum. The peritoneum may appear as a more or less
thick membrane. Paradoxical bowel or omentum movements can be seen
underneath the peritoneum when the membrane is thin. The peritoneum is
then pinched between two hemostats, drawn up, and opened with scissors.
Penetration into the peritoneal cavity, lined by a smooth and shiny wall, is
obvious. The bowel or the omentum is now apparent. If the omentum
appears, rather than omentectomy, we recommend pushing it gently up
towards the epigastric area, with a heart-shaped forceps and maintaining it in
this position with a gauze in order to avoid being drawn along by the catheter.
A smoothly bent guide wire is inserted into the catheter, down to 2 cm near
the perforated tip, and secured in this position with a non-traumatic bulldog
clamp. The catheter is pushed downward along the anterior peritoneum.
When a soft resistance is felt, this indicates that the catheter tip is in the
pre transverse vesical fold or on top of the bladder. The catheter is then
withdrawn 2 cm; the guide wire is set upwards at an angle of 45 and pushed
downward to the pouch of Douglas or to the left lower abdominal quadrant.
230
Cooperative patients help the manipulator by saying when they feel the tip of
the catheter on genitalia and then on the anus.
If it seems impossible to find a tract offering no resistance, it may be helpful
to fill the peritoneal cavity with 500 ml of preheated isotonic saline through the
catheter. The catheter is then removed and the procedure is started again. An
elastic resistance ejecting the catheter outward must never be accepted: It
means that the tip is on a viscus (bladder or sigmoid) or that it is too long. In
this case, the perforated part must be reduced by 1-2 em with a scalpel.
The guide wire is then withdrawn and the catheter is checked for patency:
60 ml of isotonic saline are injected rapidly by the means of a 50 ml syringe
adapted to the external part of the catheter. A slow aspiration, without resistance, of at least 40 ml proves the correct positioning of the intraperitoneal
tip.
The peritoneum is closed by either separated stitches or by a purse string
tied tightly around the inner Dacron cuff with a late absorbable strand [15].
The use of catgut must be avoided because it resorbs too rapidly in a wet
environment [13, 16]. Closure of the linea alba is performed from the bottom
to the top with separated nonabsorbable sutures [17]. The catheter is now
positioned tangentially in the preperitoneal fat tissues (figure 14-3). After
closure of the linea alba, the catheter must be apparent at least 2 em above its
penetration point into the peritoneal cavity.
2.3.2. Trallsrectal access
To avoid leaks and hernias, a lateral incision into the skin overlying the rectus
muscle has been recommended [18]. Such an access may also be helpful in
patients with multiple midline scars, diastasis, or eventration. Being highly
vascularized, this area heals quickly, but this can be a source of complication if
the manipulator is not a surgeon, as the epigastric artery passes nearby [19].
When the anterior rectus sheath is exposed, a horizontal incision is made. The
fibers of the rectus abdominis muscle are separated to expose the peritoneum
adhering to the posterior aponevrosis, which is then opened inside a nonabsorbable purse-string suture. Positioning of the intraperitoneal segment of
the catheter follows the same procedure as described above. A separate stab
incision is made in the superior flap of the anterior rectus sheath,S em above
the incision of the peritoneum. The catheter is pulled through the anterior
rectus sheath. This aponevrosis is then closed with interrupted monofilament
sutures.
2.3.3. Where should the inner Dacron cuJfbe placed?
Operating teams soak Dacron cuffs either in a saline solution contammg

cephalosporin [20] or blood in order to promote faster fibrosis [21]. In our
technique, the inner Dacron cuff is stitched directly to the lowest corner of the
peritoneal incision with low-absorption sutures, in an inclined position,
forcing the caudal direction of the catheter (figure 14-3) [13].
231
Figure 14-3. Midline surgical implantation. Position of the different elements. A = skin;
B = subcutaneous fat tissue; C = linea alba; D = middle umbilical fold; E = peritoneum;
F = umbilicus. 1 = subcutaneous tract; 2 = tangential path between peritoneum and linea alba;
3 = inner Dacron cuff; 4 = intraperitoneal segment.
Such posltloning of the inner cuff avoids leaks as well as rapid bacterial
contamination of the peritoneal cavity, in the case of tunnel infection, and
never promotes adhesions to the intraperitoneal viscus. If the cuff is left
beneath or above the linea alba, it is prudent to secure it in this position by
stitching it with a low-absorption or nonabsorbable suture [22].
2.3.4. Column Disc Catheter implantation
The midline skin incision is performed 3.5-4 cm above the symphysis pubis.
Dissection to the peritoneum is as described for surgical implantation, but it
may be necessary to recline the pyramidal muscle with retractors. At this level,
the peritoneum is very often adherent to the posterior appnevrosis. Through
the 4 cm opening of the peritoneum, the Column Disc catheter, folded like
an umbralla turned inside out by the wind, is introduced into the peritoneal
cavity. The inner Dacron cuff is stitched onto the peritoneum.
2.3.5. Fixation of the internal tip
Flipping of the intraperitoneal segment is described as a frequent cause of poor

outflow, affecting 35% of implanted catheters [23]. Consequently, it was
proposed to attach the inner tip of the catheter to the lateral wall of the true
pelvis with an absorbable suture. To do so, a 8-10 cm midline low abdominal
incision is required. A 2-3 cm peritoneal tunnel from the lateral pelvic wall,
4-5 cm from the perforated tip of the catheter, is created by placing four
interrupted nonabsorbable sutures in Lembert fashion.
232
Figure 14-4. SpecifIc instrumentation for surgical implantation. The guide wire is introduced
into the catheter up to its last 2 cm and secured in this position with a non traumatic bulldog clamp.
The special needle, with a pyramidal three-faced head, is made of flexible steel. Its diameter
increases progressively to equal the external diameter of the catheter (5 mm). While creating the
subcutaneous channel, the external tip of the catheter is slid onto the three-bulbed end and secured
with a strap, allowing a perfect convex-upward tract.
2.4. Peritoneoscopic implantation
In order to visualize the intraperitoneal area of the lower left abdominal

quadrant in which the proximal tip of the catheter must be placed for optimal
functioning, Ash proposed to use a 15 cm long, 2.2 mm diameter needlescope, now called the Y-Tec system (Medigroup), which is a modification of
a cold light arthroscope. A 2 cm midline skin incision is made. This technique
requires a 2.2-mm diameter trocar surrounded by a 2.8 mm cannula and a
3-mm diameter, coiled catheter guide. These three parts are inserted through
the linea alba with a twisting guide. Intraperitoneal placement is confirmed
with the Y - Tec system introduced into the cannula after removal of the trocar.
The abdomen is insufflated with one liter of air using a steam-sterilized sphygmomanometer bulb. The Y-Tec system, with its surrounding cannula and
catheter guide, is then advanced into the furthest corner of the lower abdomen.
The Y - Tec system and the cannula are removed, the guide being left in the
desired catheter path. The peritoneal hole is dilated to a size that will snuggly
fit the catheter [24]. One modification of this technique is the use of a nitrous
oxide gas insufflator machine (Richard Wolf) [25] in order to avoid air embolism [26]. The steps that follow are the same as previously described.
2.5. Subcutaneous tunnel
It seems preferable to make the subcutaneous channel from the skin incision
towards the exit site in order to avoid contamination of the tunnel [3]. Using a
needle of the same diameter as the catheter itself, the skin will exactly fit the
silas tic, avoiding the need for stitching. For this purpose, we have designed a
special needle (Galtier) (figure 14-4). The essential point is to respect the
silastic memory, using the catheter in the shape it was given by its commercial
wrapping (figure 14-1). Indeed, implanting a silicone rubber tube under strain
will damage the surrounding tissues until the position of less strain is found
[27]. With our needle, we always respect this natural bending, thus obtaining
233
a curved subcutaneous convex-upward tunnel, with the skin exit oriented

downward, as recommended by Tenckhoff[3]. If the catheter does not present
any curve, it seems preferable to have a straight subcutaneous tunnel [28].
Two facts are of importance concerning the subcutaneous cuff: 1) Fibroblastic proliferation is not satisfactory around the Dacron when the cuff is
located too deeply in the subcutaneous fat tissues. 2) The tunnel between the
outer cuff and the exit site is rapidly covered by an epithelial layer (usually
within two months). Too long a tract (longer than 2 cm) may be difficult for
the patient to clean. It may become a collection area for skin secretions and
may further act as a possible starting point for infection. Accordingly, we
leave the outer cuff at a distance of 1-1.5 cm from the skin exit, and the last
3 cm of the tunnel are made parallel to the skin surface.
2.6. Possible problems
2.6.1. Patient's size
For adult patients of a small size, less than 140 cm tall, it may be necessary to
either shorten the perforated end of the catheter and/or to perform the skin
incision above the umbilicus.
In obese patients, it is very important to observe their abdomen in an
upright position. Their umbilicus may be very low, near the pubis symphysis.
In such cases, the skin incision may be made above the umbilicus. The
thickness of the subcutaneous fat tissue, as well as of the preperitoneallayer,
may lead to a toilsome dissection. Fat-infiltrated peritoneum is difficult to spot
from the omentum. It is preferable to choose a catheter with at least 7 cm
between the two Dacron cuffs [29].
2.6.2. Scarred abdomen
Previous abdominal scars must not be considered as contraindications for

Tenckhoff catheter placement, nor should patients with previous peritonitis
unrelated to peritoneal dialysis treatment be withheld this treatment. Thirtyeight percent of our patients presented with such a surgical history. Lateral
scars never led to any operating problems. A previous midline incision
may sometimes complicate catheter implantation because of adhesions of the
omentum to the midline incision. In our experience, it was possible to destroy
these adhesions by gentle blunt dissection and to insert the catheter. Lateral
access may help avoid this difficulty.
Levey et al. [30] report the same experience and had successful catheter
placement for more than 80% of their 13 high-risk patients. More diffuse
adhesions require the help of a surgeon.
2.6.3. Hernias and incisiollai hernias
Because of high intraabdominal pressure during peritoneal dialysis, especially

in CAPD [31, 32], a few authors consider hernias as contraindications for this
therapeutic modality [33]. We do not agree.
234
During the first clinical examination, the manipulator must look for hernias.
Rubin et al. [34] diagnosed up to 10% of patients with hernias before the start
of CAPD. The most frequent hernias are inguinal or umbilical, especially in
old males; the cough impulse test in an upright position may be helpful.
Incisional hernias due to previous surgery must also be considered; midline or
postero lumbar incisions resulting in incisional hernias, especially in obese
patients, are frequently observed (2.2% of our patients).
If peritoneal dialysis treatment can be postponed, and/or if hemodialysis is
possible, hernias should be repaired before catheter implantation [35] by using
a low-absorption strand. We delay catheter implantation for one month.
In case of severely uremic patients for whom hemodialysis is impossible or
contraindicated, two attitudes may be contemplated: 1) to implant the catheter
and to immediately start intermittent peritoneal dialysis (IPD) treatment,
compressing the hernia by placing a wad on its collar. The hernia will then be
repaired later, or, if impossible, the patient will continue on an IPD schedule
wearing a special supportive corset; 2) to implant the catheter and to repair the
hernia at the same time [36]. The peritoneum must be closed with separate
stitches of low-absoption strands. Aponevroses must be closed separately
with non-absorbable sutures. If a Redon-Jost drain is necessary, the vacuum
must be taken off during dialysis sessions in order to avoid the fistula. IPD will
be performed with low volumes over one month before starting CAPD.
2.6.4. Inflammatory bowel disease
Inflammatory bowel disease (i.e., diverticulitis, colitis, sigmoiditis) is considered by a few authors to be a contraindication to catheter placement [33].
In this case, we postpone catheter implantation until after the acute phase,
when signs and symptoms of the disease have disappeared. Sequential chronic
medical treatment is then prescribed. Such patients are urged to avoid constipation and are prescribed adequate oral medical therapy. They are also
taught to call the medical team when they notice diarrhea or constipation
lasting more than two days.
2.6.5. Abdominal stoma
Gastrointestinal stoma seems to be a contraindication for PD treatment.

However, two successful peritoneoscopic catheter placements were reported
(one ileostomy, one colostomy), but the followup of these patients is not
known [24].
2.6.6. Diabetic patients
In our experience, constructing the subcutaneous channel is always more

difficult for diabetic patients, even when abdominal lipodystrophies are not
evident. Subcutaneous fat tissues are always fibrous. To place the Dacron cuff
underneath the skin, a straight, long hemostatic clamp is introduced from the
middle incision to the exit site, along the silas tic, and opened to enlarge the
235
subcutaneous tract to the size of the outer cuff. Healing of the exit site is often
difficult in these patients. A thick fibrosis surrounds the skin exit, which does
not fit snuggly on the catheter. We have never tried to resect such tissues; after
a few months, the skin has a normal aspect.
3. RECOMMENDED PROTOCOLS FOR CATHETER BREAK-IN
To prevent catheter obstruction by blood or a fibrin clot, and infection due to

possible contamination of the peritoneal cavity that may have occurred during
catheter implantation, Tenckhoff [3] recommended: 1) to start a three-day
dialysis in the hour following insertion; 2) to use dialysate containing 100 IU IL
heparin; and 3) thereafter, to perform daily dialysis, increasing the injected
volumes progressively from 500 ml to 2 liters over a fortnight. We always
follow Tenckhoffs recommendations, asking the patient to remain in a supine
position for the first two days, the abdomen being held by an elastic bandage.
Undue abdominal muscular activity and straining during defecation must be
avoided [31].
To reduce the time of hospitalization, an outpatient irrigation technique was
developed [37]: The catheter is linked to a 500 ml bag containing dialysate with
1500 IU of added heparin; four times a day the patient irrigates the catheter by
injecting the solution and draining it immediately; the bag is changed every
day. CAPD training is started on the fourth day.
4. CATHETER EXIT SITE CARE
Considering that a good healing of the skin exit (epithelialization of the tunnel
and fibroblastic proliferation within the Dacron cuff) is obtained after two
months, we recommend that during this period, dressings be made three times
a week and the external part of the catheter be maintained with an adhesive
strip, in as natural a curved position as possible, so that direct traction on the
exit site is avoided.
After this first period, we recommend using a regular dressing of the skin exit
at least once a week (three times a week for IPD patients). For dressings, the
patient is taught a unique technique without any variation [38]: The patient is
asked to wear a mask and a cap, and to leave the disinfectant in contact with
the catheter itself and the 10 cm skin area around it for at least five minutes.
Betadine is removed with 70 alcohol, except for the exit site. A precut piece
of gauze is placed around the catheter, respecting its natural curve, and is taped
with a large porous adhesive strip.
During the first two months of treatment, the patient is asked to take a
shower at least once a week, the dressing being covered with a waterproof
plastic cloth (Albuclair or Tegaderm). The dressing is changed after the
shower. After two months, the dressing is removed before the shower. To
ensure protection of the bag and tubings, we do not think a colostomy bag is
necessary: The patient keeps them out of the shower cabin, or disconnects the
236
whole system when using a disconnectable device. As regards baths, they are
possible either as sitz baths or in chlorinated water: 150 ml of 12 French
degrees hypochlorite sodium (38 giL chlorine) (bleach) are added to 150 L of
water. Swimming, although preferable in private pools, is not without risk in
rivers or in the ocean. A stoma adhesive device remains on the skin for approximately one week, and a stoma bag protecting the exit site and tubings
should be worn during bathing l39].
Antibiotic ointments should not be used, as they may lead to the buildup of
undesira ble material as well as to the selection of resistant organisms [40]. The
use of a colored but nonstaining solution is preferable for painting the skin area
around the exit site with disinfectants [40]. Povidone-iodine is not always
well tolerated by the skin. In such cases, other disinfectants may be used.
Iodine tincture in alcohol is very efficient on most bacteria within a few
seconds, but it dries and even burns the skin. Other less drying alcoholic
solutions are available: chlorhexidine (Frekaderm, Hibitane), hexamidine
(Hexomedine), and phenyl mer cure (Merfene), but they are colorless, except
for a single solution of Merfene that stains. One should keep in mind that
iodated solutions must never be used with mercurial ones because they
counteract each other. When alcoholic solutions are not tolerated, lathering
solutions can be used, including household soap.
5. COMPLICATIONS AND THEIR TREATMENT
A recent multicenter study showed that more than 26% of catheters implanted
in 338 patients led to 0.4 replacements per patient year [41].
5.1. Early complications
5.1.1. Hemorrhage
5.1.1.1. SUBCUTANEOUS HEMATOMA. Subcutaneous hematoma is not frequent as the catheter is placed in the midline, which is poorly vascularized. It
may result from blind creation of the subcutaneous tract [42]. Lateral access
through the rectus muscle seems to yield a greater incidence of this complication.
5.1.1.2. INTRAPERITONEAL BLEEDING. In the immediate postimplantation
period, the effluent may be bloody during the first exchanges, but a more
serious hemorrhage can be encountered with a hematocrit of3% to 22% in the
peritoneal fluid [30]. Patients may complain of severe abdominal pain andlor
hypotension with a fall in blood hematocrit. Patients with prior abdominal
surgery seem more prone to develop this complication, because of the necessity of destroying previous adhesions to create the intraperitoneal pathway.
Column Disc catheters (Bernas) (which do not require blind dissection for the
intraperitoneal segment) should be recommended for these patients [30].
Treatment should consist of: 1) controlling the patient's coagulation
parameters; 2) giving blood transfusions according to the patient's tolerance;
3) performing continuous peritoneal lavage with cold dialysate containing
heparin (lOOO lUlL, our experience, to lO,OOO lUlL [30)); and 4) when bleed-
237
ing is supposed to come from the abdominal wall, it may be useful to distend
the tissues surrounding the catheter by injecting sterile saline through a
21-gauge needle [43J.
5.1.2. Pain and abdominal discomfort
Pain appearing late between two IPD sessions is due to too rapid a reabsorption of the dialysate remaining in the peritoneal cavity. Pain accompanying
inflow is due to a catheter that is too long and/or to a jet effect in the cuI
de sac of Douglas [44]. Pain at the end of drainage is due to too long a drainage
duration. Pain in the right upper quadrant, mimicking a biliary colic, may be
the consequence of the catheter tip flapping in a subhepatic position.
The following may be tried in succession: 1) increase the fluid volume left in
the peritoneal cavity at the end of each session; 2) add 20 ml of 2% xylocaine
to the first dialysate injection; 3) reduce the drainage duration; and 4) revise
and/or shorten the catheter.
Pain can also be due to the characteristics of the dialysate solution, such as
the pH (lower tolerance if the pH is inferior to 5.2) or the buffering anion
(acetate was more often responsible than lactate in our experience).
When the patient complains of shoulder pain, an important pneumoperitoneum should be suspected.
5.1.3. Disloil.,?cIIICIlt and/or ollc-way obstYllctioll
Dislodgement is not always synonymous with one-way obstruction. Three

causes of one-way obstruction may be evoked:
l. Dislodgement, which rarely occurs after the first month post-implantation.
Medical stimulation of bowel movements often replaces the catheter tip in
an area allowing normal outflow: sorbitol or 25% hypertonic mannitol is
given per os; an injection of 1.5 L dialysate is left in the peritoneal cavity for
two hours before another outflow is tried. We prefer this practice rather
than enema, which may cause a few accidents. Manipulation of the catheter
after medical failure must be tried either medically or surgically.
2. Omentum or viscus flap. This is diagnosed on jerky effluent. A screw
clamp is enough to reduce Bernoulli forces created by the velocity of the
dialysate entering the side holes of the catheter and attracting the bowel or
omentum towards the catheter [44]. Stimulation of bowel movement will
be sufficient to allow further normal dialysis sessions.
3. Omentum aspiration. It is more frequent when the catheter tip is dislodged
from the pelvis. Removal or revision of the catheter becomes necessary.
5.1.4. Leaka,,?c
Early leakage may be evident at the exit site (a most common feature after
implantation) or may be suggested by a swelling of the subcutaneous tissues
238
(implantation area, upper thighs, genitalia). To distinguish whether light

moisture of the dressing is due to a leakage or to a small phlyctena secondary to skin abrasion, 0.5 ml of methylene blue can be added to a 2 L
dialysate exchange. After 30 minutes dwell time, a blue color will appear on
the dressing.
Fluid accumulation in the anterior abdominal wall with swelling of the skin
may be due either to a defect in peritoneal closure, with no adhesion of the
peritoneal membrane to the inner cuff, to a tear in the subcutaneous segment
of the catheter, or to the migration of the unfixed internal cuff out of the
rectus sheath [17].
In most cases, early leakage will disappear spontaneously within 4- 7 days in
an empty peritoneal cavity [45]. Because early leakage is often associated
with peritonitis, we perform one 48-hour IPD session with small volume
exchanges, giving antibiotics intra peritoneally (kanamicin 25 mg/L) and intravenously (vancomicin 1 g). The next IPD session is delayed as long as possible, depending on the patient's biological and clinical parameters. When
the leak has disappeared, we always wait for two weeks before starting
CAPD treatment.
5.1.5. Bowel and bladder perforation
All cases reported in the literature followed trocar placement of the catheter
r431 and/or were caused by the needle used to fill the peritoneal cavity before
blind catheter placement (sudden watery diarrhea) [14]. An overdistended
bladder requires urethral catheterization.
More serious and frequent is bowel perforation when catheters are implanted
for intraperitoneal chemotherapy [46, 47].
5.1.6. Other complications
Reflex ileus was observed in 10% of our patients. Prompt medical treatment
usually solved the problem.
Allergic reactions to silicone rubber [48] and injury to lymphatic vessels [49]
ha ve been reported.
5.2. Late complications
5.2.1 Injection
Infection of the tissues surrounding the catheter is a serious complication,

leading in many cases to the loss of the catheter and inducing a high rate of
transfer to hemodialysis (HD) [50]. The number of patients experiencing
catheter infection varies from 25% (tunnel infection only) [45] to 41 %, with
one infection every 39 patient months [51].
Exit-site injection is seen in the short epithelialized channel, between the
external Dacron cuff and the skin exit. Our patients are trained to call the
staff as soon as they notice deposits or crust formations on the precut gauze
239
covering the exit site. They know that granulation tissues mean infection [22].
Too long a channel allows accumulation of skin material and predisposes the
patient to infection. For this reason we try to place the outer cuff no deeper
than 1 em from the skin exit. Training of the patients includes how to make a
gentle pull on the catheter at each dressing to have this area cleaned with
antiseptics using long ear sticks. Bacteriological diagnosis is assessed by using
Culturette (Marion). Infection is treated with 1 g vancomicin intravenously
followed by the shortening of the tunnel between the skin exit and the outer
cuff using a scalpel, with a guiding probe protecting the catheter. The fibrosis
around the outer cuff is respected.
Outer-cuff infection is confirmed when, after pulling the catheter gently and
squeezing the cuff between the thumb and index finger, a drop of pus appears.
To prevent peritonitis with the same organism, we prefer to use the shaving
technique after intravenous injection of 1 g vancomicin, as the most common
bacteria in this infection is Staphylococcus aureus or S. epidermidis.
After shaving the outer cuff, dressings are made daily using antiseptics or
antibiotics, according to the identified organism. A gentle pull on the catheter,
which is taped in an elongated position, thus reducing its diameter slightly,
permits easy drainage of the infected area. Treatment should last one week
after a negative culture is obtained. However, a few days after debridement,
we systematically remove the catheter in the case of infection by Pseudomonas
species because of its particular adherence to the silastic, leading to prolonged
positive cultures [52].
Diagnosis of tunnel infection is often more difficult to establish. Signs and
symptoms may be totally absent, except for swelling along the tract. Scanning
with Indium-Ill-labeled leukocytes can help confirm catheter-tunnel infection
[53]. We treat tunnel infection by the shaving technique, together with
systemic antibiotherapy, followed by catheter revision (see below).
5.2.2. Cuff extrusion
Cuff extrusion is rarely observed in our hands; involving only 16 catheters

(2%), it is seen mainly in children. Causes that can be evoked are: 1) the forces
exerted on the silastic memory to create an upward convex curve; 2) progressive weight loss and cachexia (three of our patients); and 3) implantation
of the catheter while the patient has a water overload and presents with gross
edema of the abdominal wall, resulting in shrinkage when trying to reach the
patient's dry weight [54].
5.2.3. Bloody iffiuent
Bloody effluent during 2-4 consecutive exchanges occurs very often in young
females still under gonadic activity, in association with menstrual bleeding.
Sometimes it is noticed in the absence of menstruation, but other signs of high
progesterone impregnation are present, such as breast tension. Abdominal
240
pain may be the only sign in IPD patients. Our proposed explanations are
either a uterine reflux into the peritoneal cavity via the permeable fallopian
tubes or an endometriosis.
Serious cases of late hemoperitoneum are reported in patients with associated pathology: radiation injury of the pelvic area for a bladder carcinoma,
lupus thrombocytopenia, granulosa cell tumor, or rupture of a polycystic
kidney.
Minor hemoperitoneum may be encountered after accidental abdominal
trauma (three cases in our experience), severe peritonitis (13 cases in our
experience), uncomplicated colonoscopy following a peritonitis [55], or
enema [56].
5.2.4. Fibrous encasement
Fibrous encasement results from the formation of a fibrous sheath around the
intraperitoneal segment of the catheter. The initial finding is a low outflow
appearing after several months or years of normal functioning. Lacke et al.
proposed that it might be a consequence of recurrent or occasional asymptomatic peritonitis [57]. An x-ray after injection of contrast material into the
catheter may allow the diagnosis; the contrast material is seen sheathing the
catheter tract, diffusing poorly into the peritoneal space.
5.2.5. Clottillg
Difficult or impossible gravity inflow and outflow must evoke a plugged

catheter, either by fibrinous deposits (especially during peritonitis) or by
blood. Addition of 500 to 10,000 IU of heparin to the dialysate during the
first peritoneal dialysis sessions, or when peritonitis occurs, can prevent
clotting.
Obstruction of the catheter by proliferation of hyphae of filamentous fungi
without any signs of peritonitis has also been described.
Treatment consists of trying a light aspiration with a syringe in a full
abdomen or of pushing 50 ml of isotonic saline solution vigorously into an
empty abdomen. Even if one of these maneuvers is effective, we always inject
75,000 IU of urokinase to make sure all the lateral holes are cleared. This
enzyme is left for four hours in the peritoneal cavity before resuming peritoneal dialysis sessions [58]. A success rate of68% has been reported with the use
of streptokinase [59]. Urokinase or streptokinase may also be successful in the
treatment of recurrent peritonitis [60].
5.2.6. Tearinlt and pe~foratioll
Despite silas tic rubber resistance, few accidental openings of the catheter
lumen may occur [61]. Tearing may be responsible for leakage or peritonitis
[62]. We forbid patients to use scissors to remove their dressings, metallic
clamps on the catheter (wooden clothes-pegs are used instead), or safety pins
on their clothes near the waist.

antibiotherapy is mandatory.
Should the case arIse,
241
prophylactic
5.2.7. Visceral lesions
As regards visceral lesions, three predisposing factors must be evoked:

1. Dislodgement: Dislodged catheters have been reported to cause erosion of
the liver [63] or of the spleen [64].
2. Peritonitis: Bowel perforation may occur following gram negative peritonitis [65] and also Staphylococcus epidermidis peritonitis (peritoneovaginal
fistula) [66].
3. A catheter left in place for a long time (few months) without regular
irrigation of the peritoneal cavity [67-70].
5.2.8. PncliltloperitOllCli1tl
An air crescent underneath the right diaphragm may be seen frequently on

x-ray. Such a finding is not systematically associated with a perforated viscus;
air introduced into the peritoneal cavity needs up to seven days to be resorbed.
But progressively increasing pneumoperitoneum should trigger a search for
bowel perforation.
5.2.9. Hernias
Abdominal or internal hernias are reported as a consequence of CAPO

treatment that creates permanent abdominal pressure [17,22,34,36,71-74].
Although an intra abdominal pressure of up to 5 cm of water is relatively free
from side effects in a lying position [32], it is increased considerably during
straining for defecation, coughing, or lifting weights [31], leading to herniation of the weakest parts of the abdomen (umbilicus, inguinal and femoral
rings, rectus muscles diastasis, previous scars). When diagnosis is not evident,
signs and symptoms may be reduced to leakage.
Diastasis of the rectus muscles or a poorly muscularized abdominal wall in
multipara women may also lead to this late complication. In such patients, it
seems preferable to use a transrectal catheter implantation [18]. We recommend to patients to exercise to reinforce the abdominal wall and to wear a
supportive corset during the day.
True hernias must not be mistaken for pseudo hernias, defined by DiazBuxo as a dilatation of the fibrous tract surrounding the silas tic catheter by
intraabdominal fluid [6].
The most questionable fact is the high percentage of hernias appearing on
the catheter implantation site and very often associated with leakage [72],
ranging from 4% to 28% of the total CAPO population. The very low
incidence of incisional hernias recorded in our population (1. 8%) may be due
to the stitching of the inner Dacron cuff directly to the peritoneum with
low-absorption sutures, of the linea alba with separate non-absorbable strand
242
- while the catheter path is made tangent to the linea alba (figure 14-3) stressing the efficacy of a dense fibrosis involving the peritoneal membrane.
Factors predisposing patients to hernias seem to be: 1) sex and parities, 73%
of the patients with hernias were females with more than three parities [72, 75];
2) age over 40 years; 3) previous abdominal surgery [73] (i.e., 28% of our
patients); and 4) poor nutritional status.
The most frightening complication of hernias is incarceration. This abdominal catastrophe is observed in 15.5% to 22.7% of patients with hernia (24% in
our experience) [72, 75, 76]. All authors repair all hernias as soon as possible.
After surgical repair, it is recommended to wait one month before resuming
CAPO. In the meantime, the patient can be treated either by hemodialysis or
IPD using small-volume exchanges. To prevent hernias, it seems commendable
to have all patients at risk wear a special supportive corset.
Hiatal hernias, very often seen in elderly patients, are not a contraindication
to peritoneal dialysis, provided that particular attention is paid during the
treatment of peritonitis, as peptic oesophagi tis develops easily in malnourished
patients submitted to antibiotherapy.
5.2.10. Leakage
Late leakage appearing after several months of PD treatment is closely related

to hernias: 14% of patients treated for a mean time of12 months (3-36 months)
have been reported to suffer from late leakage [19]; while in our experience
only nine patients (1. 6% of total population) presented late leakage.
Diagnosis of leakage is made based on a swelling of the abdominal wall
around a scar due to previous surgery, on the genitalia, or on the suprapubic
area. A watery vaginal discharge is evident when secondary to an abnormally
permeable fallopian tube (diagnosis is often associated with a peritonitis due
to vaginal organisms).
The evidence is that CAPD treatment is a greater factor for promoting
leakage than IPD because of the constant pressure exerted on the weakest
parts of the abdomen. For this reason, leakage will very often be successfully
treated with temporary cessation of CAPD (two weeks) or definitive transfer
to IPD or HD [77]. It is very strange to note that patients who develop a
hydrocele after having been treated for several months, may be cured by two
weeks ofIPD with low-volume exchanges (800 to 1000 ml) and do not relapse
afterwards! Ligature of the fallopian tubes or persisting processus vaginalis,
after unsuccessful discontinuation of CAPD, is another therapeutic approach.
6. CATHETER REMOVAL
6.1. Causes of removal

6.1.1. Infection
Systematic removal of the catheter [17] when exit-sit e or tunnel infection is

diagnosed reflects an excessively cautious attitude leading to the loss of several
well-functioning catheters. Only peritonitis occurring during an infection of
243
the catheter site (i. e., exit site or tunnel) and caused by the same infecting
organism(s) necessitates removal of the catheter. The most difficult step is to
make sure that the infecting organism is really the same, especially when
Staphylococcus is involved.
Under these circumstances, we treat infection of the catheter site and peritonitis separately in order to avoid: 1) recontamination of the peritoneal cavity
during removal; 2) seeding of the new implanted catheter; 3) temporary
hemodialysis; and 4) development of adhesions by continuous lavage. Removal is performed a few days after debridement, when daily catheter-site
and effluent cultures have remained negative for 2-3 days. When Pseudomonas
aeruginosa is involved, prompt removal is recommended [78]. Removal and
replacement are done at the same time [79].
Persisting peritonitis may also lead to removal and replacement of the
catheter [45), resulting in sterility of the dialysate cultures within 48 hours after
surgery in 83% of the cases [80]. As sclerosing encapsulating peritonitis has
been shown to possibly result from stopping PD treatment too soon after a
severe peritonitis [81], we thus recommend, when the decision of transfering
the patient to HD is taken, to wash the peritoneal cavity regularly every 2-3
days, until the protein concentration and C-reactive protein levels in the
dialysate reach normal values.
Other authors consider that infection caused by specific microorganisms
such as yeasts, Mycobacterium tuberculosis, and fungi are an absolute indication
for removing the catheter [82]. We add Pseudomonas aeruginosa to this list (eight
of our cases) [78, 83]. We are less categorical as regards fungal peritonitis
because of the high rate of success we obtain without recurrence and without
catheter removal by using a high concentration of 5-fluorocytosine [84] and
urokinase [58, 85] in the catheter lumen and oral ketoconazole. Recurrence of
yeast peritonitis can occur if this treatment is of too short a duration and is
not monitored by dialysate filtration [86]. Routine dialysate cultures without
concentration may remain negative with a positive catheter culture [87]. Removal of the catheter is still mandatory when filamentous fungi such as
Fusarium, Aspergillus, Curvularia lunata, and Dreschlera spicifera cause catheter
obstruction or peritonitis [88, 89] (ten cases in our experience).
6.1.2. Mechanical impairment
The incidence of catheter removal for one- or two-way obstruction ranges

from 3% [45] to 14% [19] of implanted catheters. After 1983, when we started
to systematically revise the catheters, no removal was necessary. We also
revise catheters for pain, cuff extrusion, or persistent leakage, for which
removal is sometimes considered.
6.1.3. Cessation ofperitoneal dialysis treatment
Cessation ofPD treatment may be due to transfer to hemodialysis, remission,

or transplantation. The main question is whether to remove the catheter at the
244
time of transplantation or to keep it in place for eventual dialysis in the

immediate post-transplant period, the latter being common practice.
During transplantation surgery, the external part of the catheter must be
kept away from the operation site if possible in a contralateral position [90].
The surgeon must take extra care when stripping the peritoneum to reach the
iliac vessels, in order to avoid opening the peritoneal cavity. This may be
difficult because the peritoneum is even more adherent to the pelvic wall and
more vascularized.
However, if an exit-site infection is present at time of transplantation [91, 92]
or a peritonitis episode is still under treatment, removal of the catheter is
mandatory [90-92]. A lapse of time of one to two weeks after successful
treatment of peritonitis is advisable before accepting the renal graft [90,~93].
In three studies, no evidence of peritonitis was described in spite of the
immunosuppressive treatment [90, 92, 93], while in two other studies, the
rate of peritonitis was 10.3% [94] and 20% [91] of the recipients.
Exit-site care must be practiced every day post-transplantation; as soon
as redness or a pus discharge appears, sampling is mandatory. In case of a
positive culture, appropriate antibiotherapy must be given, both parenterally
and intraperitoneally, and the catheter must be promptly removed.
The time interval for removing the catheter varies between 12 days [91] and
four months [93]. In the case of late removal, we recommend irrigating the
peritoneal cavity at least once a week after the first month in order to avoid
viscus perforation. Another advantage of keeping the catheter in situ may be
easy drainage of ascites.
6.2. Technique for removal
To remove a double-cuff Tenckhoff catheter, we suggest delimiting the

operating site, keeping the exit site out of the field. Under local anesthesia, we
reopen the incision site. The subcutaneous silas tic is freed from its fibrous
sheath and cut. By gentle blunt dissection, the inner cuff is delivered. In our
experience, the inner cuff being stitched to the peritoneum, the fibrous tissue
around the inner cuff is very dense; but in spite of that we never found any
adhesions, either to the omentum or to bowel loops, that would have impeded
this maneuver. Because of the size of the incision, it is not always possible, but
is recommended, to close the peritoneum separately with low-absorption
sutures [74]. The aponevrosis must be closed with two to three stitches of
nonabsorbable strand in order to avoid late hernia formation through the
cannula site. The subcutaneous fat tissue is closed by a capitonnage, and then
the skin is closed.
In a second step, the exit site is exposed. A 1 cm incision allows the outer
cuff to be freed. A deep transcutaneous stitch is always sufficient to obtain
good hemostasis. This complementary step does not seem to us to be so timeconsuming as to make one prefer single- to double-cuff catheters [95].
245
t.t.1B1UCUS
SIl).STIC RING
CONNECTOR
Figure 14-5. Schematic representation of the skin incision permitting debridement of the outer
cuff and its removal from the silas tic tubing.
7. COMPLEMENTARY TECHNIQUES
Several complementary surgical techniques may help keep a well-functioning

catheter in place.
7.1. Shaving technique in skin-exit infection
When the outer cuff alone is infected, without involving the subcutaneous
tunnel, the shaving technique may be used [96-98]. After intravenous perfusion of 1 g vancomicin (the infecting organism often being a Staphylococcus
species), local anesthesia around the exit site is performed, taking care not to
puncture the catheter. A guiding probe is pushed between the cuff and the
skin. A 1-2 cm incision is made with a scalpel, the guiding probe protecting
the catheter. The cuff is thoroughly freed from the surrounding infected
tissues and the Dacron cuff is peeled off from the silas tic tubing (figure 14-5).
This maneuver is very easy with the Tenckhoff catheters manufactured by
Cobe Laboratories (Cobe), the Dacron being glued on a supplementary ring of
silastic. Our technique must be considered only when the inner Dacron cuff is
embedded tightly by the fibrosis underneath the aponevrosis, hindering catheter extrusion. We recommend prophylactic antibiotherapy in the dialysate for
the five following days.
When the scar is healed, two approaches are possible: 1) to consider the
246
catheter as a single cuff; 2) when the exit site culture remains negative for at
least seven days, to glue on another cuff (Quinton) with a special sterile silastic
glue (Quinton) on the silas tic tubing, perfectly sterilized either by Betadine or
iodated alcohol. It is preferable to glue the new cuff 4 to 6 hours before making
the new exit site in order to avoid damage of the subcutaneous tissue by the
acetic acid contained in the glue. Another approach was proposed, known as
the splicing technique [99]: A 2-3 cm incision is made across the catheter
tunnel; the external part of the catheter is cut and a new external segment is
connected using a ridged connector (Quinton), which may be secured with
ties. Antibiotic treatment is recommended as above.
7.2. Unroofing technique in tunnel infection
We propose opening the implantation scar 2-3 cm. After skin exit-site
debridement, the catheter is freed from its fibrous tract and pulled out through
the reopened incision scar. The "unroofing" technique is rather similar [100].
This maneuver must be performed after systemic antibiotherapy: 1 g vancomicin is given even before getting the laboratory results and an aminoside
is put in the dialysate for at least five days. The infected tunnel can then
be treated independently by irrigation with antiseptic agents from the open
exit site towards the midline incision. An iodophorm wick is useful. After
sterilization, the catheter can be treated as a single-cuff catheter. It is also possible to glue a new Dacron cuff and to reimplant the catheter from the midline
(or lateral) incision to the controlateral side. In this case, we recommend
removing the wound tissues surrounding the midline (or lateral) incision with
a scalpel, the two corners being maintained under tension by two towel
clamps. It is then possible to stitch the midline incision.
7.3. Repositioning the intraperitoneal segment of the catheter
When the catheter is dislodged, provoking pain and/or malfunction, or when a

probable omentum wrapping is diagnosed, it is possible to reposition the
intraperitoneal segment and/or free it from the aspirated omentum, either by
medical or surgical techniques, keeping the advantages of a satisfactory
subcutaneous tract and a mature fibrosis.
7.3.1. Medical technique
The connector is removed under strict aseptic conditions. The catheter is

flushed with 20 ml of2% xylocaine. A trocar, gently curved at an angle of 30,
with a blunt end and 2 em shorter than the catheter, is introduced into the
lumen. The trocar is rotated full circle to dislodge the catheter from adhesions.
A second rotation serves to establish a new position for drainage. By repeating
this maneuver up to five times, a high success rate has been reported, especially
in catheters implanted for more than three weeks [101].
Other medical techniques have been proposed [102, 103].
247
- UMBlUCUS
Figure 14-6. Surgical revision for dislodgement and/ or omentum wrapping. A suprapubic
incision allows the intraperitoneal segment of the catheter to be taken out of the peritoneal cavity
and allows the pedicles of omentum aspirated through the lateral holes to be destroyed one by
one, by electrocoagulation .
7.3.2. Surgical techllique
In 49 cases, we used the technique described by Tenckhoff [3] . Under local

anesthesia, the skin is opened 5-6 cm, 1-2 cm above the pubis symphysis.
Fibers of the pyramidal muscle are cautiously reclined using Faraboeuf retractors. The posterior aponevrosis is then picked up between two hemostats and
opened. At this level, the peritoneum is often adherent to the aponevrosis. The
incision of the peritoneum is enlarged with scissors to 4 cm. The manipulator's
index is introduced into the peritoneal cavity in order to search for the catheter,
which is drawn out. If it is wrapped by the omentum, the vascularized pedicles
aspirated through the lateral holes are destroyed one by one with electrocoagulation (figure 14-6). When the catheter is completely freed, it is reintroduced
into the pouch of Douglas with a finger or a heart-shaped clamp. The peritoneum and the posterior aponevrosis are sutured with an overcast stitch
using a low-absorption strand. The anterior aponevrosis is closed with nonabsorbable thread. The subcutaneous tissue and the skin are stitched as
described previously.
The same approach may be used to shorten a catheter that is too long and
causes pain on the pelvic floor or genitalia.
7.4. Replacement of the catheter
It has been demonstrated that coccoid as well as rod-shaped bacteria are liable
to adhere to the silastic catheter [52]. It has been proposed to treat unres-
248
ponsive bacterial peritonitis by removal of the catheter and replacement with a

new catheter at the same time [79, 80], with the hope of avoiding formation
of adhesions by stopping PD. The new catheter can be implanted through the
existing peritoneal insertion site [52], positioning the new exit on the opposite
side. We prefer, during the same operation, 1) to implant the new catheter
above the umbilicus or on the contralateral side (trans recta access) and 2) to
remove the infected catheter.
When filamentous fungi are the responsible infecting organisms, it is
necessary to wait 3-4 weeks after removal of the infected catheter before
inserting the new one.
7.5. Repair
Tears on the subcutaneous channel or on the external segment can be repaired

as previously described using the ridged connector (Quinton). We prefer using
the Peri Patch technique (Quinton), which allows an injection of silastic glue
into a plastic mould placed around the two segments of the catheter, this
mould being removed after 24 hours.
8. INTERCURRENT ABDOMINAL SURGERY
Abdominal catastrophes necessitating surgery, such as appendicitis, cholecystitis, diverticulitis, bowel perforation, and spleen rupture, which may be
related or unrelated to the presence of an intraabdominal catheter, may
raise the question of whether or not to keep the Tenckhoff catheter during
operation. If a peritoneal infection is involved, we must bear in mind that the
whole peritoneal cavity is always involved in peritonitis, due to the constant
presence of fluid, which is not the case in patients with natural defenses
(physiological role of the omentum). If the catastrophe necessitates a stoma to
the abdominal wall, we recommend removing the Tenckhoff catheter. In
other cases, the Tenckhoff catheter may be kept in place, in order to wash the
peritoneal cavity of blood or bacteria. It is then mandatory to ask the surgeon:
1) to check the correct positioning of the catheter tip before closing; 2)
to very carefully close the peritoneum with a separated low absorption strand;
3) to avoid all other drainage of the peritoneal cavity; 4) to perform careful
hemostasis of all the tissues; 5) if a Penrose drain is necessary the vacuum
must be taken off during the following dialysis sessions; 6) to perform the
following dialyses with low volumes; 7) to wrap the abdomen with a supportive elastic bandage; 8) to maintain the patient in an anabolic status using
parenteral nutrition as soon as possible; and 9) to leave the patient in the
hands of specialized nursing staff who are well trained in peritoneal dialysis
procedures [104].
If the problem is not infectious, it is probably preferable to transfer the
patient to hemodialysis during the three weeks following surgery, in order to
avoid leakage and hernias on the site of laparotomy.
249
9. RADIOGRAPHY AND NEW IMAGING
9.1. Radiography
The first Tenckhoff catheters were not radiopaque and catheterograms were
done after injection of iodated contrast material into the catheter. When
manufacturers produced striped barium-impregnated catheters, radiography
made locating the tip easier, but catheterograms remained useful in the
diagnosis of problems involving the lumen of the catheter or its surrounding
area. Totally opaque catheters render the detection of intraluminal problems
impossible [12].
One-way obstruction by aspiration of the omentum will be detected easily,
as it shows up as multiple round shadows within the lumen [105]. Blockage of
the catheter by a fibrous sheath will show up as contrast material along a line
parallel to the external part of the catheter. Injection of large volumes of
dialysate containing the same cont,rast material will confirm whether distribution of the dialysate into the peritoneal cavity is free or hampered (cystic
formation) [106].
9.2. Fluoroscopy
Fluoroscopy is useful in manipulating malfunctioning catheters by medical

technique that does not require surgery [101, 107].
9.3. Computerized tomography
Medically undetectable hernias responsible for leakage can be diagnosed by

computerized tomography. Two ways of opacification of the peritoneal cavity
may be used: 1) technetium-labeled tin colloid (TC99) at a dose of 110-150
MBq per liter dialysate and 2) iodated contrast material concentrated at 60%,
at a dose of 50 mIlL dialysate [108].
Because the site ofleakage may not be a defect of the inguinal ring, but may
be situated in another part of the peritoneal cavity (previous surgery) [109], the
best technique consists of using great volumes (3 liters) injected over a 15minute period, followed by an upright position and walking for a few minutes
or up to three hours [110, 111].
10. CONCLUSION
The actuarial survival rate of 57% obtained at eight years (figure 14-7) in our
hands with the double-cuff Tenckhoff catheter confirms the appropriateness of
the device and pleads in favor of our technique.
ACKNOWLEDGMENTS
Our thanks go to Professor Michel Balmes who guided my first steps in the
surgical technique; to Drs. B. Branger, B. Canaud, G. Chong, G. Deschodt,
B. Laroche, and G. Mourad, who agreed to follow our teaching; to the
medical and nursing staff of Service de Dialyse, Clinique Medicale "Le Mas de
250
0;
OJ
ez
.s:
675 405 243 145 88 54 35
, 100
~
~
~
~2
B
17
10
ooueu CUf'F nllCltHOfF
90
80
70
60
50
2345678
yEARS
Figure 14-7. Cumulative survival of 675 double-cuff Tenckhoff catheters (the shadowed area
represents the confidence interval at 5%).
Rochet" Castelnau-Ie-Lez; Service de Nephrologie (Professeur Charles Mion)

H6pital Lapeyronie, Montpellier; and Service de Ncphrologie (Professeur
Jacques Fourcade), H6pital de Nimes, and to Maguy Elie, without whom this
work would not have been possible.
This work is dedicated to Fran~ois Alleaume.
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KD, Prowant B, et al. (eds) Advances in CAPD: Proc 5th Ann CAPO Conference, Kansas
City, February 1985, pp 45-48.
52. Craddock CF, Edwards R, Finch RG: Pseudomonas peritonitis in continuous ambulatory
peritoneal dialysis: Laboratory predictors of treatment failure. J Hosp Infect 10:179-186,
1987.
53. Steiner RW, Kipper S, Savoia MC, Witztum KF: Identification of peritoneal dialysis catheter tunnel infection by scanning with Indium-III-labeled leukocytes. Ann Int Med 99:
44-45, 1983.
54. Jenkins DAS, Cumming AD: Extrusion of subcutaneous cuff after resolution of gross edema
(letter). Perit Dial Bull 4:109, 1984.
55. Nace GS, George Jr AL, Stone W]: Hemoperitoneum: A red flag in CAPD. Perit Dial Bull
5:42-44, 1985.
56. Oreopoulos DG, Khanna R, Williams P, Vas SI: Continuous ambulatory peritoneal dialysis
- 1981. Nephron 30:293-303, 1982.
57. Lacke C, Kozak SM, Senekjian HO, Knight TF, Weinman E]: Peritoneal catheter complications in CAPD patients. In: MoncrefJW, Popovich RP (eds) CAPD Update. New York:
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58. Mion CM: Practical use of peritoneal dialysis. In: Drukker W, Parsons FM, Maher JF (eds)
Replacement of Renal Function by Dialysis, 2nd edition. Boston: Martinus Nijhoff, 1983,
pp 457-492.
59. Wiegmann TB, Stuewe B, Duncan KA, Chonko A, Diederich DA, GranthamJJ, Savin VJ,
MacDougall ML: Effective use of streptokinase for peritoneal catheter failure. Am J Kidney
Dis 6:119-123, 1985.
60. Block RA, Taylor B, Frederick G: Intraperitoneal infusion of streptokinase in the treatment
of recurrent peritonitis. Perit Dial Bull 3:162-163, 1983.
61. Golper TA, Carpenter J: Accidents with Tenckhoff catheters (letter). Ann Int Med 95:
121-122, 1981.
62. Roxe DM, Santhanam S: Structural defects in chronic peritoneal dialysis catheters contributing to peritonitis. Nephron 34:267-268, 1983.
63. Shohat J, Shapira Z, Yussim A, Boner G: An unusual cause of massive intraperitoneal
bleeding in CAPD. Perit Dial Bull 4:257-258, 1984.
64. De los Santos CA, von Eye 0, d'Avila D, Mottin CC: Rupture of the spleen: A complication
of continuous ambulatory peritoneal dialysis. Perit Dial Bull 6:203-204, 1987.
65. Fang G: Peritoneal catheter perforating into the colon - a serious complication of peritoneal
dialysis. In: Maher JF, Winchester JF (eds) Frontiers in Peritoneal Dialysis. New York: Field,
Rich & Assoc, 1986, pp 521-523.
66. Diaz-Buxo JA, Burgess P, Walker PJ: Peritoneovaginal fistula - unusual complication of
peritoneal dialysis. Perit Dial Bull 3:142-143, 1983.
67. Braden GL, Germain MJ, Guardione V A, Fitzgibbons JP: Infected intra-abdominal hematoma associated with an indwelling Tenckhoff catheter. Perit Dial Bull 4:248-250, 1984.
68. Parvin SD, Beaman M: Ileal erosion by the Tenckhoff catheter (letter). Perit Dial Bull
5:82, 1985.
69. Watson LC, Thompson JC: Erosion of the colon by a long-dwelling peritoneal dialysis
catheter (letter). JAMA 243:2156-2157, 1980.
70. Della Volpe M, Iberti M, Ortensia A, Veronesi GV: Erosion of the sigmoid by a permanent
peritoneal catheter (letter). Perit Dial Bull 4:108, 1984.
71. Swartz RD: Chronic peritoneal dialysis: Mechanical and infectious complications. Nephron
40:29-37, 1985.
72. Digenis GE, Khanna R, Mathews R, Oreopoulos DG: Abdominal hernias in patients undergoing continuous ambulatory peritoneal dialysis. Perit Dial Bull 2:115-117, 1982.
73. O'Connor JP, Rigby RJ, Hardie IR, Wall DR, Strong RW, Woodruff PWH, Petrie JJB:
Abdominal hernias complicating continuous ambulatory peritoneal dialysis. Am J Nephrol
6:271-274, 1986.
74. Griffin PJ, Coles GA: Strangulated hernias through Tenckhoff cannula sites. Br Med J
284:1837, 1982.
75. Spinowitz B, Leggio A, Galler M, Golden R, Rascoff J, Chary tan C: Prognostic indicators
of hernia development in patients undergoing CAPD. In: Maher JF, Winchester JF (eds)
Frontiers in Peritoneal Dialysis. New York: Field, Rich & Assoc, 1986, pp 519-520.
76. Rocco MV, Stone WJ: Abdominal hernias in chronic peritoneal dialysis patients: A review.
77. Beaman M, Feehally J, Smith BA, Walls J: Anterior abdominal wall leakage in CAPD
patients; management by intermittent peritoneal dialysis. Perit Dial Bull 5:81, 1985 . .
78. Schleifer CR, Morfesis FA, Cupit M, Chen C, Smink RD: Management of hernias and
Tenckhoff catheter complications in CAPD. Perit Dial Bull 4:146-150, 1984.
79. Paterson AD, Bishop MC, Morgan AG, Burden RP: Removal and replacement of Tenckhoff catheter at a single operation: Successful treatment of resistant peritonitis in continuous
ambulatory peritoneal dialysis. Lancet 11:1245-1247, 1986.
80. MarichalJF, Faller B, Mengus C, Wagner JD, Frey G: Replacement of the peritoneal dialysis
catheter in persistent peritonitis in continuous ambulatory peritoneal dialysis. Nephrologie
6:7-10,1985.
81. Slingeneyer A, Elie M, Mion C: Sclerosing encapsulating peritonitis. Results of an
international survey (abstract). Abstracts EDT A, 1986, P 176.
82. Kerr CM, Perfect JR, Craven PC, Jorgensen JH, Drutz DJ, Shelburne JD, Gallis HA,
Gutman RA: Fungal peritonitis in patients on continuous ambulatory peritoneal dialysis.
254
Ann Int Med 99:334- 336, 1983.

83. Krothapalli R, Duffy B, Lacke C, Payne WP, Patel H, Perez V, Senekjian HO: Pseudomonas peritonitis and continuous ambulatory peritoneal dialysis. Arch Int Med 142:
1862-1863, 1982.
84. Slingeneyer A, Laroche B, Stec F, Canaud B, Beraud JJ, Mion C: Oral ketoconazole plus
intraperitoneal 5-fluorocytosine as the sole treatment of fungal peritonitis (abstract). Perit
Dial Bull 4(Suppl):S60, 1984.
85. Benevent D, Peyronnet P, Brignon P, Leroux-Robert C: Urokinase infusion for obstructed
catheters and peritonitis (letter). Perit Dial Bull 5:77, 1985.
86. Stec F, Slingeneyer A, Perez C, Despaux E, Mion C: Large volume filtration of peritoneal
fluid in intermittent or continuous ambulatory peritoneal dialysis. In: Gahl GM, Kessel M,
Nolph KD (eds) Advances in Peritoneal Dialysis. Int Congress Series 567, Amsterdam:
Excerpta Medica, 1981, pp 158-163.
87. Bastani B, Westervelt FB Jr: Persistence of Candida despite seemingly adequate systemic
and intraperitoneal amphotericin B treatment in a patient on CAPD. Am J Kidney Dis 8:
265-266, 1986.
88. PearsonJG, McKinney TD, Stone WJ: Penicillium peritonitis in a CAPD patient. Perit Dial
Bull 3:20-21, 1983.
89. DeVault GA Jr, Brown ST 3d, King JW, Fowler M, Oberle A: Tenckhoff catheter obstruction resulting from invasion by Curvularia IUI/ata in the absence of peritonitis. Am J
Kidney Dis 6:124-127, 1985.
90. Gokal R: Renal transplantation in patients on CAPD. In: La Greca G, Chiaramonte S,
Fabris A, Feriani M, Ronco C (eds) Peritoneal Dialysis. Milano: Wichtig Editore, 1986,
pp 283-288.
91. Wood CJ, Thomson NM, Scott DF, Holdsworth SR, Boyce N, Atkins RC: Renal transplantation in patients on CAPD. In: Maher JF, Winchester JF (eds) Frontiers in Peritoneal
Dialysis. New York: Field, Rich and Assoc, 1986, pp 353-356.
92. Hymes LC, Warshaw BL: Renal transplantation in children undergoing peritoneal dialysis.
Perit Dial Bull 6:74- 76, 1986.
93. Ryckelynck JP. Verger C, Pierre D, Sabatier JC, Faller B, Beaud JM: Early post
transplantation infections in CAPD patients. Perit Dial Bull 4:40-41, 1984.
94. Cardella CJ: Renal transplantation in patients on peritoneal dialysis. Perit Dial Bull 1:
12-14,1980.
95. Moncrief JW, Popovich RP: Early and long term catheter care. In: La Greca G, Biasioli S,
Ronco C (eds) Peritoneal Dialysis. Milano: Wichtig Editore, 1982, pp 139-144.
96. Slingeneyer A, Mion C, Charpiat A, Balmes M: Is an alternative to the Tenckh6ff catheter
necessary? In: Gahl GM, Kessel M, Nolph KD (eds) Advances in Peritoneal Dialysis.
International Congress Series 567, Amsterdam: Excerpta Medica, 1981, pp 179-184.
97. Piraino B, Bernardini J, Peitzman, Sorkin M: Failure of peritoneal catheter cuff shaving to
eradicate infection. Perit Dial Bull 7:179-182, 1987.
98. Nichols WK, Nolph KD: A technique for managing exit site and cuff infections in Tenckhoff
catheters. Perit Dial Bull 3(Suppl):S4-S5, 1983.
99. Roman J, Gonzalez AR: Tenckhoff catheter repair by the splicing technique. Perit Dial Bull
4:89-91, 1984.
100. Andreoli SP, West KW, GrosfeldJL, BergsteinJM: A technique to eradicate tunnel infection
without peritoneal dialysis catheter removal Perit Dial Bull 4:156-158, 1984.
101. Davis R, Young J, Diamond D, Bourke E: Management of chronic peritoneal catheter
malfunction. Am J Nephrol 2:85-90, 1982.
102. Korten G, Arendt R, Brugmann E, Klein B: Relocation of a peritoneal catheter without
surgical intervention (letter). Perit Dial Bull 3:46, 1983.
103. Wilson JA, Swartz RD: Peritoneoscopy in the management of catheter malfunction during
continuous ambulatory peritoneal dialysis. Digest Dis Sciences 30:465-467, 1985.
104. Laroche B: La chirurgie abdominale chez les insuffisants renaux chroniques en traitement
de suppleance par dialyse peritoneale. Memoire, C.E.S. Nephrologie, University of Montpellier, 1987.
105. Oreopoulos DG, Khanna R: Complications of peritoneal dialysis other than peritonitis. In:
Nolph KD, (ed) Peritoneal Dialysis. The Hague: Martinus Nijhoff, 1981, pp 309-343.
106. Adnersen KE, Damgaard-Morch P: Catheterography in the diagnosis of catheter failure in
255
peritoneal dialysis. Clin NephroI16:142-145, 1981.

107. Degesys GE, Miller GA, Ford KK, Dunnick NR: Tenckhoff peritoneal dialysis catheters:
The use of fluoroscopy in management. Radiology 154:819-820, 1985.
108. Johnson BF, Segasby CA, Holroyd AM, Brown CB, Cohen GL, Raftery AT: A method for
demonstrating subclinical inguinal herniae in patients undergoing peritoneal dialysis: The
isotope 'peritoneoscrotogram.' Nephrol Dial TranspI2:254-257, 1987.
109. Orfei R, Seybold K, Blumberg A: Gential edema in patients undergoing continuous
ambulatory peritoneal dialysis. Perit Dial Bull 4:251-252, 1984.
110. Schultz SG, Harmon TM, Nachtnebel KL: Computerized tomographic scanning with
intraperitoneal contrast enhancement in a CAPD patient with localized edema. Perit Dial
Bull 4:253-2n4, 1984.
111. Singal K, Segel DP, Bruns FJ, Fraley DS, Adler S, Julian TB: Gential edema in patients on
continuous ambulatory peritoneal dialysis. Report of 3 cases and review of the literature.
Am J Nephrol 6:471-475, 1986.
15. THE PERMANENT TORONTO WESTERN HOSPITAL CATHETERS
RAMESH KHANNA and DIMITRI OS G. OREOPOULOS
Since Palmer et al. [1-2] introduced an indwelling silicone rubber peritoneal

catheter in 1964, several modifications have been made to original design that
were directed chiefly towards improving its anchoring on the tissues and decreasing the frequency of complications, such as one-way (outflow) obstruction, and preventing its free movement inside the peritoneal cavity [3-7].
One of these modifications is the Toronto Western Hospital catheter, designed by Oreopoulous and Zellerman in 1976 [7]. Its main distinguishing
feature is two flat silicone rubber discs on the intraabdominal portion of the
catheter.
These flat discs prevent the free movement of catheter tip within the peritoneal cavity and thereby help the catheter remain in the minor pelvis. A prospective controlled study [7] in 1976 showed a lower incidence of catheter-tip
dislodgement from the pelvis with Toronto Western Hospital catheters (7%),
when compared with Tenckhoff catheters (33%). Another complication encountered in this study with the Toronto Western catheter was rectal cramping abdominal pain, which lasted for two to six weeks in 33% of the patients.
The major disadvantage recognized with the use of a Toronto Western catheter was the need for surgical implantation and removal.
Whereas the basic design of the intraabdominal segment of the Toronto
Western catheter remains unchanged, further modifications were made since
1976. The intraabdominal segment was shortened to eliminate the rectal pain
experienced by some patients in the initial study (Toronto Western Hospital
257
258
1--- - - - - t : l B r - - - - - - 1 1
~\jl!i!ii!ii'i5!i!i!i!E=3(Q~:.:
o
1_ _ _ _ _ _ _ _::--_ _ _ ___+.11
Figure 15-1. Diagram of the Toronto Western Hospital catheter. A = distance between two
discs (5 cm); B = intraperitoneal segment (15 em long); C = groove between silastic bubble and
Dacron disc; D = Dacron felt cuff with disc; E = intramural segment (2 em long); F = external
segment (20 em long).
Type 1 catheter). Further alterations were made at the level of the peritioneal
Dacron cuff to reduce the incidence of early and late dialysate leaks and the
risk of incision hernias. These modifications included the addition of a Dacron
disk, 1 cm in diameter, on the base of the peritoneal cuff, which at the time
of insertion is placed between the peritoneum and fascia, to seal the peritoneal
hole, and a silas tic ring 1 mm distal to the Dacron disk to provide a groove
(C in figure 15-1) between them, in which the surgeon ties the peritoneum
tightly (Toronto Western Hospital, Type 2 catheter).
In 1981 Ponce et al. [8] reported an experience with the two most frequently
used Toronto Western Hospital catheters (Type 1 and 2) and compared them
with the straight Tenckhoff catheters implanted either medically or surgically
(94 Toronto Western Hospital, Type 1 catheters; 83 Toronto Western Hospital, Type 2 catheters; and 90 straight Tenckhoff catheters). Cumulative catheter survival rates at the end of the first and second years were significantly
better (p < 0.05) for Toronto Western Hospital Type 2 catheters compared
to the Straight Tenckhoff catheters inserted medically. No significant differences were observed between the other groups. The data on catheter survival
among various subgroups showed a trend to lower survival of catheters in patients older than 60 years and diabetics, compared to younger patients and
nondiabetics, respectively. Considered together, all first-time catheters had
significantly better one-year survival than all the second-time or subsequent
catheters.
A significant complication, observed among all catheters, was early dialysate leak, which occurred at a rate ranging from 18% to 32%. Patients older
than 60 years had a higher incidence ofleakage (42.3%) than younger patients
(26.9%) (p < 0.01). Also women had a higher incidence of leakage (36.2%)
than men (18.6%) (p < 0.01), and leakage was more common among second
or subsequent catheters (42.7%) than in first catheters (26.9%) (p < 0.01).
Immediate postoperative complications related to the catheter were: perioperative pain (1%-6%), infection (1%-5%) and poor drainage (11%-22%),
cuff extrusion (1 % -7%), and late one-way obstruction (9% -16%). In all four
groups, the major cause of catheter failure and consequent removal was oneway obstruction due to dislodgement of the catheter from the pelvis and encasement by omentum, or two-way obstruction.
In an effort to reduce the frequency of dialysate leak, the catheter implan-
15. Toronto Western Hospital catheters
259
tation technique was modified in such a way that the catheters passed through
the rectus muscle rather than through the midline, and the first postoperative
dialysis was delayed for at least 24 hours after implantation of the catheter
instead of starting immediately. This approach practically eliminated the complication of dialysate leak.
This chapter describes in detail the catheter design, insertion technique,
postoperative care of the catheter, and complications observed with Toronto
Western Type II catheters.
1. CATHETER DESIGN
The Toronto Western Hospital catheters are made of medical-grade silicone

rubber, thus making them soft, flexible, and atraumatic to the bowel. The
silicone rubber is nonimmunogenic, induces no tissue reaction, and is not water
wettable. These catheters are available with a barium-impregnated radiopaque
stripe to assist in the radiological localization of the intraabdominal section.
Adult Toronto Western catheters are 41 cm long, whereas pediatric catheters
are 35 cm long. The extraabdominal section (segment F in figure 15-1) of the
catheter is about 20 cm long and is identical in design to the Tenckhoff catheter. This long length of the extra abdominal section allows easy handling and
reserves enough length to permit trimming if a catheter split occurs at the
connector site during its long use. The subcutaneous and transmural segment
(segment E in figure 15-1) is about 2 cm long. A Dacron felt cuff 1 cm wide
is bonded to the catheter by the manufacturer (Accurate Surgical Instruments
Corporation, 588 Richmond St. W., Toronto, Ontario, Canada M5V 1 Y9) at
the junction of the extraabdominal section and the subcutaneous part. Except
for the absence of the subcutaneous cuff, the Toronto, Western II single-cuff
catheter is identical in design to the Toronto Western II double-cuff catheter.
The short intramural section of the catheter that passes through the abdominal wall muscles has several functions. It provides a mechanical anchorage,
a watertight peritoneal seal, and a further bacterial seal. In order to maximize
the efficiency of this segment, the end of the intramural segment in Toronto
Western II catheters is provided with another Dacron felt cuff (D in figure
15-1) identical to the subcutaneous cuff, and a Dacron disk 1 cm in diameter
at the base of this cuff. One millimeter distal to the Dacron disk, an elastic
ring or bubble is provided to create a groove (C in figure 15-1) on which the
peritoneum is tightly tied. The fibrous tissue ingrowth bonds the catheter
firmly to the muscle and fascia to prevent its displacement. When the cuff is
routed obliquely to the tissues, this bond will stabilize the intraperitoneal segment (B in figure 15-1) of the catheter in a direction pointing towards the
pelvis (figure 15-2). At the level of the Dacron cuff, tissue fibrosis in and
around the peritoneum forms an effective seal, preventing fluid leak from
occurring. This design affords a good barrier against early or late dialysate
leaks and later incision hernias.
The intraperitoneal segment of this catheter is 15 cm long (figure 15-1)
260
Dacron diS1C---::J,11
intestine
Silastic rincl--/
Figure 15-2. Diagram showing position of a Toronto Western Hospital catheter when inserted
deep into the pelvic cavity. Note that the catheter tip is farther away from the reach of the
omentum. C = groove where peritoneum is sutured; E = intramural segment of the catheter.
and is designed to provide an unrestricted flow of dialysis solution to and

from the peritioneal cavity. When the peritoneal cavity is full of dialysis solution, the freely mobile small intestine and the active omentum tend to float
over the fluid sump. During the drainage, typically fluid runs out at a rate
of 200 ml/min, thus creating a negative suction due to the siphon effect, the
force of which is determined by the difference in height between the catheter
tip and the empty dialysis bag. This force tends to pull the abdominal contents towards the catheter tip and side holes, tending to occlude and prevent
free drainage of dialysis solution. When the catheter tip is placed deep in the
true pelvis, as shown in figure 15-2, the omentum is unable to reach the side
holes and tip, thus allowing free fluid flow without being obstructed by the
intraabdominal contents. With the object of stabilizing the catheter tip deep
in the true pelvis, Toronto Western catheters are provided with two flat silicone rubber discs that are 1 mm thick, 28 mm in diameter, and 5 em apart
on the intraabdominal portion of the catheter (figure 15-1). Because of their
shape and design, two discs prevent the free mobility of the intraabdominal
section of the catheter in the peritioneal cavity.
2. CATHETER INSERTION TECHNIQUE
2.1. Pre-insertion preparation of patients

It is important to ascertain the patient's own preference regarding the location
of the exit site on the abdominal wall. This could be placed either above or
261
below the belt line, easily accessible and visible to the patient. To help the
surgeon locate the preferred site during the insertion, the belt line is identified
on the skin surface prior to the procedure and a site is marked. Some exceptions are made with regard to the selection of the length of the catheter. Obese
patients require a catheter with an extra long intraperitoneal segment.
The catheters are provided in both sterile and nonsterile packages. The
following instructions are followed for sterilizing the catheter. The catheter
should only be handled wearing gloves. The catheters are washed in warm
liquid soap diluted in two gallons of tap water. They are soaked for two minutes, then rinsed under tap water to clear them of the soap. All excess water in
the catheters are dried and laid on a clean table, patted dry, placed in a flat
pouch, and sealed with a heat sealer. Then, they are steam-sterilized for 40
minutes at 270C.
Abdominal hair is clipped from the xiphisternum to the symphysis pubis
and is cleaned with a betadine solution. One gram of vancomycine or cephalothin is given in slow intravenous infusion one day prior to surgery. The
patient is asked to void and defecate. Some patients may need assistance and
are given a rectal enema. The choice of anesthesia is dictated by the patient's
age, medical condition, and the likely extent of the surgical procedure. It may
be desirable to postpone catheter insertion if the patient is suffering from acute
upper respiratory infection with a cough. It is important to inform the patient
as to the exact procedure; what to expect before, during, and after the procedure; and the likely break-in technique after he or she returns from the operating
room.
2.2. Technique ofinsertion
Catheters are inserted by an experienced surgeon using a strict aseptic technique. It is desirable to have one or two surgeons in a unit undertake all the
catheter-related work to minimize avoidable complications. After a routine
surgical scrub, a lateral transverse abdominal incision is made. The anterior
rectus fascia is incised transversely and the rectus muscle is split longitudinally. The peritoneum is incised with care to avoid injury to the viscera. The
catheter is inserted under direct manipulation and visualization into the deep
pelvis. Placement of the catheter tip in the deep pelvis is aided by grasping
the catheter tip by a sponge-holding forceps and directing the tip deep into
the pelvis, away from the omentum (figure 15-2). The peritoneum is closed
around the catheter in the groove (figure 15-2, marked C) with Dexon
suture. Care is taken to tilt the catheter 45 cephalad to give the intraperitoneal
segment a caudal direction (figure 15-2). The Dacron disk is positioned flat
against the peritoneum surrounded by the rectus muscle. The rectus fascia is
sutured over the cuff. The catheter is brought out through a separate stab hole
through the anterior rectal fascia superior to the transverse incision. Then,
through a short tunnel-directed cephalad (almost the size of the outer diameter
of the catheter), the catheter is brought out superior to the transverse skin
262
incision. The subcutaneous cuff is positioned under the skin at least 2 em from
the exit site. The skin exit should fit the catheter as snugly as possible. Figure
15-2 shows the catheter after implantation. Before the final closure, a titanium
adaptor is attached to the external end of the catheter and a sterile extension
tube is connected with the adaptor. A one-liter, dialysis-solution bag containing 1000 IU of heparin is spiked and the solution is infused and drained
immediately. At least 200 ml of solution should drain within one minute. This
step is necessary to ensure good functioning of the catheter before closure. If
the solution does not flow freely, the catheter is removed from the external
tunnel and repositioned until good function is observed. After the final closure,
the operative site is covered with several layers of gauze dressings. The
position of the intraabdominal segment of catheter is checked by a plain x-ray
of the abdomen.
In the recovery room or in the patient's room, additional one-liter in-andout exchanges of dialysis solutions are performed to check the patency of
the catheter and also to wash out the blood that entered the peritoneal cavity
during surgery.
3. CATHETER BREAK-IN TECHNIQUE
The early leak of dialysis solution into the subcutaneous tissue not only inhibits tissue growth into the cuffs, but also provides a medium for bacterial
growth. In order to prevent early dialysate leaks, the intraabdominal pressure
should remain low during early dialysis (the first 24 hours), except in patients
who are at high risk for leakage; in these patients, dialysis should be delayed
for several days. In high-risk patients, the catheter is irrigated daily with heparinized solution until the day of dialysis. Dialysis solution is medicated with
heparin (500 lUlL) and cephalothin (100 mg/L) for the first few dialysis treatments. To minimize the risk of dialysis solution leak, sufficient time is allowed
for tissue healing in every patient who will be trained for CAPD; thus the
patient is maintained on supine peritoneal dialysis or hemodialysis for a period
of about ten days. During this period, if supine peritoneal dialysis is chosen,
the peritoneal cavity is gradually stretched to accommodate 2-3 liters of dialysis
solution by graded increases of 500 ml in volume.
If a dialysis solution leak occurs around the catheter, it is usually possible
to promote incision healing by lowering the dialysis solution exchange volume,
continuing to carry out dialysis in the supine position, and avoiding activities
that increase intraabdominal pressure such as coughing, straining, weightlifting, etc. Some physicians prefer to manage such patients by hemodialysis
until the peritoneal catheter insertion site is well healed. This way takes one
to two weeks.
4. CARE OF EXIT SITE AND TREATMENT OF EXIT -SITE INFECTION
The exit site is that part of the skin surrounding the catheter. The tunnel is the
pathway of the catheter from the skin through the underlying fat and muscle
263
to the peritoneal cavity. Maintaining a noninfected exit site is an essential part

of successful peritoneal dialysis. A noninfected exit site is one that is clean,
dry, and scab- and crust-free. A normal exit site is painless and not red. Scab
is found following trauma to the exit site when serous discharge dries on it.
This usually falls off after healing. Crust, on the other hand, is a dried drainage or debris at the exit site, usually due to infection. It should be removed
during the cleaning.
Special care of the exit site is essential to prevent infection. Routine exitsite care includes: 1) examining the exit site and tunnel for signs of infection,
2) cleaning the skin to remove dirt and to decrease bacteria, and 3) securing
the catheter to avoid tension and tugging movements. Routine exit-site care
should be performed daily and any time the exit site is red or dirty. Several
methods of exit-site care are currently practiced. The three commonly used
methods are: 1) daily cleaning and leaving the exit site exposed, 2) daily cleaning and topical application of povidone-iodine, or 3) daily cleaning, topical
application of povidone-idoine, and covering the exit site with a sterile gauze.
Problems of the exit site include inflammation and infection. Inflammation
is said to have occurred when there is redness around the exit site. If, in addition to redness, tenderness, pain, hardness, swelling, or drainage is present,
infection is said to have occurred. The therapy for exit-site infection should
include frequent, daily exit-site care. Anyone of the methods of exit-site care
described above is satisfactory. If the infection is severe, care of the exit site
more than once a day may be necessary. Systemic antibiotics are indicated if
exit-site care does not alleviate the infection. The choice of antibiotic depends
on the organism isolated from the exit site and its sensitivity. Antibiotics are
given intravenously or intraperitoneally when patients are unable to take antibiotics orally or the antibiotic selected cannot be given orally. Topical application of antibiotic includes local spraying of powder or injection in and
around the exit site. In the majority of cases, the above measures are adequate
to control exit-site infection. However, in a minority of patients, the infection may be resistant to therapy. With repeated courses of antibiotics followed
by long-term, maintenance therapy, if the infection persists, the next step is removal of the subcutaneous Dacron cuff if it is a double-cuffed catheter. Shaving the superficial cuff is a minor but delicate procedure. It can be done at the
bedside or in an operating room. With appropriate antibiotic coverage and
local anesthesia, the subcutaneous Dacron cuff, if it is not already extruded,
is exposed through a small incision. With the help of fine scissors and/or a
scalpel blade, the Dacron felt is shaved off the catheter, taking care not to
puncture the catheter during the procedure. It is important that the remaining
catheter surface be smooth after cuff removal. If it is rough, it may cause irritation and inflammation of the skin due to the constant friction and pulling
movements at the exit site. As a last measure, the catheter may have to be
removed if the exit-site infection persists. When a catheter is removed because
of persistent exit-site skin infection, ideally it should not be replaced by a new
catheter at the same time, but, after one or two weeks, a new catheter is in-
264
serted at a site opposite the site of the catheter that was removed. In this way,
infection of the new catheter will be avoided. In the mean time, the patient
may have to be maintained on hemodialysis through a subclavian catheter. If
for some reason hemodialysis is not feasible, the catheter may be replaced after
three or four days under the cover of an appropriate antibiotic.
The subcutaneous peritoneal cuff is intended to prevent periluminal propagation of organisms and their entry to the peritoneum, but it remains to
be established whether it achieves this purpose. A prospective clinical study
was undertaken to compare single- and double-cuff Toronto catheters with
respect to their influence on exit-site infection [9]. From February 1983 to
January 1984, alternate patients were assigned to receive a single-cuff or a
double-cuff catheter. All catheters were implanted through the paramedian
approach by the same surgeon. Thirty-seven patients received a single-cuff
catheter, and 38 patients received a double-cuff catheter. For the first two
weeks after catheter insertion, all CAPD patients practiced IPD to prevent
leakage of dialysis solution. The exit site of IPD patients was covered with a
sterile gauze dressing, which was changed twice a week; the exit site of those
on CAPD remained exposed and they had a daily shower. All patients were
assessed monthly. The diagnosis of exit-site infection was made if the skin
around the site was red or covered with crust. Over an average followup of
six months, no significant differences were observed between the two groups
with regards to either early or late catheter-related complications, including
exit-site infection. This study did not demonstrate that the double-cuff peritoneal catheter had any significant advantage over the single-cuff catheter.
Both the incidence of exit-site infection and the response of exit-site infection
to medical therapy were similar. There are several disadvantages to having a
subcutaneous cuff. It needs to be placed accurately at least 2 cm from the exit
site, and even in this position there is no guarantee that cuff extrusion and cuff
infection will not occur. Moreover, exit-site infections will not be observed
exclusively in those with double-cuff catheters. It is possible that the presence
of a second cuff may contribute to the high incidence of infection seen in patients with double-cuff catheters. Until a definitive study showing the advantage of one type of catheter over the other is shown, we recommend the use
of either a single- or a double-cuff catheter. Exit-site infection with drainage
or redness and other signs of inflammation should be treated by local therapy
and systemic antibiotics. If the exit-site infections does not clear within a reasonable time of medical therapy, one should consider replacing the catheter.
5. EXPERIENCE WITH THE TORONTO WESTERN HOSPITAL CATHETER
During the period between January 1, 1981 and December 31, 1985, 312
Toronto Western Hospital catheters (in 80 diabetic and 232 nondiabetic patients) and 32 Tenckhoff catheters were implanted and the probability of
survival of these catheters was calculated. In calculating their survival, all
catheters removed because of outflow obstruction, skin-exit infection, or per-
265
sistent peritonitis were considered as end events. Functioning catheters in

patients who died or were transplanted were considered as lost to follow-up.
For Toronto Western catheters, the cumulative catheter survival rates at the
end of 6, 12, and 24 months were 84%, 70% and 51 % respectively. For the
Tenckhoff catheters, the survival rates at the end of6, 12, and 24 months were
63%, 52%, and 47%, respectively. The survival of the Toronto Western
catheters was marginally better than that of the Tenckhoff catheters. Of the
312 Toronto Western catheters, 150 were single-cuff and the remaining 162
were double-cuff catheters. At 24 months, single-cuff catheters had a significantly longer probability of survival (p < 0.04) when compared to the
survival rate of double-cuff catheters. The survival of catheters implanted in
diabetic and nondiabetic patients was not significantly different.
National CAPD Registry of the National Institute of Health reported in
1987 the results of a survey that attempted to determine the natural history
of implanted peritoneal catheters and to estimate the survival distribution of
different types of catheters [to]. The survey also estimated the frequency of
catheter complications as well as the reasons for catheter removal. Standard
straight (n = 957, 64%) and curled (n = 330, 22%) Tenckhoff catheters, and
Toronto Western Hospital catheters (n = 94, 6%) comprised the majority of
the catheters reported for the survey. The survey did not clearly show major
differences in catheter survival among various types of catheters. The probability of catheter survival at 6, 12, 18, 24, and 36 months for the double-cuff
standard straight Tenckhoff catheter was 80%, 70%, 60%, 51 %, and 33%;
for the standard curled Tenckhoff catheters was 85%, 69%, 51 %, 43%, and
34%; and for the double-cuff Toronto Western catheter was 80%, 70%, 60%,
51 %, and 33%, respectively. Among the different catheters studied, patients
using the Toronto Western Hospital catheter were more likely to claim peritonitis as a reason for catheter removal than patients using the standard-type
catheter. However, no patients using a Toronto Western Hospital catheter
claimed failure to drain as a reason contributing to catheter failure, while a
range of 5% -8% was claimed for the other types of catheters. Exit-site infection requiring catheter removal accounted for no more than 8% of patients
using any type of catheter. This survey also found exit-site infection and peritonitis to be disproportionately distributed among the cuff types. Exit-site
infections were reported in proportionately more patients using single, subcutaneously placed, cuff catheters (13%) than in patients using a double-cuff
catheter (7%). However, peritonitis as a contributing cause for catheter removal was claimed in proportionately fewer patients using a single-cuffcatheter.
Grefberg from Sweden [11] reported in 1984 his comparative experience
with the Tenckhoff and Toronto Western Hospital catheters. Catheters were
randomly selected and both were surgically inserted. Fifty-nine Tenckhoff
catheters were observed for 592 treatment months and 24 Toronto Western
catheters were observed for 220 treatment months. At 18 months, the cumulative lifespan of both catheters were similar - 80%. With regards to com-
266
plications, 11 of the 59 Tenckhoff catheters became obstructed, as opposed

to 1 of 24 Toronto Western catheters. Swedish workers believe this high
incidence of Tenckhoff catheter blockage was due to inexperience and that
this complication would disappear with experience. With regard to exit-site
infection, tunnel abscess, and dialysis leak, there was no difference between
the two groups. Despite the obvious advantages of the Toronto Western catheters, they abandoned their use because laparotomy was needed whenever
the catheter was removed, and the bowel was perforated during the removal
of two Toronto Western catheters.
More recently, Hogg et al. [12] used the Toronto Western catheter with
considerable success in children on long-term CAPD. Six of the Toronto
Western catheters were inserted in children who had previously had either
obstruction or leakage with 1-4 Tenckhoff catheters. Overall, they used 15
Toronto Western Hospital catheters in 12 children and compared the results
of 23 Tenckhoff catheters in nine children. The rate of obstruction with
Toronto Western catheters (7%) was much lower than that with Tenckhoff
catheters (45%).
A retrospective analysis of single- and double-cuff Tenckhoff catheters
and Toronto Western Hospital catheters by Flanigan et al. [13] showed that
drainage failure occurred less frequently with Toronto catheters (9.4%) compared to single-cuff (11.3%) and double-cuff (20.6%) Tenckhoff catheters.
However, in contrast to the experience of most centers with the use of
Toronto Western Hospital catheters, Flanigan et al. observed a significantly
lower survival for Toronto Western Hospital type I catheters. They attributed
the lower survival of Toronto catheters to a higher incidence of unresponsive peritonitis in their patients using such catheters.
6. CATHETER-RELATED COMPLICATIONS
6.1. Complications of catheter insertion
Intraperitoneal hemorrhage and perforation of the viscus are the major complications of catheter insertion. These complications are seen more often when
the catheters are inserted with a closed technique. This problem is easier to
deal with during an open insertion technique when general anesthesia is used.
Usually the site of bleeding is recognized and controlled with adequate hemostasis. Occasionally postoperative intraperitoneal bleeding may occur from
an unsecured blood vessel severed during the procedure. During the course
of catheter insertion, significant bleeding into the abdominal wall may occur
from accidentally severing the inferior epigastric vessels. Therefore it is important for the surgeon to recognize and dissect these vessels out of the way
while the catheter is being inserted.
Intraperitoneal hemorrhage is recognized immediately because of the bloodstained dialysis effluent. Minor bleeding is usually self-limiting and requires
no major intervention. However, when the bleeding is major or the patient
requires significant blood transfusion, exploratory laparotomy is indicated.
267
The risk of viscus perforation is very low during an uncomplicated peritoneal dialysis catheter insertion. However, the risk increases significantly
in patients with intraabdominal adhesions from previous surgery or peritonitis. The most common cause of perforation is advancement of the catheter against resistance into a bowel wall that has been fixed to the parietal
peritoneum by previous adhesions. We have not encountered this complication
using Toronto Western catheters because of the extensive experience of our
surgeon, who has been inserting the catheters for us for the past 15 years.
6.2. Dialysis solution leak
Dialysis solution leak can occur early during the postoperative course or late
after a period of successful CAPD. Also, dialysis solution leak can occur externally or internally. External dialysis solution leak is recognized when clear
dialysis fluid leaks through the catheter insertion wound or from the catheter
exit site. Internal leak occurs when there is infiltration of dialysis solution
into the abdominal wall through a hernial sack or through a weak abdominal
incision. Such a leak is generally recognized as an edematous swelling in the
abdominal wall. Inadequate ultrafiltration is a common presenting complaint
in these patients. The incidence of early dialysis solution leak has been reported to be from 7% to 24%. Early dialysate leak is common when an inappropriate break-in technique is applied immediately after catheter insertion.
Ponce et al. [8] reported an overall incidence of27% early dialysate leak when
Toronto Western catheters were used through midline. After adopting the
lateral placement technique, the incidence of early dialysate leak with the use
of Toronto catheters has been practically eliminated. Also, to minimize early
leaks, the commencement of CAPD is delayed for about 10 to 15 days. Despite the above precautions, there are certain high-risk patients in whom early
leaks have been observed with a higher frequency. The patients at high risk for
early leak are: 1) age over 60 years, 2) patients with poor abdominal muscle
tone, 3) those receiving steroid treatment, 4) those with extensive abdominal
incisions, and 5) patients who have had multiple catheter insertions.
The cause oflate dialysate leak is not clear. It occurs suddenly after patients
have been on successful CAPD for 1-2 years, and both forms of leak may
occur. External leak is easy to recognize, whereas internal leak is recognized
because of poor ultrafiltration volume. The sudden reduction in the volume of
dialysate effiuent and/or sudden and rapid weight gain may give early evidence of internal dialysate leak. When the dialysis solution leaks into the layers
of the abdominal wall, and diffuses evenly throughout, it may be extremely
difficult to differentiate it from abdominal wall edema, which is a part of systemic fluid retention. In such situations, ultrasound and radiographic examinations, including the use of contrast material in the dialysis solution, are of
little value in recognizing the leak. However, computerized tomography aided
by contrast material in the dialysis solution has been successful in identifying
the site and extent of the leak [14]. Managment of late leak usually requires
268
replacement of the catheter or suturing the site where the leak is occurring.
However, one may attempt to seal the leak by discontinuing CAPD and
continuing the patient on supine peritoneal dialysis with low-volume exchanges. Alternatively, peritoneal dialysis may be discontinued altogether
for a period of 15 days, and in the meantime the patients could be maintained
on hemodialysis.
6.3. Poor fluid drainage
Poor drainage is usually due to an obstruction that may affect either inflow or
outflow. Inflow obstruction develops when there is an acute angle along the
course of the catheter. This kink may occur either at the catheter's course
through the abdominal wall or on the free intraperitoneal portion. Outflow
obstruction is generally seen when fibrin or a blood clot is trapped in the catheter lumen and blocks the terminal holes, especially when the dialysis is
complicated by major hemorrhage or peritonitis. Intraluminal catheter obstruction may also be caused by entrapment of tissue, i.e., omentum, in the
catheter lumen. When the catheter tip is placed in the vicinity of an active
omentum, entrapment generally occurs. Such an entrapment complication is
generally seen during the first week after catheter insertion when the omentum, recognizing the catheter as a foreign body, tries to clear it off from the
peritoneal cavity. Through a mechanism that is not entirely clear, with the
passage of time, the catheter becomes more biocompatible with the omentum and such obstructive complications are not usually seen after a successful
CAPD treatment for 1 to 2 weeks. In order to minimize such tissue entrapment, the Toronto Western Hospital catheter is provided with two flat silicone discs, which mechanically keep the omental tissue and bowel away from
the draining holes. In addition, if the catheter tip is placed deep within the
pelvic cavity beyond the reach of the omentum, such a complication can be
avoided. Thus, obstructive complications are reported to be very low with
the use of Toronto Western catheters.
The treatment of poor drainage usually depends on the cause of the problem. Fibrin or blood clots usually require their removal and the addition of
heparin to the dialysis solution. The amount of heparin recommended is 10002000 IU per two-liter exchange. The use of heparin not only reduces the
chance of catheter plugging by fibrin or a blood clot, but also has been observed to minimize subsequent adhesion formaton. If the obstruction persists
despite the addition of heparin, the catheter is forcefully irrigated with the
heparinized saline solution in an attempt to expel the clot or tissue material
stuck in the catheter. We have successfully used, in a few cases, the Italian
corkscrew wire, a soft non traumatic guide wire, to dislodge the clot from
the catheter. The procedure is done under aseptic conditions at the bedside.
If, despite these manuevers, poor drainage persists, the catheter may have
to be replaced. It is very rate to encounter hemorrhagic complications late in
the life of a catheter. Late bleeding into the peritoneal cavity is seen in young
269
women in association with menstruation. However, this degree of hemorrhage does not usually cause obstruction.
Catheter obstruction due to omental trapping is difficult to correct simply
by irrigration. A plain radiographic picture will reveal the catheter tip to be
in its proper position, deep in the pelvis. However, the contrast material injected into the lumen will show negative shadows of tissues in the terminal
portion of the catheter lumen. This condition usually necessitates removal of
the catheter and its replacement by a new one.
Another cause of poor drainage is catheter-tip displacement from the pelvic
cavity. To avoid such a problem, certain preventive measures are taken during catheter insertion (discussed in detail under the section on technique of
catheter insertion). Moreover, the two flat silicone discs provided on the
Toronto Western catheter help to keep the catheter tip deep in the pelvis. As
a result, such complications are reported infrequently with the Toronto
Western hospital catheter.
7. INDICATIONS FOR CATHETER REMOVAL
The need for catheter removal occurs under various conditions. These may
be broadly categorized under two headings: catheter malfunction and complications with a functioning catheter.
7.1. Poorly functioning or nonfunctioning catheter
These problems may be seen under the following conditions: 1) intraluminal

obstruction with blood or a fibrin clot or omental tissue incarceration; the
decision to remove the catheter is usually made only when conservative measures to dislodge the obstruction have failed; 2) catheter-tip migration out of
the pelvis with poor drainage; 3) a kink in the catheter along its course; and 4)
the catheter tip gets caught in a mass of adhesions following severe peritonitis.
In these situations, there are usually both inflow and outflow draining problems.
7.2. Functioning catheter with a complication
Under the following conditions, the catheter may have to be removed: 1)

recurrent peritonitis with no identifiable cause; 2) peritonitis with exit-site
and tunnel infection; 3) a catheter with a persistent exit-site infection; 4) tunnel infection and abscess; 5) late recurrent dialysate leak through the exit site
or into the layers of the abdominal wall; 6) unusual peritonitis, i.e., tuberculosis, fungal, etc.; 7) bowel perforation with multiple-organism peritonitis;
8) severe abdominal pain, either due to the catheter impinging on internal
organs or due to solution inflow; 9) catheter cuff erosion with infection; and
10) an accidental break in the continuity of the catheter.
7.3. Functioning catheter that is no longer needed
This situation is encountered after a successful renal transplantation or CAPD

is discontinued because dialysis is no longer needed or the patient is transferred
to another form of dialysis.
270
REFERENCES
1. Palmer RA, Quinton WE, Gray jR: Prolonged peritoneal dialysis for chronic renal failure.
Lancet 1:700- 702, 1966.
2. Palmer RA, Newell jE, Gray EF, Quinton WE: Treatment of chronic renal failure by prolonged peritoneal dialysis. N Engl j Med 274:248-254, 1966.
3. Gutch DF: Peritoneal dialysis. Trans Am Soc Artif Intern Organs 10:406-407, 1964.
4. McDonald HP, Gerber N, Mishra D, Wolin L, Peng B, Waterhouse K (1968): Subcutaneous
dacron and tefton cloth adjuncts for silastic arteriovenous shunts and peritoneal dialysis
catheters. Trans Am Soc Artiflntern Organs 14:176-180,1968.
5. Tenckhoff H, Schechter H: A bacteriologically safe persistent access device. Trans Am Soc
ArtifIntern Organs 14:181-186,1968.
6. Goldberg EM, Hill W, Kabins S, Levin B: Peritoneal dialysis. Dial Transpl 4:50-56, 1975.
7. Oreopoulos DG, Izatt S, Zellerman G, KaranicoIas S, Mathews RE: A prospective study of
the effectiveness of three permanent peritoneal catheters. Proc Clin Dial Transplant Forum
6:96-100, 1976.
8. Ponce SP, Pierratos A, Izatt S, Mathews R, Khanna R, Zeller man G, Oreopoulos DG: Comparison of the survival and complications of three permanent peritoneal dialysis catheters.
9. Kim D, Burke D, Izatt S, Mathews R, Wu G, Khanna R, Vas S, Oreopoulos DG: Single
or double cuff peritoneal catheters? A prospective comparison. Trans Am Soc Artif Intern
Organs 30:232-235, 1984.
10. Lindblad As, NovakjW, Stablein DM, Cutler Sj, Nolph KD: Report of the National CAPD
Registry of the National Institutes of Health 10:1-8,1987.
11. Grefberg N: Clinical aspects ofCAPD. Scandj Urol and Nephrology S72:7-38, 1983.
12. Hogg Rj, Coin D, Changj, Arant BS, Houser M: The Toronto Western Hospital catheter in
a pediatric dialysis program. Am j Kidney Disease 3:219-223, 1983.
13. Flanigan Mj, Ngheim DD, Schulak jA, Ullrich GE, Freeman RM: The use and complications of three peritoneal dialysis catheter designs: A retrospective analysis. Trans Am Soc
14. Twardowski Zj, Tully Rj, Nochols KW, Sunderrajan S: Computerized tomography (CT) in
the diagnosis of subcutaneous leak sites during CAPD. Perit Dial Bull 4:163-166, 1984.
16. SWAN NECK PERITONEAL DIALYSIS CATHETERS
ZBYLUT J. TWARDOWSKI and RAMESH KHANNA
One of the most important components of the peritoneal dialysis system is

a permanent and trouble-free access to the peritoneal cavity. Today, despite
all the advancements in catheter technology, the Tenckhoff catheter is still
the most widely used catheter [1]. Catheter-related complications such as catheter-tip migration, dialysis solution leak, and exit-site infection are frequently
encountered with the use of Tenckhoff's catheter, mainly due to improper
insertion technique. Overall one-year survival of the peritoneal catheter is
60% - 70% [1]. Catheter exit-site and tunnel infections are frequent in patients
on CAPD and result in increased morbidity, prolonged antibiotic therapy,
recurrent peritonitis, and catheter failure. According to the National CAPD
Registry, 12.41 % of catheters are removed because of exit-site or tunnel infection [1]. No accurate data are available on the morbidity related to catheter
exit-site infection, but according to our experience, infected exit sites require
antibiotic treatment for 2.5% of the catheter life [2].
Based on our past experience, we have designed a catheter that has a reduced incidence of catheter complications. In this view we will describe the
theoretical background of the new catheter design, implantation, and break-in
technique, and the results of our initial experience with the use of this catheter.
1. BACKGROUND OF THE NEW CATHETER DESIGN
1.1. Catheter skin-exit direction
Since Tenckhoff's original recommendation of a downward-pointing exit [3],

little attention has been paid to catheter skin-exit direction. In our retrospecAndreucci. V.E. (cd.), VASCULAR AND PERITONEAL ACCESS FOR DIALYSIS.
271
272
\.
y
Figure 16-1. Exit-site infection with cranial tunnel direction (left). Exit easily contaminated with
down-flowing sweat, water, and dirt. Difficult pus drainage prolongs treatment. Exit-site
infection with downward-directed tunnel (right). Good pus drainage and decreased chances of
superinfection facilitate treatment. Reproduced from Twardowski ZJ et al: The need for a "Swan
Neck" permanently bent, arcuate peritoneal dialysis catheter. Perit Dial Bull 5:219-223, 1985,
with permission.
tive analysis of catheter experience, we found that catheter skin exits directed
downward tended to be infected less often and, when infected, were significantly less resistant to treatment than exits in other directions [2]. Upwardly
directed exits and tunnels facilitate exit contamination by downward-flowing
sweat, water, and dirt on the skin surface (figure 16-1). Whenever the exit is
infected, it tends to be resistant to treatment because of poor outside drainage, and the pus tends to penetrate deep down into the tunnel. Moreover,
immediate postimplantation drainage of necrotic tissue is facilitated by gravity
when the exit is directed downward.
The rationale of gravity helping to prevent and facilitate treatment of infection has similarities in several other clinical conditions: periodontitis, which
may be considered as a biologically occurring "foreign"-body, exit-site infection, more often inflicts the lower incisors because of their "exits" directed
upward [4]; maxillary sinus infection occurs in humans frequently and is resistant to treatment because the ostium maxillare in the upright position of
the body is located at an unfavorable site (at the top of the sinus cavity),
hindering free drainage of secretion, and all of the other body cavities in the
human appear to have evolved more favorably for drainage [5]; and longterm subclavian catheters, which have a downward-directed tunnel, are less
frequently infected at the exit site than those of peritoneal catheters [6, 7].
1.2. Sinus tract length
In a completely healed tunnel, the term sinus tract refers to that part of the
tunnel covered with the epidermis from the exit to the collagen epidermal
interface at the cuff The epidermis covering the sinus tract undergoes a turn-
16. Swan Neck catheters
273
Figure 16-2. Double-cuffed Tenckhoff catheter placed as proposed by Tenckhoff (left). Natural
resilience of the straight catheter ("shape memory") forced into an arcuate tunnel tends to extrude
the external cuff because the deep cuff cannot move (right). Reproduced from Twardowski ZJ
et al: The need for a "Swan Neck" permanently bent, arcuate peritoneal dialysis catheter. Perit
Dial Bull 5:219-223, 1985, with permission.
over that is probably similar to normal epidermis with cell maturation and
desquamation. Desquamated cells, if not expelled, create a favorable milieu
for bacterial growth. With a long sinus tract, the incidence of infection is
higher [8-10]. Therefore, the sinus tract should be as short as possible.
Tenckhoff recommended that the subcutaneous Dacron felt cuff should
be placed immediately beneath the skin exit [11]. Such a location of the cuff,
however, predisposes it to extrusion and infection [12], and thus, the wisdom
of using a superficial cuff is questioned. There are at least three forces that tend
to extrude a cuff from its subcutaneous location: 1) a resilience force of the
silas tic catheter gradually pushing the superficial cuff through the exit, since
the deep cuff cannot move, especially with a short subcutaneous tunnel [11];
2) pulling and tugging on the catheter during its use; and 3) a vector force,
directed to the exterior, created by maturing epidermal basal cells attached to
the cuff velour, which tends to extrude the implant [8]. The rate of implant
migration due to this vector force has been calculated at 1 mm/month in
miniature pigs [8]. This concept was challenged by Tenckhoff, who considered
cuff extrusion as an early phenomenon (within weeks or months), whereas
late extrusions would be more common if a vector force played a role in humans [13]. Contrary to Tenckhoff's experience with intermittent peritoneal
dialysis patients, in CAPD patients, cuff extrusion could be seen even several
years after successful CAPD treatment. The discrepancy between the rapid
extrusion found in animal experiments and the rather slow process in clinical
experience may be related to the higher epidermal turnover rate in animals
compared to humans [14]. The resilience of the straight catheter implanted in
an arcuate tunnel (figure 16-2) undoubtedly plays a major role, but pulling
and tugging on the catheter with frequent CAPD exchanges probably also
274
contributes to this complication. Moreover, the high pressure in the abdomen, along with the constant presence of fluid in the peritoneal cavity while
the patient is ambulatory during CAPD, may also tend to push the external
cuff.
Based on the above mentioned principles and our long experience with the
use of various types of catheter, we recommended, as a compromise, that
the cuff be implanted approximately 2 cm from the exit of fulfil the requirement of not too long a sinus tract in order to prevent infections and not too
short a tract in order to prevent cuff extrusions. Also, resilience forces should
be eliminated with a molded catheter and tugging on the catheter should be
avoided.
The exit should be kept clean of desquamated cells. Some patients are able
to maintain perfectly clean exits by using soap and water. The importance of
a clean exit is supported by the experience with periodontitis, which usually
is a sequela of poor oral hygiene. Interestingly, deep gingival suleuses (> 3
mm) in some individuals are difficult to clean and are more susceptible to
infection [15].
1.3. Material for the external cuff
The external cuff should provide a strong attachment of collagen fibers to

limit epidermal cell spreading [8]. Living materials like cementum, with which
periodontal ligament creates a strong bond [16], is unlikely to be used in the
near future for the external cuff. Poirier et al. [17] evaluated collagen attachment to various materials on their elaborate external seal for the percutaneous
energy transmission systems. The seal is composed of a semirigid polyurethane skirt positioned at the subdermal level and a hollow collar protruding
through the skin. The polyurethane is covered with sintered titanium spheres,
porous polytetrafluoroethylene, and Dacron velour. In experiments on
miniature pigs, the Dacron velour, especially when wetted with saline before
implantation, provided the strongest collagen attachment, with an excellent
inhibition of epidermal down growth. Ogden et al. [18] found a very high rate
of chronic exit-site infections with Right Angle GoreTex catheters. These
catheters are provided with a subcutaneous flange covered with expanded polytetrafluoroethylene and a cuff of the same material. Ten of 17 catheters
developed chronic exit-site infection and seven of them had to be removed
when antibiotics failed to eradicate infections. These results indicated poor
epidermal growth inhibition due to weak collagen attachment. Thus, salinewetted Dacron velour seems to be the best material for the external cuff at
present.
1.4. Double-cuff or single-cuff catheter
Figure 16-3 portrays tissue structures in relation to cuff position. Catheters

with no cuffs were predisposed to pericatheter penetration of bacteria into
the peritoneal cavity and were abandoned after introduction of Tenckhoff
275
- -.... ,-
.:::.-
'--::;:
Figure 16-3. Tissue structures in relation to cuff position in a completely healed tunnel. In
catheters without cuffs, the epidermal and mesothelial cells stop spreading after they meet each
other and a peritoneal fistula is formed. The fibrous tissue ingrown into the cuff inhibits epidermal
and mesothelial cell spreading. A single, deep cuff creates a shallow peritoneal recess and a deep
sinus tract predisposing to exit infection. A single subcutaneous cuff generates a shallow sinus tract
and a deep peritoneal recess predisposing to pseudoherniae. Properly positioned two-cuff catheters
limit the depth of both structures.
catheters . Singl-cuff (only external) catheters were used by Tenckhoff for

acute renal failure. This type of catheter, when used in patients undergoing
chronic intermittent peritoneal dialysis, yielded similar results to those of the
double-cuff catheter; however, with continuous ambulatory peritoneal dialysis, double-cuff catheter survival was better than single-cuff catheter survival
[19]. The major complication of single, subcutaneous, cuff catheters was a
development of pseudoherniae due to high intra abdominal pressure with the
constant presence of fluid in the peritoneal cavity.
Another type of single-cuff catheter is provided with only a deep cuff at the
peritoneal level. This type of catheter came to be used because of problems
with external cuff extrusion and its questionable value in preventing exit-site
infection. A prospective, randomized study showed exit-site infections to be
similar with single- and double-cuff catheters [20]; however, in another survey of catheters, although retrospective, in 395 patients, the tunnel infections
were almost three times more frequent with single-cuff than with double-cuff
catheters [12] . Also, in our experience, exit infections tended to be more
frequent and were significantly more resistant to treatment with single-cuff
catheters compared to double-cuff ones [2]. The discrepancy in the results
reported may in part be due to the length of the sinus tract with different implantation techniques. A longer sinus tract is to be expected with a single,
deep, cuff catheter. If sinus tract sizes (from the cuff to the skin exit) are alike,
the incidence of exit infections should be similar irrespective of which cuff
limits the tract (figure 16-4).
1.5. Catheter tip migration
One-way or two-way catheter obstruction is usually the result of catheter

wrapping by the omentum. The best conditions for dialysate drainage are
created with the catheter tip in the true pelvis because, in the majority of people, the omentum does not reach the true pelvis. Tenckhoff recommended
276
SHORT SINUS TRACT
LONG SINUS TRACT
Figure 16-4. Sinus tract length with various implantation techniques of single- and double-cuff
catheters. A single, "subcutaneous," cuff catheter (lower center) may be associated with a longer
sinus tract than a single, deep, cuff catheter (upper right).
a caudal direction of the intraperitoneal catheter segment to prevent cathetertip migration out of the true pelvis [11]. We found that when a catheter was
implanted with a straight subcutaneous tunnel, with the external exit directed
downward and the intraperitoneal entrance directed upward, even if catheter
tip was placed in the true pelvis, it migrated out to the upper abdomen significantly more frequently when compared to the opposite tunnel direction [2].
Figures 16-5 and 16-6 illustrate the influence of silastic resilience forces on
catheter-tip translocation. To avoid the unfavorable influence of resilience
forces on the intraabdominal catheter segment, the catheter needs to be molded
in the shape in which it is to be implanted in the body.
1.6. Tissue reaction to a skin-penetrating foreign body
The tissue reaction begins immediately after a break in the integument occurs.
Bleeding from capillaries and body fluids form a coagulum of clot and cellular
debris. Polymorphonuclear leuckocytes phagocytize local bacteria and, together with the coagulum, form a scab. Healing of the wound starts with the
production, beneath the scab, of granulation tissue composed of new vessels
and fibroblasts. There is a peripheral ingrowth of new epithelial cells upon
this tissue. These cells stop spreading over the granulation tissue only if they
meet cells from the opposite shore (marsupialization) or encounter collagen
fibers attached to the foreign body, (Dacron cuff in the case of the peritoneal
catheter), thus, creating a sinus tract [8], an interrelationship is produced that
is similar to that seen between the tooth and the gingival epithelium. The tooth
is the only natural "foreign" body penetrating through the epithelium in
humans. The peridental membrane (alveolar periosteum), a vascular fibrous
tissue, is firmly attached to the cementum (substantia os sea) of the tooth.
Squamous epithelium covering the gum penetrates only to the level of attachment between the peridental membrane and the cementum. The resulting
gingival sulcus is only 1-3 mm deep [21]. However, the collagen fibers do
not attach to the smooth surface of the silicone rubber, the material from
277
Reversible
Catheter Tip Malposition
Placement
y
CR = Catheter Re.mence
DCP =Deacendlng Colon Peristalsis
Figure 16-5. Forces responsible for catheter-tip migration out of the true pelvis. Potentially
reversible catheter-tip migration with right downward external exit (intraperitoneal entrance
directed left upward). The catheter resilience may translocate the tip to the left upper abdomen,
but descending colon peristalsis may restore the proper position of the tip before it is wrapped by
the omentum.
Placement
..
Permanent
Catheter Tip Malposition
\.
" ..- ,', I

','
,~~,
IIII,,~
CR
y
,I
""......-:.::,-:.'..,
y
CR
ACP
=Catheter Ream_
=A_ndlng Colon Peristalsis
Figure 16-6. Usually permanent catheter-tip migration with left downward external exit (intraperitoneal entrance directed right upward). Both forces of catheter resilience and ascending colon
peristalsis may permanently translocate the tip to the right upper abdomen with subsequent
omental wrapping.
278
which peritoneal dialysis catheters are made, but they grow in and attach
to the rough surface of Dacron and nylon velour or of porous poly tetrafluoroethylene [9].
1. 7. Factors influencing early infection and prolonged healing
Part of coagulum is absorbed and part of it, along with necrotic tissue, is
gradually drained out from the tunnel. The tunnel should be big enough to
allow free drainage of necrotic tissue and to prevent pressure necrosis with
skin sloughing. On the other hand, too large a tunnel prolongs healing because of the shear volume of repair needed and the movements it would allow
a loose tubing to undergo in the tunnel. Mechanical stresses slow the healing
process. [10]. Thus, to promote unhindered healing, the catheter should be
firmly anchored in the tunnel and should be well-immobilized outside the
tunnel, especially during the break-in period.
Antibiotic penetration into the coagulum is poor, therefore antibiotics
should be present in sufficient concentration in the blood and tissue fluids
before the coagulum is formed. This may be achieved if antibiotics are given
prior to implantation.
Epidermal cells grow over the granulation tissue beneath the scab. If the
scab is forcibly removed during cleansing, the epidermal layer is broken, thus
prolonging the process of epidermization. We feel that the healing process is
complete when the epidermis reaches the collagen attachment.
To reconcile all the requirements for an ideal catheter, we designed new
catheters, Swan Neck catheters, which feature most of the principles discussed above. In addition, we are recommending some guidelines for insertion, break-in, and exit care of these catheters.
2. SWAN NECK CATHETER DESIGN
The distinguishing feature of Swan Neck peritoneal dialysis catheters is the

molded bend between the two cuffs. As a result of this design, catheters can
be placed in an arcuate tunnel in an unstressed condition, with both the external and internal segments of the tunnel directed downward [22]. A permanent bend between the cuffs eliminates the silas tic resilience force or the
"shape memory," which tends to extrude the external cuff (figure 16-7).
As reported previously, Swan Neck catheter prototypes, made from 80 arc
angle tubing and provided with 8.5-cm spaced cuffs, decreased catheter migration and leak rates but, due to an insufficient bend and too long a distance
between the cuffs, did not eliminate resilience forces completely, resulting
in external cuff extrusions [23, 24]. Based on this observation, the catheters
were modified; the new catheters, Swan Neck 2, were made from 170 arc
angle tubing and the distance between the cuffs was shortened to 5 cm.
2.1. Swan Neck Toronto-2 catheter
The Toronto type of the Swan Neck catheter, a modification of the Toronto
Western Hospital (TWH) catheter [25-27] has a flange and bead circumfer-
279
Figure 16-7. Straight and Swan Neck catheters in arcuate tunnels. Upper panel shows catheter
configuration immediately after implantation; lower panel portrays catheter shape several months
later. Straight catheters forced into arcuate tunnels gradually assume natural, straight configuration. Single-cuff catheters do not extrude cuffs. With a long distance between cuffs and a shallow
subcutaneous tunnel, the external cuff extrusion is inevitable (center), whereas a short distance
between cuffs and a deep position of the subcutaneous cuff precludes its extrusion. Swan Neck
catheter maintains its shape.
entially surrounding the catheter just below the internal cuff. Unlike the TWH
catheter, the flange and bead are slanted approximately 45 relative to the axis
of the catheter (figure 16-8). When the slanted flange is positioned flat against
the posterior rectus sheath, the desired direction of the catheter is maintained
within the abdominal wall, with the intraperitoneal portion pointing in the
desired caudal direction within the peritoneal cavity. Like TWH catheters,
these catheters are also provided with two intraperitoneal discs.
2.2. Swan Neck Missouri-2 catheter
The Missouri catheter is identical to the Swan Neck Toronto catheter, with
the exception that it is not provided with the intraperitoneal discs (figure
16-9).
2.3. Swan Neck Tenckhoff-2 Catheter
The Tenckhoff type of the Swan Neck peritoneal dialysis catheter is provided
with two Dacron cuffs. It differs from the double-cuff Tenckhoff catheter
only by being permanently bent between the cuffs (figure 16-10). This type
of catheter may be inserted at the bedside and does not require surgical insertion; however, a subcutaneous tunnel has to be created in the same way as for
other Swan Neck catheters (see below).
2.4. Radiopaque stripe
The slanted flange and bead, and the bent tunnel segment require that the
Swan Neck Missouri and Toronto catheters for right and left tunnels be mir-
280
Left
Right
Intornal
Cull
~
,.'
i:iing.---BOld
nn
StenCils lor Skin Markings
!!!i!!!
Loft
G.CUlfPO 0
o-Skln Exll
Figure 16-8. Swan Neck Toronto 2 catheters with two intraperitoneal discs, slanted flange and
bead, and bent intercuff segment. A radiopaque stripe in front of the catheter helps to avoid
confusion regarding the right and left catheters. The designations riJ?ht and leji refer to the position
of the tunnel relative to the intraperitoneal entrance rather than to the side of the body. Stencils for
skin markings reflect precisely the shapes of the catheters. Reproduced from Twardowski ZJ et al:
Swan Neck peritoneal dialysis catheters - Design, features, sterilizing, insertion and break-in.
Accurate Surgical Instruments Corp., 588-590 Richmond St. W .. Toronto. Ontario, Canada,
1986, with permission.
Left
Right
~
Fiiiig.----
Internal
Cull
Bold
nn
'r
q
Stonclll lor Skin Marklngl
!!!I!!!
Loft
UlfPO
o-Sldn Exit
Figure 16-9. Swan Neck Missouri 2 catheters without intraperitoneal discs, otherwise identical
to the Swan Neck Toronto 2 catheters. Reproduced with permission, see figure 16-8.
Right
281
Left
Stencil. for Sldn .orld....
!!!I!!!
!:!!!
D~
OSIlln Ex"
Figure 16-10. Swan Neck Tenckhoff2 catheters with right and left bend. Radiopaque stripe is in
the front of the catheter. Stencils for skin markings are also shown. Reproduced with permission,
see figure 16-8.
ror images of each other. To facilitate recognition of right and left Toronto
and Missouri catheters, each tubing has a radiopaque stripe in front of the
catheter (figures 16-8 and 16-9). The stripe is also useful during insertion
and postimplantation care, facilitating recognition of catheter twisting. Because of this last feature, Tenckhoff-type catheters are also provided with
the stripe. Right and left Swan Neck Tenckhoff catheters differ only with respect to the position of the stripe (figure 16-10). Unlike Swan Neck Toronto
and Missouri catheters, the Swan Neck Tenckhoff catheter, intended for
either the right or the left tunnel, may be implanted in an opposite tunnel. In
this case, the stripe should be kept in back of the catheter. Nevertheless, to
retain uniformity of the stripe position, it is recommended that Swan Neck
Tenckhoff catheters be inserted in the corresponding tunnel direction (right
tunnel with right catheter, left tunnel with left catheter).
2.5. Stencil
The catheter must be implanted with its shape undistorted. If catheters are not
implanted properly, no advantage will result from their use, rather worse
results may be expected. For instance, if the right Missouri catheter were to
be implanted with the left tunnel, the catheter tip would almost inevitably migrate out of the true pelvis because of unfavorable resilience forces. If the
tunnel is too short, the external cuff will inevitably extrude out of the skin
exit or the catheter will kink in the tunnel, causing obstruction.
To facilitate the creation of a proper tunnel during surgery, stencils have
been developed for skin markings before surgery. Stencils reproduce exactly
the shapes of Swan Neck catheters (figures 16-8 to 16-10).
282
Figure 16-11. Examples of stencil sites for Swan Neck catheter placement in a lean person.
Stencils show n are for catheters: 1 = right Missouri 2 inserted through the right rectus muscle; 2 =
left Missouri 2 inserted through the left rectus muscle; 3 = left Tenckhoff2 inserted through th e
midline; 4 = left Missouri inserted through the right rectus muscle with the left til/mel. Exists sites
are at least 2 cm away from the belt line. Reproduced with permission, see figure 16-8.
3. SWAN NECK MISSOURI AND TORONTO

CATHETER IMPLANT A TION TECHNIQUE
3.1. Preinsertion catheter preparation
The catheters are delivered from the manufacturer in nonsterile plastic bags.
To avoid contamination, the catheters should never be touched with bare
hands. The catheters are carefully withdrawn from the package, washed, drip
dried, further dried on lint-free towels, inserted into labeled peel packs, and
then sterilized at 270F (132C) for six minutes at 30 PSI (2.11 kg/cm 2 ) and
dried at 270F for 20 minutes.
Immediately before implantation, the catheter is removed from the sterile
peel pack and immersed in sterile saline. Both the Dacron cuffs and the flange
are gently squeezed to remove air. When air is removed, the catheter sinks.
Thoroughly wetted cuffs provide markedly better tissue ingrowth compared
to unwetted, air-containing cuffs.
3.2. Preinsertion patient preparation
Usually one day prior to surgery, the belt line of the patient is identified, preferably in a sitting or standing position, with slacks and belt as they are
usually worn. Depending on the size and shape of the abdomen, the presence
of previous scars, and taking into account the patient's preference, the tunnel
is marked using the stencil in such a way that the exit hole is to be created at
least 2 cm from the belt line, the catheter will not be subjected to excessive
motion with the patient's activities, and there will be no pressure on the tunnel when the patient bends forward (figure 16-11). Skin markings may be
made with any good surgical marker. We found the Devon surgical marker
very resistant to washing. Men usually prefer a belt line below the umbilicus,
283
Figure 16-12. Examples of stencil sites for Swan Neck catheter placement in obese persons. The
belt line may be either below the skin fold (usually in men) or high above the umbilicus (usually in
women). Stencils are for catheters: 5 = left Missouri 2; 6 = right Missouri 2; 7 = left Tenckhoff2.
Reproduced with permission, see figure 16-8.
and there may not be enough space below the belt line; therefore, a stencil is
frequently marked above the belt line in male patients. Women usually wear
a belt above the umbilicus, hence stencils are marked below the belt line in
female patients. In obese people with pendulous abdomens, it is mandatory
to insert the catheter above the skin fold (figure 16-12).
One gram of vancomycin is given in slow intravenous infusion one day
prior to surgery. Prior to operation, the patient should empty the bladder.
Tap-water enemas are also required in most patients.
General anesthesia is avoided, if possible, because it predisposes patients to
vomiting and constipation, and requires voluntary coughing during the postoperative period as a part of pulmonary atelectasis prevention; coughing,
vomiting, and straining markedly increase intraabdominal pressure and predispose patients to abdominal leaks. Patients frequently receive 5 to 20 mg of
diazepam intravenously during catheter placement to aid in relaxation.
3.3. Surgical technique
The surgical preparation of the abdominal wall consists of a threefold scrub

with Betadine suds and threefold paintings with Betadine alcohol solution.
Skin markings are usually very faint after surgical preparation and require
remarking with sterile 5% brilliant green in ethanol. Finally, the abdomen
is covered with a sterile, transparent surgical tape. The skin and subcutaneous
tissue of the tunnel are anesthetized with 1 % lidocaine. A 3-4 cm transverse
incision is made through the tape, skin, and the subcutaneous tissue. A perfect
hemostasis, preferably using cauterization, is mandatory. Then an incision is
made in the anterior rectus sheath and the rectus muscle fibers are dissected
284
II. Peritoneal access for dial ysis
I ':~:::~ ,-"
-". ~
Ant. Rectus- -I-"'-+
Parietal Peritoneum
Sheath
f ' t - - -- - Flange Suture
1iI"".......- - -Purse String
---
I+- - -Sead
Figure 16-13. Missouri catheter after impl antation (left). Details of flange and bead anchoring
(right). Purse string through the posterior rectus sheath, transversalis fascia , and the peritoneum is
tightened between the flang e and bead. Two of the sutures (at twelve and six o ' clock) anchoring
the flange to the posterior rectus sheath and transversalis fascia are also shown. Reproduced with
permission, see figure 16-8.
bluntly in the direction of the fibers down to the posterior rectus sheath. More
anesthesia may be required during muscle fiber dissection. A purse-string
suture is placed through the posterior rectus sheath, transversalis fascia, and
the peritoneum. A 5 mm incision reaching the peritoneal cavity is made with
a scalpel. Care is used to protect the viscera from injury during this maneuver.
The catheter is threaded on a stiffening stylet and introduced deep into the
true pelvis. Only a straight stiffening stylet is used, because a curved one tends
to pull the catheter tip into the upper abdomen during its removal. The patient may feel some pressure on the bladder or rectum. The radiopaque stripe is
kept facing up. The stylet is removed, and then a 50 ml syringe containing
sterile saline is attached to the catheter and the saline is injected into the peritoneal cavity. If the solution flows freely, the bead is placed in the peritoneal
cavity, the flange on the posterior rectus sheath, and the purse string is tightened between them. The flange is sewn into the posterior rectus sheath with
four sutures at twelve, nine, six, and three o'clock (figure 16-13).
3.4. Creation of subcutaneous tunnel
The catheter tunnel extending from the cuff to the skin exit should have a
diameter close to that of the catheter tubing. If the tunnel is too tight, it will
not allow free drainage of necrotic tissue and may cause pressure necrosis with
skin sloughing. On the other hand, a large tunnel prolongs healing relative to
the volume of tissue repair required and allows movement of the catheter
within the tunnel. This mechanical stress further delays the healing process.
Thus, the last portion of the tunnel (from the external cuff to the exit) should
285
be made with a trocar of external diameter similar to that of the catheter tubing.
A superior subcutaneous pocket is made to the level of the skin markings
to accommodate the bent portion of the catheter. The area between the subcutaneous pocket and the skin exit is anesthetized, and the pocket is extended
by blunt probing with the hemostat up to the point where the external cuff
will lodge. A small stab wound is made in the anterior rectus sheath above
the transverse incision. The catheter is grasped with the hemostat and pulled
through the wound. The transverse incision in the anterior rectus sheath is
sewn. The bent portion of the catheter is positioned carefully in the subcutaneous pocket. A trocar is attached to the catheter and directed through the
exit site. The external cuff is positioned about 2 cm from the skin surface.
Care is taken to keep the stripe facing forwards. Figure 16-13 shows the catheter after implantation.
3.5. Catheter patency testing and postoperative care
A titanium adapter is attached to the catheter and a sterile extension tube is

connected to the adapter. A one-liter bag of sterile saline containing 1000 units
of heparin is spiked via the extension tubing and the solution is infused and
drained immediately. At least 200 ml of solution should drain within one
minute. If good flow is obtained, the skin incision is closed with absorbable
subcuticular sutures. The operative site is covered with several layers of gauze
dressings and secured with microfoam surgical tape. Care is taken to keep the
stripe facing the front.
The position of the catheter is checked by a plain x-ray of the abdomen and
the patient is sent to the ward. The catheter is anchored with several layers of
microfoam tape and the dressing is to be left in place for a week. Additional
in-and-out, one-liter exchanges are performed to check the patency of the
catheter, and to remove residual blood from the peritoneal cavity, if present.
The exchanges are continued until the dialysate is clear. If the position of the
catheter is not in the true pelvis, even if the catheter is not functioning, no correction of the position is attempted. Due to favorable resilience forces, the
catheter translocates spontaneously into the true pelvis within a few days.
Failure to translocate would require surgical catheter repositioning; however,
we have not experienced such an event with Swan Neck catheters. Drainage is
usually slow 150 mllmin) if the catheter is not in the true pelvis. If the
catheter is not functioning, the patient is maintained on hemodialysis, if urgent
dialysis is required. If the catheter tip is in the true pelvis but the catheter does
not function for 2-3 days, omental wrapping is most likely to have occurred
and omentectomy is required. Analgesics with constipating side effects (opiates)
should be avoided in the postoperative period.
3.6. Catheter break-in and catheter care
Ambulatory peritoneal dialysis is delayed for at least ten days after the implantation. If the catheter is functioning, peritoneal dialysis in the supine posi-
286
tion is usually started immediately after in-and-out exchanges are completed.

One-liter volumes of dialysis solutions are used for the first supine peritoneal
dialysis. The usual cycler settings are: 10 minutes inflow, 10 minutes dwell,
and 12 minutes outflow. The outflow time may be prolonged to 15 minutes
in the case of slow drainage. Each liter of dialysis solution contains 1000 units
of heparin. In spite of clear dialysate in postimplantation washouts, the dialysate is usually blood tinged during the first cycler dialysis.
The surgical dressing is removed after one week. Care is taken to avoid
catheter pulling or twisting. The exit and skin surrounding the catheter are
cleansed with povidone-iodine scrub, rinsed with sterile water, patted dry
with sterile gauze, covered with several layers of gauze dressings, and secured
with micro foam surgical tape. The dressing is changed after another week.
The patient may start CAPD ten days postoperatively. Weekly dressing changes
are continued until the healing process is completed. There are no data in humans with respect to the time needed for the firm fibrous tissue ingrowth into
the cuff and completion of sinus tract formation. We assume that it may take
up to six weeks. The patient may shower only before the dressing change and
otherwise must take sponge baths.
Good catheter protection from mechanical stress seems to be extremely
important, especially during break-in. The catheters should be anchored in
such a way that the patient's movements are only minimally transmitted to
the exit. The method of catheter immobilization is individualized, depending
on the exit location and the shape of the abdomen. We think that better exit
protection prevents infections in most patients.
Late care, after the healing process is completed, seems to be easier. The
results of a prospective study [28] indicate that cleaning with soap and water
is the least expensive type of cleaning and tends to prevent infections better
than povidone-iodine painting and hydrogen-peroxide cleaning.
4. EXPERIENCE WITH SWAN NECK MISSOURI-2 CATHETERS
At the University of Missouri, Columbia, between April 1, 1986 and April

30, 1987, exclusively 23 Swan Neck Missouri-2 catheters were implanted and
cared for by the technique described above. Survival and complications were
monitored prospectively. The prospectively collected data with the Swan
Neck Missouri-2 catheters and the Swan Neck catheter prototypes (used between August 1985 and March 1986), and retrospectively collected data with
Tenckhoff and Toronto Western Hospital catheters were compared [29]. The
survival and complications observed with these catheters are described in table
16-1.
One-year catheter survival tended to be higher for Missouri-2 catheters
compared to other types. Up to one year followup, cuff extrusion, a major
problem with the Swan Neck prototype catheters, did not occur with Missouri2 catheters, and the improvement was significantly better than with the Swan
Neck prototypes and other catheters. Leaks and tip migrations occurred in-
287
Table 16-1. Catheter complications and survival
Number of catheters
Double-cuff catheters
Days at risk
Exits ever infected (%)
Number of tunnel infections
Pericatheter leaks
Permanent obstruction
Cuff extrusions
Survival at 12 months (%)
1-Swan Neck
Missouri 2
2-Swan Neck
Prototypes
3-0thers
P1
vs. 2
P1
vs.3
P2
vs.3
23
23
4295
10 (43)
0
0
P
0
95
22
22
7164
13 (59)
3
1
0
5
79
83
46
48,325
42 (51) ns
12
0.07
8
ns
12
ns
7
0.02
79
ns
ns
0.06
ns
ns
0.05
ns
ns
ns
ns
OJ)6
ns
ns
'Catheter tip in the true pelvis (see text).
frequently with both Swan Neck Missouri-2 and prototype catheters. Only
one Missouri-2 catheter was permanently obstructed; however, the catheter
was wrapped by the very active omentum in the true pelvis, not in the upper
abdomen. This catheter was replaced by a second catheter, which also was
wrapped by the omentum in the true pelvis. Finally, function in this catheter
was restored only after omentectomy. Obstruction due to omental wrapping
is unavoidable in patients with long, aggressive omentum reaching to the true
pelvis and requires omentectomy. Fortunately, according to our experience,
less than 3% of patients, usually lean, young men, present such a problem.
Although not significantly different from other catheters because of low
numbers, exit-site infections tended to be less frequent with Missouri-2 catheters. Significantly, no tunnel infection was seen with Missouri-2 catheters.
Despite the short observation period, the results with the Swan Neck Missouri2 catheters are very enouraging. Four major catheter complications were virtually eliminated: external cuff extrusion, catheter-tip migration, pericatheter
leaks, and tunnel infections. Low complication rates with Swan Neck catheters
have been confirmed by others [30].
In summary, favorable Swan Neck Missouri-2 catheter survival at one year
(95 %) and extremely low complication rates seem to confirm the theoretical
expectations. Silicone rubber is a biocompatible and satisfactory material for
the tubing. The ingrowth of fibrous tissue into the Dacron cuff seems to be
sufficient to limit the down growth of the epidermis by collagen inhibition.
However, exit infection rates are unsatisfactory. Improvements in the catheter care, as described above, have been instituted and are expected to further
lower infectious complications.
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Schroeder HE, Page RC: The normal periodontium. In: Schluger S, Youdelis RA, Page RC
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Poirier VL, Daly BDT, Dasse KA, Haudenschild CC, Fine RE: Elimination of tunnel infection. In: Maher JE, Winchester JF (eds) Frontiers in Peritoneal Dialysis. Proceedings of the
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Ogden DA, Benavente G, Wheeler D, Zukoski CF: Experience with the Right Angle GoreTex peritoneal dialysis catheter. In: Khanna R et al (eds) Advances in Continuous Ambulatory Peritoneal Dialysis. Toronto: Peritoneal Dialysis Bulletin, 1986, pp 155-159.
Diaz-Buxo JA, Geissinger WT: Single cuff versus double cuff Tenckhoff catheter. Perit Dial
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Twardowski ZJ, Nichols WK, Khanna R, Nolph KD: Swan Neck peritoneal dialysis catheters - Design, features, sterilizing, insertion and break-in. Instruction manual published
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25. Khanna R, Izatt S, Burke D, Mathews R, Vas S, Oreopoulos DG: Experience with the Toronto Western Hospital permanent peritoneal catheter. Perit Dial Bull 4:95-98, 1984.
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the effectiveness of three permanent peritoneal catheters. Proc Clin Dial Transplant Forum
6:96-100, 1976.
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LM: A randomized prospective evaluation of three peritoneal exit site procedures. Abstracts
of the IVth Congress of the International Society for Peritoneal Dialysis. Venice, Italy, June
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30. Bozkurt F, Keller E., Schollmeyer P: Swan Neck peritoneal dialysis catheter can reduce
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17. THE CHOICE OF ACCESS FOR LONG-TERM

PERITONEAL DIALYSIS
MICHAEL]. FLANIGAN
Long-term peritoneal dialysis depends upon sterile technique and a safe dialysis access. Early authors performed continuous flow peritoneal dialysis using
two catheters placed either surgically or by trocar [1]. These cannula consisted
of a variety of instruments, including metal needles, gall-bladder trocars,
Foley catheters, whistle-tip catheters, stainless-steel surgical sump drains, and
brass tubing [2]. Grollman's 1951 demonstration that a single, repetitively
placed cannula combined with sterile dialysate could maintain anephric dogs
for up to 69 days prompted further human evaluation of peritoneal lavage [3].
While Grollman et al. [3] and Fine et al. [4] demonstrated that a sterile
dialysis system was necessary for successful dialysis, it was the commercial
availability of dialysate and nylon catheter/trocar sets that permitted widespread
use of peritoneal dialysis [5, 6]. Subsequent descriptions of peritoneal dialysis
kinetics [7], inspired Gutch et al. [8], Merrill et al. [9], Barry et al. [10], and
Boen et al. [11, 12] to investigate peritoneal dialysis in patients with irreversable kidney failure.
Unfortunately, the need for repetitive abdominal punctures made dialysis
inconvenient, uncomfortable, and dangerous. Thus Gutch began leaving
catheters in place for protracted time periods [13]. These cannulae were stiff,
uncomfortable, and limited patient mobility. In 1962, Teflon-fiberglass mesh
and Teflon-nylon (subsequently steel-reinforced silas tic) transabdominal conduits designed to simplify repetitive peritoneal cannulation were described [9,
11]. Unfortunately, infection and/or fibrosis caused these surgically implanted
291
292
conduits to fail following 1 to 12 weeks of use [14]. These conduits were not
superior to prior indwelling cannulae, which functioned for eight weeks and
longer before failing because of obstruction [13].
In 1964, Gutch [13] addressed the problem of catheter obstruction, noting
that silastic catheters reduced the incidence of obstruction from that noted
with polyvinyl chloride catheters and that silas tic catheters reduced protein
exudation into dialysate. Palmer et al. [6] then employed silastic in designing a
catheter with a triflanged fascial seal to prevent dialysate leakage and a long
subcutaneous tunnel to impede bacterial migration into the peritoneum. A
1966 report described the use of these cannula in ten patients and noted the
occurrence of peritonitis in seven individuals, five tunnel infections, and five
pericannula dialysate leaks [15]. Heal et al. [16] confirmed these findings, and
prompted Tenckhoff and Schechter [17] to undertake design of "a bacteriologically safe peritoneal access device. " This catheter would be combined with
a closed sterile fluid path to eliminate infection without continuous antibiotic
administration or repeated abdominal puncture. Since Dacron was known to
incite extensive tissue reaction and fibroblast growth, Dacron felt cuffs were
afixed to the cannula. These cuffs sealed the sinus tract and prevented total
epithelialization of the catheter tunnel. This fibrous interruption of the sinus
tract would eliminate dialysate leaks and bacterial migration from the skin into
the peritoneum while preventing catheter dislodgement. A second superficial
cuff was added to stabilize the catheter and prevent skin trauma at the exit site.
Only 2 of 6 patients using this cannula developed peritonitis, and there were
no episodes of dialysate leakage or tunnel infection.
1. IMPORTANCE OF THE DIALYSIS ACCESS
The dialysis catheter is pivotal to the success of a peritoneal dialysis program.

In our center, 23% of patients who begin home training eventually transfer to
hemodialysis because of access complications. Nissenson et al. [18] reported
that 56% of patients abandoning CAPD do so because of peritonitis or exitsite/tunnel infections. Gokal et al. [19] similarly documented that 60% of
patients transferring to hemodialysis do so because of peritonitis or other
catheter complications. Gloor et al. [20] proposed that access complications
are the major reason for discontinuing peritoneal dialysis and that registry
data seriously underestimate the magnitude of these complications, because
1 in 10 patients beginning CAPD withdraw from training because of an access
complication [20, 21]. Equally disturbing results were obtained by pediatric
programs where unresolving peritonitis and exit-site infections are the major
causes of catheter removal and median catheter survival is only 24 months
[22-24].
2. EARLY EXPERIENCE WITH THE TENCKHOFF CATHETER
Brewer et al. [25], Lankish et al. [26], Rae and Pendray [27], and Heal et al.
[16] described the use of 203 "Tenckhoff-like" catheters in 164 patients. Only
17. Choice of access for dialysis
293
57 episodes of peritonitis were identified in these 164 patients, confirming the

desired resistance to peritonitis. In general, the incidence of exit-site/tunnel
infection requiring catheter removal was approximately 6%, and dialysate
leakage was rare. The leading cause of catheter failure was poor dialysate
drainage or catheter obstruction, which occurred in 13% -24% of the patients
undergoing percutaneous catheter placement.
3. MODIFICATIONS TO PREVENT DRAINAGE FAILURE
The complications of peritoneal dialysis are frequent and are readily identified
[28] (table 17-1). During the first month of dialysis, catheter losses are
disproportionately common. Seventy-five percent of these early (within 30
days of placement) catheter removals are the result of poor dialysate drainage
[29] (figure 17-1). It was inevitable that catheter modifications would be
proposed to resolve this problem. Goldberg et al. [30] recognized that "oneway" obstruction was the result of omental wrapping about the catheter
and designed a cannula that would sink to the pelvis when its distal balloon
was filled with saline. Goldberg also championed the advantages of surgical
catheter placement through a muscle-splitting incision and the need for sterile
technique to prevent peritonitis. Goldberg's catheter was reportedly used in 50
patients without drainage failure, and during a 24-month observation period
only 10% of the catheters were removed to permit resolution of infection [30].
Goldberg's design was followed by the introduction of the less complex
Oreopoulos-Zellerman cannula with its internal discs designed to prevent
catheter migration [31]. Unlike Goldberg's catheter, this cannula required
surgical insertion. Further refinements of the Oreopoulos-Zellerman catheter
have shortened the subcutaneous catheter segment and enlarged the internal
Dacron barrier to simplify surgical insertion and to reduce the incidence of
postoperative complications.
Table 17-1. Peritoneal dialysis catheter complications
EARLY
Placement risks
Failure to entcr peritoneum
Perforation of viscus
Bleeding
Catheter dysfunction
Inflow failure
Inadequate drainage
Pericathcter leak
Postoperative infection
LATE
Infectious
Peritonitis
Tunnell exit site
Pericatheter leaklhernia
Toxic-mechanical injury to the viscera
294
C1
A
T
H
E
T
E
R
S
U
R
V
I
(3)
V
A
L
"
12
18
24
3B
36
42
4B
54
MONTHS POST PLACEMENT
Figure 17-1. Peritoneal dialysis catheter survival at the author's institution (total catheters
= 195). Access complications are common, especially in the early postoperative period. This
graph represents the time, in months, between catheter insertion and the subsequent replacement
of any inadequately functioning catheter. Early (within 30 days of placement) catheter losses were
extremely common and resulted in the removal of 19% of the catheters placed. Following this
early post-operative period, the risk of catheter loss falls remarkably to 25% per annum. From:
Flanigan M, Ngheim DD, Schulak JA, Ullrich GE, Freeman RM: The use and complications
of three peritoneal dialysis catheter designs. Trans Am Soc Artif Intern Organs 10:33-38, 1987,
with permision.
Other cannulae with intraperitoneal modifications designed to eliminate

drainage failure have been introduced. Unique among these is the column-disc
or Lifecath access [32]. The peritoneum is a potential space with pressures 20
mmHg above atmospheric, thus any transabdominal fluid conduit should
drain the peritoneum unless the conduit is obstructed. Omental and mesenteric
wrapping of the inlet ports, and not catheter position, cause one-way catheter
obstruction. In an effort to prevent outflow obstruction, Ash [32, 33] designed
a catheter whose inlet port is fixed to the anterior abdominal wall. The large
size of the intake manifold minimizes Bernoulli forces and subsequent omental
movement toward the catheter's drainage port. The success of this device
when it is placed distant from intraabdominal adhesions attests to the importance of avoiding catheter entanglement by omental tissues [32-33].
While Goldberg et al. [30], Oreopoulos et al. [31], Ash et al. [32, 33],
Rottemburg et al. [34], and Valli et al. [35] have redesigned peritoneal catheters, others have attempted to improve the performance of Tenckoff
catheters by perfecting implantation techniques [36-41]. The realization that
omental/mesenteric wrapping must be avoided when catheters are inserted has
resulted in fewer early catheter failures. Straight tunneling of the subcutaneous
catheter segment and visualization of the intraperitoneal catheter segment by
peritoneoscopy have been associated with excellent results. Thus practiced
295
individuals, usmg stylet techniques, have reported the incidence of catheter

drainage to be as low as 7%. Surgical placement can provide technical advantages over closed placement systems. Filling the abdomen with saline
causes the omentum to float up to the Tenckhoff trocar and to be carried with
the catheter tip into the pelvis during catheter placement. This leads to omental
wrapping of the catheter and subsequent retraction of the encased cannula
into the anterior abdominal space. Surgical placement allows air to enter the
abdomen, and, by lifting the abdominal wall, the surgeon creates a free space
through which he or she can slide the catheter along the anterior abdomen free
of omentum. When the catheter tip is below the omental cape, the curved
stylet is rotated to place the catheter on the floor of the pelvis free of omentum
and mesentery [42]. Reports from our group [29] and others [40-50] reveal
that Tenckhoff catheters can be placed into selected patients by technically
proficient persons using percutaneous, operative, or peritoneoscopic placement, with results equivalent to those obtained with specially designed
catheters. Further, the incidence of early complications observed by Hamilton
et al. [51] and Odor et al. [52] were closely related to the individual inserting
the cannula, and not to the catheter design employed.
4. LIMITING EXIT-SITE COMPLICATIONS
The extended use of peritoneal dialysis, and particularly CAPD, has revealed
that exit-site infections and catheter cuff erosion affect both catheter survival
and the occurrence of peritonitis [53]. Initial attempts to prevent these complications involved skin cleansing and wound care. While it is popular to
assume that catheter care and pericatheter dressings have no measureable effect
upon the occurrence of these complications, there is little evidence confirming
or contradicting these assumptions [54]. CAPD does increase the risk of exitsite complications when compared to IPD [50, 55], and this risk may also be
influenced by the connection system employed. Modifications of catheter
materials and design have been undertaken to eliminate exit-site complications
(table 17-2) [28-29, 33, 35-36, 39-40, 45, 56-59]. While little comparative
evidence justifies these structural changes, there are indications that procedural
modifications such as peritoneoscopy, paramedian insertion, delayed catheter
Table 17-2. Proposals to reduce dialysis catheter exit-site complications

Double-cuff catheter
Single-cuff catheter (deep cuff placement)
Delay use for two weeks
Paramedian incision
Peritoneoscopy
Lifecath
Gore-Tex catheter
Swan-Neck catheter
Winged catheter
296
use, and intramuscular placement of the catheter cuff may have reduced the
incidence of exit-site complications in specific institutions.
s.
LONG-TERM CATHETER SURVIVAL
In our center, catheters are removed for a limited number of indications

broadly categorized as (table 17 -3): access unsuitable for routine dialysis (poor
dialysate drainage), unresolving peritonitis, exit-site complications, and other
problems. While technical parameters (patient selection, asepsis, surgical
technique, catheter break-in, and location of the patient recovery area), as well
as catheter design, are determinants of early catheter survival, it is not obvious
how these parameters influence long-term catheter performance. We had used
several catheters concurrently, each the choice of the staff physician responsible for its insertion. Our transplant-nephrology surgeons used the
Oreopoulos-Zellerman catheter, while two nephrologists placed either oneor two- cuff Tenckhoff catheters in the midline with the subcutaneous cuff
1- 2 cm proximal to the exit-site.
Early catheter complications were common and resulted in removal of 19%
of the catheters placed. Inadequate dialysate drainage was the leading cause of
early catheter failure and accounted for 75% of these early catheter losses
(figure 17-2). The remaining early catheter losses involved post-operative
wound infection or catheter dislodgement, both the result of poor wound
healing or early catheter use.
Late (more than 30 days post insertion) catheter losses are primarily the
result of infections associated with an implanted foreign body. Unresolving
peritonitis and exit-site infections accounted for 67% and 22% of the late
catheter losses seen at this center (table 17-3). In Gokal's survey [19], 43%
of 610 CAPD patients underwent catheter removal. The reasons given for
Table 17-3. Reasons for removal of dialysis catheters, University ofIowa data
Tenckhoff one-cuff Tenckhoff two-cuff Oreopoulos-Zellerman
n = 79
n = 53
n = 63
Functional
34 (43%)
Death
17
Transplant
17
Inadequate access 9 (11 %)
Exit site
Early
8 (10%)
Fell out
3
Wound inf.
5
Late
5 (06%)
Erosion
3
Tunnel
0
Exit inf.
2
Peritonitis
6 (08%)
Other
0
32 (44%)
15
13
13 (21%)
9 (17%)
4
5
5 (09%)
1 (02%)
1
0
2 (03%)
0
1
1
11 (18%)
1 (02%)
0
1
1 (02%)
0
0
1
8 (15%)
3
Total
n = 195
84 (38%)
27 (14%)
10 (05%)
8 (04%)
25 (13%)
4
297
(195)
C
A
T
H
E
T
E
R
S
U
R
V
I
V
A
L
12
18
24
3B
DAYS POST PLACEMENT
Figure 17-2. Peritoneal dialysis catheter losses due to inadequate dialysate outflow at the author's
center (total catheters = 195). The time between the initial insertion of a dialysis catheter and its
replacement because of slow or inconsistant dialysate drainage is depicted. Poor dialysate drainage
accounted for 75% of the 34 early catheter failures and caused us to replace 15% of the cannulae
inserted. From Flanigan M, Ngheim DD, Schulak JA, Ullrich GE, Freeman RM: The use and
complications of three peritoneal dialysis catheter designs. Trans Am Soc Artif Intern Organs
10:33-38, with permission.
these catheter losses were peritonitis (44%), obstruction to flow (35%), exitsite/tunnel infection (10%), and other causes (11 %).
In our experience fungal, gram-negative bacterial, and Staphylococcus aureus
infections are the usual causes of unresolving peritonitis. Thus, despite a
reduced incidence of coagulase negative staphylococcal infections, it is unlikely
that there will be a major decrease in catheter losses due to peritonitis. Unresponsive peritonitis results in a 15% annual risk of catheter loss, and we find
this risk to be increased by using the Oreopoulos-Zellerman Catheter (figure
17 -3). Ponce et al. [43] and Grefberg et al. [46] have also reported that, despite
improved early catheter performance, Oreopoulos-Zellerman catheters fail to
function longer than do two-cuff Tenckhoff cannulae.
These results are consistent with a hypothesis that the design of the Oreopoulos-Zellerman catheter is less biocompatible than that of the Tenckhoff
catheter. Indeed, the Toronto-Western Hospital reports annual rates of late
catheter loss (actuarial survival following six months of successful catheter
use) to be 26.1 % for Oreopoulos-Zellerman and 16.5% for the two-cuff
Tenckhoff catheter [56].
Swartz et al. [50], Rottembourg et al. [34], and Bierman et al. [49] have
compared the function of curled catheters to similarly inserted Tenckhoff
cannulas and have not detected an increased incidence of catheter removal
during peritoneal infection [34, 49-50]. Preliminary reports regarding the
Column Disc and Valli catheters quote removal rates of 8% and 7% during
298
(78)
19..
1
~ii1
TENCKHOFF
(6)
Sec
U
R
V
I i!IiI'C
V
A
L
L....~~~~.~~~ ..~
ZELLERIWI
"
12
18
24
3B
36
42
4B
54
6B
Figure 17-3. Peritoneal catheter losses due to unresolving peritonitis at the author's center
(Tenckhoff catheters = 142; Oreopoulos-Zellerman catheters = 53). Following eight months of
use, catheter removal to permit resolution of peritonitis becomes prominent. This risk is higher
for Oreopoulos-Zellerman catheters than for Tenckhoff catheters (p = 0.04). From Flanigan
M, Ngheim DD, Schulak JA, Ullrich GE, Freeman RM: The use and complications of three
peritoneal dialysis catheter designs. Trans Am Soc Artif Intern Organs 10:33-38, 1987, with
permission.
recalcitrant peritomtis. Unfortunately, these catheters were not at risk long

enough (greater than eight months) - (figure 17-3) to permit accurate
estimates of their true risk. Shah et al. [48] have reported that Column Disc
and surgically placed Tenckhoff catheters do not have different rates of early
dysfunction or late complications. However, late catheter losses due to infection
and drainage failure were disproportionately common among the Column
Disc catheter group [48]. Perfumo et al. [60] have detected no early or late
catheter survival benefits for the Valli catheter in comparison to surgically
placed two-cuff Tenckhoff catheters [60].
Exit-site complications precipitate catheter removal both in the early
post placement period and during later use. The early complications involve
post-operative infection and pericatheter leaks. Lucas et al. [61], Helfrich,
Winchester [36], Khanna et al. [44], and Kim et al. [45] have reported that
these early complications are reduced by antibiotic use, paramedian catheter
insertion, and intramuscular fixation of the Dacron cuff. These authors report
exitsite leakage in 3%-13% of patients, findings similar to the 3%-11 % incidence ofleakage following midline catheter placement with delay of CAPD for
10 to 14 days [40, 62]. Since catheter irrigation is generally unnecessary
following catheter insertion, our preferred catheter break-in is to delay dialysis
for 14 days. This procedure minimizes exit-site and subcutaneous leaks, unless
the patient is receiving steroids. Proponants of paramedian catheter placement
presume that this approach prevents incisional leaks and hernias. These individuals fail, however, to acknowledge the role of delayed catheter use
299
[44-45, 57, 63]. Schleifer et al. [63] point out that despite paramedian placement, instituting CAPD within 14 days of catheter insertion resulted in 14%
of patients developing dialysate leaks. In addition, the resultant poor wound
healing may lead to later hernia formation. Lovinggood [64] has advocated
avoiding dialysis within 48 hours of catheter insertion and delaying CAPD
until ten days following catheter placement to reduce pericannular leaks. It is
possible that paramedian catheter placement will reduce the incidence of
peri catheter hernias in children, although the majority of these hernias appear
not to be incisional [22, 65]. Diaz-Buxo and Geissinger [55] found only eight
pseudohernias in 115 adult CAPD patients using one-cuff catheters that had
been placed through a midline incision. In each case this complication was
resolved, and recurrence avoided, by using a two-cuff replacement catheter
[55]. Paramedian catheter insertion is not universally superior to midline
placement with a deep cuff on the fascia and a prolonged "heal-in" regimen,
but appears to permit early dialysis with a reduced incidence of dialysate
leakage.
Late exit-site complications involve pericatheter infections and hernias. In
some centers, exit-site infection has become the major cause of catheter failure
[44,55] (table 17-4). We have confirmed [22,55,63] that catheter removal due
to these problems is reduced by using two-cuff catheters (figure 17-4). Other
reports describe no inherent advantage to the use of two-cuff catheters [45, 56,
66]. These reports involve paramedian placement of single-cuff Oreopoulos-
Table 17-4. Reasons for dialysis catheter removal, Literature reports

Reference
Outflow failure
Khanna [44]
93
Valli [35]
75
Diaz-Buxo [55]
434
Stone [221
167
Watson [23]
78
Rubin [74]
123
Gokal [19]
610
Handt [41]
98
Bierman [49]
56
43
Flanigan [29]
195
Peritionitis
leak
6%
3%
13%
surgical / Oreopoulos-Zellerman
11%
7%
surgical! Valli catheter
8%
4%
3%
mixed/1 and 2-cuffTenckhoff
7%
17%
surgical / 2-cuff T enchhoff
17%
8%
surgical/ 1-cuffTcnckhoff deep placement
23%
23%
8%
surgical! 1-cuffTenckhoff
15%
19%
2%
mixed/mixed
8%
9%
peritoneoscopy /2-cuffTenckhoff
32%
13%
5%
surgical/2-cuffTenckhoff
28%
9%
2%
surgical/2-cuff curl cath
14%
13%
mixed/mixed
Exit-site
infection
1%
8%
7%
14%
8%
5%
5%
3%
0%
2%
4%
300
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45)
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(13)
1--33
1--1
19
1_____ ,
681(
10
I
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2 - CUFF CATHETERS
~--~--~~~~~~-----
1 - CUFF TENCKHOFF
12
18
24
3B
36

Figure 17-4. Peritoneal dialysis catheter losses due to exit-site complications at the author's
center (double-cuff catheters = 116; single-cuff catheters = 79). In both the early postoperative
and later periods, the risk of catheter loss due to exit-site complications is higher for catheters
with a single subcutanious cuff than for two-cuff cannulae (p = 0.0(3). From Flanigan M,
Nghcim DD, Schulak JA, Ullrich GE, Freeman RM: The use and complications of three
peritoneal dialysis catheter designs. Trans Am Soc Artif Intern Organs 10:33-38, 1987, with
permission.
Zellerman and Lifecath catheters with the Dacron disc placed in the rectus
sheath. Thus deep placement of a single cuff is preferred when a short subcutaneous tunnel and/or closely approximated catheter cuffs are used. It is not
clear whether the high risk of catheter removal occurring in the single-cuff
Tenckhoff catheter could be averted by deep, rather than superficial, cuff
positioning. Twardowski has confirmed Tenckhoff's early proposition that
gravity drainage of exit sites can minimize infections and has proposed a
Swan Neck catheter to permit such drainage without incurring the outflow
obstruction caused by curved catheter tunnels [36-38, 58]. The utility of
this Swan Neck catheter [58, 67] and Rottembuourg's winged cannula [59]
remain to be detailed. It is clear, however, that the Gore-Tex catheter has an
inappropriately high morbidity due to exit-site infections [68-70].
Like Grefberg et al. [46] and Valli et al. [35], we have noted that removing
non-Tenckhoff catheters requires surgery, and occassionally a lap oro to my, to
relieve catheter-induced bowel erosion, intestinal perforation, or to free the
cannulas from adhesions [29]. This is particularly true following transplantation and infection, but has occurred without either of these precipitating events.
Catheter cuffs buried in the rectus muscle also require surgical excision in an
operating room and have resulted in hemorrhage when adherent cuffs tear
open an epigastric vessel. Extensive surgical dissections delay catheter reinsertion, and both bulky intraperitoneal catheter segments and muscle-splitting
incisions add to the morbidity of catheter removal.
301
6. BIOCOMP A TIBILITY
Future catheter modifications should receive long-term evaluation to substantiate the biocompatibility of both materials and design. The survival of
peritoneal access devices will be limited by:
1. Their ability to avoid peritoneal toxicity: The materials used (plastic,
plasticizers, sterilants) must not induce cytotoxic responses, either directly
or indirectly through stimulation of inflammatory processes.
2. Their ability to avoid intraperitoneal trauma: Intraabdominal structures
must move freely over the access surface without incurring pressure
necrosis, abrasions, tissue incarceration, or tears. Intraperitoneal catheter
materials must not incite fibroblast differentiation or inflammatory reactions [71].
3. Their ability to resist microbial colonization: Polymers promote or inhibit
bacterial growth by the texture and the electrostatic-chemical properties of
their surfaces [72-73].
4. Their ability to minimize skin irritation: Exit-site infections are influenced
by local factors; silas tic promotes epithlization of the catheter tunnel and
should improve the resistance to bacterial infection unless trauma or obstruction promote microabcess formation.
5. The ability to form an impenetrable seal: The cuff material must resist
bacterial invasion and provide an impenetrable, physically strong seal
between internal and external catheter segments.
Dialysis access remains an obstacle to successful therapy. Early access complications are mechanical and are more closely related to patient selection,
operator experience, catheter break-in, and implantation technique than to the
design of the catheter. The presently recognized late complications of these
devices are predominantly infections. Unresolving peritonitis occurs in 10%
of peritonitis episodes and is likely the result of bacterial adherence/sequestration, either at points of cannula-induced tissue irritation upon cannula
materials or within the preperitoneal catheter cuff. Exit-site/tunnel infections
are the result of tissue trauma at the catheter sinus tract followed by bacterial
invasion of subcutaneous structures. When these bacteria destroy the epithelialcatheter cuff interface, they colonize the cuff matrix, forming an unsterilizable
sequestrum. These late complications will be reduced by improving the
biocompatibility of access materials and the host's resistance to infection [74].
Altered catheter materials and designs need to be viewed with skepticism
until in-vivo testing confirms their benefits. Frequently experiential reports
are the sole means of judging the merits of a redesigned catheter. In these
situations, an access may benefit a center's specialized needs and may be
entirely unhelpful to another user. Repetitive dialysis requires a safe, nontoxic,
biocompatible, durable passage through which dialysate but not infectious
agents may enter and exit the peritoneum. Such a device does not yet exist.
302
Table 17-5. Determinants of peritoneal dialysis catheter choice

Device materials
Catheter
biocompatibility
chemical
mechanical! design
durability
Cuffs
reactivity
bacterial resistance
Patient selection
Prior surgery
Abdominal tissues
type of dialysis
Placement procedure
Insertion technique
Insertion location
Catheter break-in
Presently no device has demonstrated its superiority 'to a properly placed

double-cuff Tenckhoff catheter, and this access has a limited life expectancy.
The choice of access must consider both the patient and implantation
technique (table 17 -5). Percutaneous placement of a long or curled Tenckhoff
catheter remains justified and expedient in patients without intraabdominal
pathology or prior surgery. Patients with prior outflow failure or intraabdominal pathology should undergo catheter insertion using either a peritoneoscopic or surgical approach. Should the surgeon be unfamiliar with peritoneal
access placement, then the Oreopoulos-Zellerman or Lifecath might be recommended. Paramedian insertion sites should be selected for children, patients
receiving steroids, and when early use of a surgically placed cannula is anticipated. One catheter cuff should be placed on the preperitoneal fascia, and the
tunnel should exit the skin in a dependent direction. The need for a second
subcutaneous cuff at the skin exit site remains undefined, but sterile technique
is critical to successful catheter placement.
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10. Barry KG, Schwartz FD, Matthews FE: Further experience with the flexible peritoneal
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cannulae for long-term peritoneal dialysis. Br Med J 4:596-600, 1973.
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18. Nissenson AR, Gentile DE, Soderblom RE, Oliver DF, Brax C, Medical Review Board,
NCC #4: Morbidity and mortality of continuous ambulatory peritoneal dialysis: Regional
experience and long-term prospects. AmJ Kidney Dis 7:229-234, 1986.
19. Gokal R, Jakubowski C, King J, Hunt L, Bogle S, Baillod R, Marsh F, Ogg C, Oliver D,
Ward M, Wilkinson R: Outcome in patients on continuous ambulatory peritoneal dialysis and
haemodialysis: 4-year analysis of a prospective multicentre study. Lancet 11:1105-1108, 1987.
20. Gloor HJ, Nichols WK, Sorkin MI, Prowant BF, Kennedy JM, Baker B, Nolph KD:
Peritoneal access and related complications in continuous ambulatory peritoneal dialysis. Am
J Med 74:593-598, 1983.
21. Gokal R, Jakubowski C, King J, Hunt L, Bogle S, Baillod R, Marsh F, Ogg C, Oliver D,
Ward M, Wilkinson R: Peritonitis and catheter problems during the period between catheter
insertion and start of CAPD (pre-phase) (abstract). Perit Dial Bull 7:S36, 1987.
22. Stone MM, Fonkalsrud EW, Salusky IB, Takiff H, Hall T, Fine R: Surgical management
of peritoneal dialysis catheters in children: Five-year experience with 1,800 patient-month
follow-up. J Pediat Surg 21:1177-1181,1986.
23. Watson A, Vigneux A, Hardy B, Balfe JW: Six-year experience with CAPD catheters in
children. Perit Dial Bull 5:119-122, 1985.
24. von Lilien T, Salusky IB, Hall TL, Fine RN: Five Years experience of CAPD/CCPD in
children with end-stage renal disease (ESRD) (abstract). Perit Dial Bull 7:S83, 1987.
25. Brewer TE, Caldwell FT, Patterson RM, Flanigan WJ: Indwelling peritoneal (Tenckhoff)
dialysis catheter. JAMA 219:1011-1015,1972.
26. Lankisch PG, Tonnis HJ, Fernandez-Redo E, Girndt J, Kramer P, Quellhorst E, Scheler F:
Use of Tenckhoff catheter for peritoneal dialysis in terminal renal failuire. Br Med J 4:
712-713, 1973.
27. Rae A, Pendray M: Advantages of peritoneal dialysis in chronic renal failure. JAMA 225:
937-941, 1973.
28. Veitch P: Surgical aspects of CAPD. In: Gokal R (ed) Continuous Ambulatory Peritoneal
Dialysis. N ew York: Churchill Livingston, 1986, pp 110-144.
29. Flanigan M, Ngheim DD, SchulakJA, Ullrich GE, Freeman RM: The use and complications
of three peritoneal dialysis catheter designs. Trans Am Soc Artif Intern Organs 10:33-38,
1987.
30. Goldberg EM, Hill W, Kabins S, Levin B: Peritoneal dialysis. Dial Transplant 4(4):50, 52,
56, 1975.
31. Oreopoulos DG, Izatt S, Zellerman G, Karanicolas S, Mathews RE: A prospective study of
the effectiveness of three permanent catheters. Proc Dialysis Transplant Forum 96-97, 1976.
32. Ash S, Struewing JD: Clinical trials of the column-disk peritoneal catheter (Lifecath). Perit
Dial Bull 3:77-80, 1983.
304
33. Ash SR: Biocompatibility and hydraulic function of Tenckhoff and Lifecath catheters. Perit
Dial Bull 4:SI03-SI06, 1984.
34. Rottembourg], ]acq D, Vonlanthen M, Issad B, Shahat YE: Straight or curled peritoneal
catheter for continuous ambulatory peritoneal dialysis (CAPD). Perit Dial Bull 1:123-124,
1981.
35. Valli A, Comotti C, Torelli D, Crescimanno U, Valentini A, Riegler P, Huber W, Borghi M,
Gruttadauria C, Scarovanati P, Pecchini F: A new catheter for peritoneal dialysis. Trans Am
Soc Artiflntern Organs 29:629-631,1983.
36. Helfrich GB, Winchester ]F: What is the best technique for implantation of a peritoneal
catheter? Perit Dial Bull 2:132-133, 1982.
37. Helfrich GB, Pechan BW, Alijani MR, Barnard WF, Rakowski T A, Winchester ]F: Reduction
of catheter complications with lateral placement. Perit Dial Bull 3:S2-S4, 1983.
38. Colombi A, Gianella C: Straight implantation of the Tenckhoff catheter for continuous
ambulatory peritoneal dialysis. In: Legran M (ed) Continuous Ambulatory Peritoneal Dialysis. Princeton: Exerpta Medica, 1980, pp 69- 71.
39. Bay WH, Vaccaro PS, Powell SL, Erlich LF: The Gore-Tex peritoneal catheter: A clinical
evaluation and comparison with the Tenckhoff catheter. Am] Kidney Dis 4:268-279, 1984.
40. Heano], Mejia G, Arbelaez M, Sus A, Arango]L, Aramburo 0, Sanchez]: A new approach
for catheter placement and care in CAPD. Perit Dial Bull 5:223-225, 1985.
41. Handt AE, Ash SR: Longevity of Tenckhoff catheters placed by the VITEC peritoneoscopic
technique. Perspectives in Peritoneal Dialysis 2(3):30-33, 1984.
42. Nghiem DD: A technique of catheter insertion for uncomplicated peritoneal dialysis. Surg
Gyn Obst 157:574-576, 1983.
43. Ponce SP, Pierratos A, Izatt S, Mathews R, Khanna R, Zellerman G, Oreopoulos DG:
Comparison of the survival and complications of three permanent peritoneal dialysis catheters. Perit Dial Bull 2:82-85, 1982.
44. Khanna R, Izatt S, Burke D, Mathews R, Vas S, Oreopoulos DG: Experience with the
Toronto Western Hospital permanent peritoneal catheter. Perit Dial Bull 4:95-98, 1984.
45. Kim D, Burke D, Izatt S, Matthews R, Wu G, Khanna R, Vas S, Oreopoulos DG: Single- or
double-cuff peritoneal catheters? A prospective comparison. Trans Am Soc Artif Intern
Organs 30:232-235, 1984.
46. Grefberg N, Danielson BG, Nilsson P, Wahlberg]: Comparison of two catheters for
peritoneal access in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).
Scand] Urol NephroI17:343-346, 1983.
47. Schardin KE, Kopplin DD: A new peritoneal dialysis device, the Lifecath peritoneal implant,
a column disk peritoneal catheter (CDPC). Contemporary Dialysis 3(12):16, 17,20,53, 1982.
48. Shah GM, ]uler G, Sabo A: Comparison of two peritoneal dialysis catheters (abstract).
Proceed ASN, 1987, P 103A.
49. Bierman MH, Masperbauer ], Kusek A, Hammeke M, Fitzgibbons R], Egan ]D: Peritoneal
catheter survival and complications in end stage renal disease. Perit Dial Bull 5:229-233, 1985.
50. Swartz R, Rocher L, Starmann B, Reynolds], Lees P: Curled chronic catheters - complications and longevity compared to straight chronic catheters (abstract). Perit Dial Bull
7:S75, 1987.
51. Hamilton RW, Ingriam]: An assessment of peritoneal catheters. In: Khanna R, Nolph KD,
Prowant B, Twardowski Z], Oreopoulos DG (eds) Advances in Continuous Ambulatory
Peritoneal Dialysis 1986. Toronto, Canada: University of Toronto Press, 1986, pp 151-154.
52. Odor A, Alessio-Robles LP, Leuchter], Mendoza A, Bordes], Wadgymar A, Gonzalez RF,
Peon FC: Experience with 150 consecutive permanent peritoneal catheters in patients on
CAPD. Perit Dial Bull 5:226-229, 1985.
53. Piraino B, Bernardini], Sorkin M: The influence of peritoneal catheter exit-site infections
on peritonitis, tunnel infections, and catheter loss in patients on continuous ambulatory
peritoneal dialysis. Am] Kidney Dis 8:436-440, 1986.
54. Warady BA, Jackson MA, Millspaugh], Miller RM, Ford DM, Hellerstein S, Lum GM:
Prevention and treatment of catheter-related infections in children. Perit Dial Bull 7:34-36,
1987.
55. Diaz-Buxo], Geissinger WT: Single cuff verses double cuff Tenckhoff catheter. Perit Dial
Bull 4:SI00-SI02, 1984.
56. Abrahams G, Mathews R, Zlotnik M, Izatt S, Ayiomamitis A: Further experience with the
305
Toronto-Western Hospital catheter. Perit Dial Bull 7:210-211.1987.

57. Cruz C, Melendez A, Faber M, Provenzano R, Sawaya B: Can the incidence of peritoneal
catheter tunnel infections be reduced? Abstract, Proceed ASN, 1987, P 98A.
58. Twardowski ZJ, Nolph KD, Khanna R, Prowant B, Ryan LP, Nichols WK: The need
for a "Swan Neck" permanently bent, arcuate peritoneal dialysis catheter. Perit Dial Bull
5:219-223, 1985.
59. Rottembourg J, Quinton W, Durande JP: Wings as subcutanous cuff in prevention of exitsite infection in CAPD patients (abstract). Perit Dial Bull 7:S63, 1987.
60. Perfumo F, Patrone P, De Lucia E, Ciardi MR, Podesta E, Risso A, Guzmano R: CAPD
catheters in children (abstract). Perit Dial Bull 7:S59, 1987.
61. Lucas B, Michel C, Mignon F, Thibault Ph, Ponsot Y, Gattegno B, Michel F: Implantation of
peritoneal CAPD catheter by paramedian incision: Benefit of two technical modifications.
(abstract). Perit Dial Bull 7:S48, 1987.
62. Vogt K, Binswanger U, Buchmann P, Baumgartner D, Keusch G, Largiader F: Catheterrelated complications during continuous peritoneal dialysis (CAPD): A retrospective study on
sixty-two double-cuff Tenckhoff catheters. AmJ Kidney Dis 10:47-51,1987.
63. Schleifer CR, Morfesis FA, Cupit M, Chen C, Smink RD: Management of hernias and
Tenckhoff catheter complications in CAPD. Perit Dial Bull 4:146-150, 1984.
64. Lovinggood JP: 1984 Peritoneal catheter implantation for CAPD. Perit Dial Bull. 4:S106S109,1984.
65. Rocco MV, Stone WJ: Abdominal hernias in chronic peritoneal dialysis patients: A review.
66. Ash SR: Biocompatibility and hydraulic function of Tenckhoff and Life-Cath catheters. Perit
Dial Bull 4:S103-S106, 1984.
67. Twardowski ZJ, Khanna R, Nichols WK, Nolph KD, Prowant BF, Ryan LP, Russ J: Low
complication rates with Swan Neck short tunnel Missouri (SNSTM) peritoneal catheter. Perit
Dial Bull 7:S80, 1987.
68. Ogden DA, Benavente G, Wheeler D, Zukoski CF: Experience with the right angle GoreTex peritoneal dialysis catheter. Presented at National CAPD Conference Proceedings, 1986,
pp 178-179.
69. Eklund B, Honkanen E, Salmela K, Kala AR: The Gore-Tex peritoneal catheter: A clinical
long-term assessment (abstract). Perit Dial Bull 7:S27, 1987.
70. Ganger KH, Boss HP, Gluck Z: Gore-Tex versus Oreopoulos peritoneal catheters - a clinical
comparison (abstract). Perit Dial Bull 7:S33, 1987.
71. Hunter SK, Gregonis DE, Coleman DL, Hanover B, Stephen RL, Jacobsen SC: Surface
modification of polyurethane to promote long-term patency of peritoneal access devices.
Trans Am Soc Artif Intern Organs 29:250-252, 1983.
72. Hamory BH: Nosocomial bloodstream and intravascular device-related infections. In: Wenzel
R (ed) Prevention and Control of Nosocomial Infections. Baltimore: Williams & Wilkins,
1987, pp 283-320
73. Baddour LM, Smalley DL, Kraus AP, Lamoreaux WJ, Christensen GD: Comparison of
microbiologic characteristic of pathogenic and saprophytic coagulase-negative staphylococci
from patients on continuous ambulatory peritoneal dialysis. Diagn Microbiol Infect Dis
5:197-205,1986.
74. Rubin J, Adair CM, Raju S, Bower JD: The Tenckhoff catheter for peritoneal dialysis - an
appraisal. Nephron 32:370-374, 1982.
18. DERMAPORT@ PERITONEAL DIALYSIS CATHETER
BENEDICT D. T. DALY and KURT A. DASSE
Chronic peritoneal dialysis has been gaining greater popularity in the management of chronic renal failure. It provides the patient greater freedom and
mobility with less dependence on the dialysis center. A catheter that penetrates
the skin, traverses the soft tissue of the abdominal wall, and lies in the
peritoneal cavity permits the exchange of dialysate. However, chronic percutaneous access has been associated with infectious complications, limiting its
acceptance and application. Peritonitis caused by intraluminal contamination
frequently responds to antibiotic therapy. Infection of the skin and soft
tissue of the abdominal wall in the tunnel of the catheter has been a far more
serious problem, and the problem necessitating catheter removal in the majority of instances. Peri catheter infection along the tunnel comes from two
sources - the peritoneum and the skin. Cuffs, most commonly made of
Dacron velour, have been relatively effective in sealing the peritoneal end of
the catheter. The skin or catheter exit site has been the more difficult area to
manage. Most catheters require significant, and often time-consuming, exitsite care to minimize infection. This is because smooth-surfaced devices or
catheters permit epidermal migration along the catheter, which typically
results in a sinus tract - a gap between the catheter and the skin. This sinus
provides the moist and repetitively traumatized environment in which infection with tissue invasion begins. The Dermaport, on the other hand, provides a stable tissue-biomaterial seal at the level of the dermis, which prevents
307
308
Figure 18-1. Schematic drawing showing the implanted devices. a = dermis; b = subcutaneous
tissue; c = rectus abdominis muscle; d = peritoneum; e = terminal; f = skirt with six holes; g =
subcutaneous portion of the catheter From Daly et al: A new percutaneous access device for
peritoneal dialysis. Trans Am Soc Artif Intern Organs 10(3):664-671, 1987, with permission.
the epidermis from migrating into deeper tissue. It provides the tissue seal needed at the skin level to prevent tunnel infection. Because of the seal, only minimal care is required of the exit site, and free access to showers is permitted.
The Dermaport peritoneal dialysis (PD) catheter has been the product of
over ten years of research and development with materials for percutaneous
applications and has been evaluated in various systems in over 100 animals
(1-2). The clinical system (figure 18-1) is fabricated entirely from a linearsegmented aliphatic polyurethane (Tecoflex; Thermedics Inc, Woburn, MA).
The terminal that penetrates the skin (e in figure 18-1) and the skirt that lies
immediately under the dermis (f in figure 18-1) are textured with a highly
porous surface to permit the ingrowth of a vascularized connective tissue and
the development of a collagen-biomaterial interface. The skirt is perforated
with six holes to permit the establishment of lymphatic and vascular connections to the subcutaneous tissue. The implanted portion of the catheter runs
parallel to the skirt (g in figure 18-1) before angulating towards the peritoneum. A textured cuff (h in figure 18-1) is positioned within the rectus
abdominis muscle or close to the peritoneum to provide an internal seal. In
animal experiments, a small superficial sinus developed that terminated at the
junction between the terminal and the skirt. In patients, the sinus invariably
terminates at the skirt. This is because the dermis over the abdominal wall is
thin and a finite time is required for the tissue-biomaterial seal to mature.
18. Dermaport dialysis catheter
309
Figure 18-2. Light micrograph showing the histologic appearances of the sinus termination
point (s) and tissue biomaterial bond (bm). Note the vascularized connective tissue (t) completely
surrounding the polyurethane monofilaments (pm). The monofilaments were removed from the
device at the time of sectioning.
Figure 18-2 shows such a sinus termination point. The epidermis is typically
rolled up against the device, and the polyurethane mono filaments below
the dermis are firmly anchored in a dense, vascularized connective tissue.
This tissue, composed principally of collagen, provides natural inhibition to
epidermal migration in much the same way the gingiva is inhibited from
migrating along teeth by the periodontal membrane.
1. TECHNIQUE OF IMPLANTATION
The technique for implanting this device is very exacting. As with other
devices, the ideal catheter exit site should be selected based on the patient's belt
or waist line and the presence or absence of other surgical incisions. Ideally,
the exit site should be positioned on the right side of the midline at some
point below the belt line. This allows the catheter to be positioned inside the
310
Figure 18-3. Line drawing showing the completed surgical dissection and the retrograde
insertion of the device. (Abbreviations: h = circular incision for the terminal; 1 = transverse
incision 5 cm long; I = subcutaneous dissection; m = subdermal pocket; n = communication
between subdermal pocket and subcutaneous dissection; 0 = tunnel between subdermal pocket
and transverse incision; p = external portion qfthe catheter; q = peritoneal portion of the catheter;
r = peritoneal incision. The other symbols are as in figure 18-1). From Dasse et al: A polyurethane percutaneous access device for peritoneal dialysis. Proceedings, the 8th National Conference
on CAPO, 1988, in press, with permission.
abdomen from right to left, with the catheter directed towards the pelvis in an
isoperistaltic fashion relative to the colon.
The exit site is marked with a template, provided with the catheter, that
describes the site for the terminal and the margins of the subdermal skirt. A
circular coring knife (also provided with the catheter) is positioned over the
central marking and using a to-and-fro rotary motion, the tissue is incised to a
depth of approximately 7 mm (h in figure 18-3). The core is removed. A
plane of dissection immediately beneath the dermis is initiated using a knife.
This is extended radially to the margin of inscribed skin (using small scissors).
A transverse incision (i in figure 18-3), approximately 5 cm long, is made
inferior to the exit site of the catheter and is carried down to the external layer
of deep fascia (c in figure 18-3). The subcutaneous tissue is dissected off the
fascia in a superior direction (1 in figure 18-3) until a second plane is created
beneath the subcutaneous tissue, which forms the floor of the more superficial
subdermal pocket (m in figure 18-3). The floor of the subdermal pocket is
incised transversely so that the two planes (subdermal and subcutaneous)
communicate (n in figure 18-3). This dissection is necessary to permit the
retrograde insertion of the Dermaport device.
A tunnel (0 in figure 18-3) is then made for the catheter by bluntly separating the subcutaneous tissue from the margin of the subdermal pocket to
18. Dcrmaport dialysis catheter
311
the transverse incision inferiorly. The tunnel is directed in a slightly downward direction so that a few millimeters of subcutaneous tissue will be available to close over the catheter. It is important, however, that this tunnel not
bend acutely away from the margin of the subdermal pocket, since this will
force the implanted catheter to create an undesirable moment of force. This
tends to rotate the superior margin of the skirt into the dermis with enough
pressure to cause necrosis. This has been observed in animal studies but not in
humans.
The device itself is inserted in retrograde fashion. The internai and external
portions of the catheter are introduced into the inferior incision (i in figure
18-3) together and are pulled simultaneously into the subdermal pocket,
utilizing a hemostat that has been inserted through the terminal exit site (h in
figure 18-3) to the plane over the fascia and finally into the inferior incision.
The external portion of the catheter (p in figure 18-3) is pulled externally
through the terminal exit site, and the peritoneal portion of the catheter (q in
figure 18-3) is pulled into the superficial tunnel. The skirt is then seated in the
subdermal pocket with the terminal exiting through the skin core.
The fibers of the rectus abdominis muscle (c in figure 18-3) are bluntly
separated to expose the peritoneum, which is incised (r in figure 18-3). The
catheter is directed into the pelvis using forceps or a stylet. The sleeve is
adjusted to seat either just external to the peritoneum or within the rectus
abdominis muscle. Movement of the peritoneal sleeve along the catheter is
facilitated if the catheter is wet and stretched slightly. The peritoneum is
closed with a purse-string suture. The rectus abdominis muscle and subcutaneous tissue are closed in layers, and the skin is closed with a subcuticular
suture.
If the skin about the terminal is loose and separated from the terminal in any
quadrant by a millimeter or more, it should be pulled towards the terminal
with a steristrip or two. We have seen this in patients with thin, inelastic
skin.
Catheter patency, with the free flow of dialysate both into and out of the
peritoneum, should be confirmed in the operating room. In our institution,
this is done before wound closure. The catheter is radiopaque and the catheter
position can be verified radiographically.
A clear sterile wound dressing is applied over the wounds for 24 hours.
2. EXIT-SITE CARE
The clear dressing is changed if a significant amount of fluid collects beneath it.
In 48 hours it should be replaced with a nonadhering dry sterile dressing. The
wound is protected for two weeks while early attachment of the skin to the
terminal occurs. It is particularly imp")rtant to strain relieve the external
portion of the catheter during this time: using a piece of tape, and it should
continue to be strain relieved after this time, even when a dressing is no longer
needed. Some patients prefer to keep a light dressing over the system all the
312
time to prevent their clothes from catching. Free access to showers is possible
when the skin has become firmly attached to the device. This usually occurs
about six weeks after implantation. No specific wound care is required apart
from cleanliness.
3. CATHETER CARE
Catheter connections and disconnections to the dialysis apparatus should be

made with great care and sterility. When an iodine-containing solution is used
and gets on the terminal, some discoloration may be evident, but is not of any
concern.
Ideally, dialysis should be delayed for two weeks to permit early wound
healing. During this time, or whenever the catheter is left dormant, we
recommend that the catheter be flushed with heparinized saline to reduce the
likelihood of catheter obstruction. It is important to emphasize that the key
feature of this system is the tissue-material seal that develops at the skin level.
As with any healing would, a minimum of time is required to achieve a bond.
We believe two weeks is required to achieve sufficient tissue-biomaterial
adherence to tolerate the stresses associated with the use of the device.
4. COMPLICATIONS
The potential complications for this device are similar to those of any peritoneal dialysis catheter and include catheter obstruction intraluminally or
externally, peritonitis, tunnel infection, or cellulitis. To our knowledge, no
tunnel infection has been observed. However, we have seen superficial cellulitis at the exit site above the skirt. In one patient with exit-site trauma from
a back brace, this cellulitis was severe. However, prompt treatment with
antibiotics resulted in resolution of the cellulitis and restoration of a tissuebiomaterial seal. Pericatheter leakage resulting from the retrograde flow of
dialysate from the peritoneal cavity has occurred when the device was used
too early and in the few patients in whom the sleeve (peritoneal cuff) was
intentionally left off the device. Catheter-tip migration has been observed
requiring operative or laproscopic repositioning. Catheter obstruction has also
been observed most frequently in association with peritonitis. Treatment with
antibiotics and enzymes such as urokinase have been successful in
reestablishing catheter patency.
5. ADVANTAGES
The principal advantages of this system is the aesthetic appearance of the exit
site, the minimum site care required after the first several weeks following
implantation, and the free access to bathing after healing (six weeks) (figure
18-4). Exit-site infection has been shown to respond to antibiotics, and we
believe tunnel infection will rarely occur. Ideally, the complication of peritonitis secondary to pericatheter migration of bacteria will also be reduced.
The single relative disadvantage to this system is the exacting surgical tech-
18. Dermaport dialysis catheter
313
Figure 18-4. Representative clinical appearance of the exit site at one month postimplantation.
nique required for implantation. However, as with any procedure, "practice

makes perfect" . Initial clinical experience suggests a coiled catheter may minimize catheter-tip migration. These catheters are available on the market.
6. EXPERIENCE
We have reported our early and intermediate clinical experience [3, 4]. Catheters have been implanted for over a year in patients with excellent results.
Currently 20 centers in the United States have utilized this device, and controlled clinical trials are in progress at Georgetown University and the University of Pittsburgh to compare the efficacy of this device against other
catheter systems.
REFERENCES
1. Daly BOT, Dasse KA, Clay W, Gould KE, Handrahan jV, Poirier VL, Cleveland RJ: Percutaneous energy transmission: Effects of tethering on system survival. In: Nose Y, Kjellstrand
C, Ivanovich P (eds) Progress in Artificial Organs. Cleveland: ISAIO Press, 1986, pp 527-533.
2. Daly BOT, Dasse KA, Gould KE, Smith Tj, Bousquet GG, Poirier VL, Cleveland RJ: A
new percutaneous access device for peritoneal dialysis. Trans Am Soc Artif Intern Organs
10(3):664-671, 1987.
3. Daly BOT, Szycher M, Poirier VL, Robinson Wj, Haudenschild CC, Cleveland RJ: A method
of establishing permanent percutaneous energy transmission. Surgery 88: 148-155, 1980.
4. Dasse KA, Daly BDT, Bousquet G, King 0, Smith T, Mondou R, Poirier VL: A polyurethane
percutaneous access device for peritoneal dialysis. Proceedings, The 8th National Conference
on CAPO, 1988, in press.
19. PERITONEAL ACCESS FOR

DIALYSIS IN INFANTS AND CHILDREN
KLAUS-EUGEN BONZEL, HELGA ROTH and KARL SCHARER
The introduction of continuous ambulatory peritoneal dialysis (CAPD) has

opened new horizons in the treatment of children with end-stage renal disease
(ESRD). Early reports on the application of this new mode of treatment in
the young [1-7] were followed by more comprehensive descriptions on the
technique and results of CAPD in the pediatric population [8-12]. CAPD has
become a true alternative to regular hemodialysis, especially for those children
who earlier were regarded as candidates for home hemodialysis [13, 14].
In the first years of life, and especially in infants, CAPD is nowadays
regarded as the method of choice and often is the only treatment available [15].
In many countries, the application of CAPD has greatly increased the number
of young children suitable for renal replacement therapy [13, 16]. It should be
remembered, however, that the aim of any treatment in ESRD of children is to
provide the patient a suitable donor kidney as soon as possible.
In the 1960s intermittent peritoneal dialysis (IPD) has been practiced in
infants and children, mainly for treatment of acute renal failure and intoxications [17, 18] and occasionally for prolonged renal insufficiency [19, 20].
The use of the so-called repeated puncture technique with penetration of the
abdominal wall by a stylet catheter [21] for each dialysis session was common
practice [22]. Attempts to create a permanent peritoneal access, e.g., by using
special buttons or subcutaneously implanted reservoirs were unsuccessful
[23-25].
The introduction of Tenckhoff's permanent silicon catheter in 1968 [26]
315
316
revolutionized the fate of children treated by peritoneal dialysis, similar to

that of adult patients. The new technique allowed treatment of children with
ESRD over long periods by the intermittent type of peritoneal dialysis, usually
applied several times per week overnight, either at the hospital [27 -30] or at
home [27, 31-34].
It is of interest that the new mode of long-term treatment for ESRD in
children was launched at about the same time as intermittent hemodialysis
became practical for children. However, IPD by use of the Tenckhoff catheter
never became popular, at least not in Europe, where only a few centers
introduced the technique, usually characterized by a high mortality from
peritonitis and other complications.
The introduction of the continuous form of peritoneal dialysis, CAPD, in
1976 was soon transferred to the pediatric population. It became apparent that
the method is easily applicable, even in young infants, and provides a relatively
high clearance of water and solutes. CAPD allows a high degree of freedom to
the child by reduction of the number of exchanges of dialysis fluid to four or
five per day, thus enabling the child to walk around and follow his or her daily
activities, which appears of special interest to children because of their high
natural needs for physical activity. In addition, CAPD has the great advantage
of being easily practiced at the patient's home after adequate training. The
relatively simple technique can easily be learned by children starting from
about ten years of age and by their caretakers. For details on the practice of
CAPD and its complications in children, the reader is referred to the literature
[8, 10, 11, 35].

A variant of CAPD, continuous cycling peritoneal dialysis (CCPD) has
been practiced extensively in children [12] in a similar manner as in adults [36].
This technique allows the patient to be detached from bags and bag-exchange
procedures during the entire day, while during the night frequent exchanges of
dialysis fluid are performed with the help of an automatic machine (cycler).
Generally speaking, the characteristics and problems of peritoneal access are
similar in children on CCPD as in those on CAPD.
1. PERITONEAL ACCESS FOR ACUTE DIALYSIS
In emergency situations, peritoneal access is achieved by insertion of a stylet

catheter. Several models of different sizes are offered (inner diameter 1. 5 and
2.5 mm, Braun Inc.; 3 mm, McGaw/Baxter Trocath). A new catheter type
has been introduced recently, especially for newborns (inner diameter 1.5 mm,
Medical Components, Inc.), that is inserted by the Seldinger technique, as
applied for vascular access, in order to reduce the risk of organ perforation.
After emptying the bladder by catheterization and after adequate local
anesthesia, the incision of the skin is best done slightly above the umbilicus,
lateral to the midline (through the rectus muscle) in infants and toddlers and
slightly below the umbilicus in the midline in older children. The abdominal
cavity is prefilled with about 20 mllkg of prewarmed dialysis fluid through an
19. Dialysis in infants and children
8--_.--
>----7
2)
25-35 kg
. .
-
10-24 kg
4)
5-9 kg
5)
2-5 kg
subcutaneous cuff
@~----.
5~-.;=~-=:..t.',!em
3)
. .---- 5-.. -.-~ em --'-4
Peritoneal cuff
1) >35 kg body weight
e+ . . ++ . . ".' ;;;:.=
-.'
0"
317
6) <2 kg
Figure 19-1. Tenckhoff catheters of various sizes. 1: adult straight catheter; 2: pediatric curled
catheter; 3: pediatric straight catheter; 4: infant curled catheter; 5: infant straight catheter; 6:
cerebral ventricular drainage catheter for CAPD in premature infants (inner diameter 1. 85 mm,
outer diameter 2.5 mm). The corresponding body weights and the various proposed distances
are indicated.
Intracath cannula. Then the abdominal wall is penetrated by the stylet catheter,
the stylet is removed, and the catheter is introduced into the abdominal cavity.
The technique is described in detail elsewhere [37, 38] (See Chapter 13). The
stylet catheter technique has the advantage that it can be introduced immediately on the ward, while the insertion of a Tenckhoff catheter requires an
operating theater. The risk of bleeding due to disturbed coagulation should
always be considered. The risk of organ perforation, 0.5% to 1.3% in adult
patients [39], seems to be higher in young children. The access by a stylet
catheter should not be maintained for longer than seven days because of the
danger of peritonitis.
Since in most cases a longer dialysis therapy is required, the stylet catheter
technique has largely been replaced by the surgical insertion of a Tenckhoff
catheter [8], (vide infra).
2. PERITONEAL ACCESS FOR CHRONIC DIALYSIS
2.1. Catheter types
Tenckhoff catheters made from silicone rubber (Silastic) are designed primarily for permanent drainage and are offered in two main forms: straight and
curled (figure 19-1).
The straight form with a large hole at the tip and many small lateral holes in
the distal part of the catheter is available in neonatal, pediatric, and adult
varieties for a range of body weights below 10 kg, between 10 and 35 kg, and
above 35 kg, respectively [10, 12]. The Dacron felt cuffs are attached by the
318
manufacturer in three different fixed-cuff configurations. We prefer individually shaped catheters and glue the cuffs to the catheters immediately before
insertion. The location of the cuffs must take into account the size and weight
of the patient (figure 19-1).
The curled form originating from Palmer and coworkers [40] has many
lateral holes in its coil part [8, 11]. These holes and the bidimensional extension
of the curled catheter in the abdominal cavity may reduce the danger of
obstruction [41, 42]. The adult-type catheter with loose cuffs can be used in
children weighing more than 3 kg. Recently, a smaller curled catheter with
thinner Dacron felt cuffs became available for children. We use it for infants
between 2 kg and 10 kg of body weight (figure 19-1).
Both the straight and the curled forms of catheters are being used with one
or two Dacron cuffs attached to fix the device to the abdominal wall. In our
experience with the curled catheter, it is advantageous to always attach two
cuffs, except in young children below 5 kg [15].
As a peritoneal access in newborn and premature infants, Leumann and
coworkers proposed the use of a Spitz-Holter ventricular catheter designed to
drain cerebral fluid [43] (Holter-Hausner Inc., Cordis Inc.). We have applied
this device (without the cuff) (no. 6, figure 19-1) successfully in premature
infants with a body weight ofless than 2 kg and have obtained an inflow rate of
20 ml per 10 seconds and an outflow rate of 15 ml per 10 seconds. (KE Bonzel,
unpublished).
Other variants of the Tenckhoff catheter, such as the Toronto Western
Hospital [44], the column Disc [45], and the Swan Neck [46] types (see
Chapters 14, 15 and 16) have only rarely been applied in pediatric patients [10,
12,47]. In any case, the choice of the catheter should be guided by the principle
of allowing a non traumatic insertion and location in the abdominal cavity.
2.2. Preparation for catheter insertion
The site of insertion is chosen either in the midline beneath the umbilicus [10]
or, more often, lateral to the midline [8, 12, 15]. For the lateral approach,
we prefer the left upper third of the distance between the umbilicus and the
symphysis pubis.
The two-cuff curled Tenckhoff catheter is divided by the cuffs into three
sections: intraabdominal, intramuscular and subcutaneous (figure 19-2). The
peritoneal cuff is placed between the parietal peritoneum and the rectus
muscle, the subcutaneous cuff between the anterior rectus sheath and the
subcutaneous tissue (figure 19-3).
A suitable length of the intraperitoneal catheter section is the distance
measured between the umbilicus and the symphysis minus 3 cm. Considering
that the first lateral hole should be at least 3 cm apart from the peritoneal cuff,
and adding half the diameter of the coil to these 3 cm, a minimal intra peritoneallength of6 cm for the adult-type catheter (figure 19-1, no. 2) and 5 cm
for the infant-type catheter (no. 4) is necessary. Consequently, in small children
319
Figure 19-2. Lateral sectional view of the abdominal cavity with the curled Tenckhoff catheter in
situ.
2-5 em
I
2-3 em
>3
em
EPIDERMIS
SUBCUTIS
M.RECTUS
Figure 19-3. Detailed lateral sectional view of the anterior abdominal wall with penetrating
Tenckhoff catheter. From Roth H, Bonzel KE, Benz G: Implantationstechnik des Peritonealdialysekatheters in Sauglings- und kindesalter. Z Kinderchir 41:355, 1986, with permission.
320
Figure 19-4. Front sectional view of the curled Tenckhoff catheter in situ. Interrupted lines
subcutaneous site of the catheter; dotted lines = alternative route of catheter for infants.
the catheter access site has to be chosen close to the umbilicus or even above it
(figure 19-4). The length of the intramuscular catheter section may vary
between 2 and 5 cm. In very small children weighing less than 5 kg, this
distance may even be less, so that no place is available for a subcutaneous
cuff [15]. The subcutaneous section of the catheter should have a length of
3 to 4 cm, because a shorter distance might easily lead to an extrusion of
the cuff [48]. On the other hand, the catheter exit should be located at least
3 cm apart from the ribs. For this reason, the distance between the two cuffs
must sometimes be reduced to a minimum of2 cm and/or, in small children,
the exit site must be changed from the mamillary line to the epigastric region
(figure 19-4).
The catheter should be placed in a strictly caudal direction and should reach
the region behind the bladder, but a location deep in the pelvis should be
avoided. The rectus muscle may be regarded to serve as a guide rail (figures
19-2, 19-4, and 19-5).
Before the operation the optimal site of the catheter and cuffs is marked on
the skin by means of an undetachable ink. Old operation scars should be
avoided. The belt line of the child should be respected.
The Dacron cuffs should be well attached to the catheter by vulcanization
with liquid silicone rubber (Silastic, Dow-Corning, Inc.) containing acetic
acid as a biologically degradable solvent [8, 49]. Vulcanization is performed
on a dry and clean surface using disposable latex gloves in order to avoid the
attachment of fat particles. Liquid silicone is attached in thin layers to the
previously marked parts of the catheter with the aid of a scalpel. The cuff can
easily be advanced to its correct position while stretching the catheter in a
longitudinal direction and by a rotational movement. Liquid silastic is then
applied to the edgy transitional areas between the catheter and the cuff. The
321
Figure 19-5. Abdominal x-ray of the curled Tenckhoff catheter in situ: five-year-old boy. From
Roth H , Bonzel KE, Benz G: Z Kinderchir 41:355, 1986, with permission.
hardening process takes 12 hours at room temperature but may be shortened

to only two hours by autoclaving for 20 minutes at 140C.
2.3. Surgical catheter insertion technique
The insertion of the catheter in children is best performed in the operating

theater under general anesthesia by a pediatric surgeon assisted by a pediatric
nephrologist. The surgical technique described in adult patients [26, 50] has
been adopted for children [49, 51]. The various parts needed for catheter
insertion are displayed in figure 19-6.
After adequate disinfection of the skin, a 3 to 4 cm superficial paramedian
incision is made at the preoperatively marked access site (figure 19-4). One
centimeter lateral from the dermal incision, the anterior rectus sheath is incised
longitudinally before the rectus muscle is split gently in the sagittal direction.
By this procedure, the catheter is positioned lateral from the wound to avoid
tension on the access site [52]. The parietal peritoneal membrane is opened
by scissors at the caudal edge of the incision, providing an opening with a
diameter of no more than 1 cm. Before the catheter is introduced into the
abdominal cavity, the peritoneum is fixed around the opening by a pursestring suture. The tip of the catheter coil is carefully inserted into the peritoneal
322
Figure 19-6. Setup for catheter insertion in CAPO patients: A = curled Tenckhoff catheter,
infant type, with two cuffs and a Redon stylet screwed onto the outer edge; B = catheter adapter
and wrench (Safe lock); C = connecting line; D = peritoneal dialysis fluid bag; E = spring
balance.
cavity and pushed forward with the coil ahead in a sagittal and dorsocaudal
direction (figures 19-2,19-4, and 19-5). By this procedure, the coil is usually
well rearranged in the lower abdominal cavity behind the bladder. In our
opinion, an insertion guide [9] or a resection of the omentum, as recommended for straight catheters [8, 12], is not necessary.
In case the catheter is inserted across the left rectus muscle, the coil should be
directed to the right side and vice versa. It is important that the distal end of the
catheter remains completely mobile after the peritoneal cuff has contacted the
peritoneal membrane. Thereby, a one-way obstruction can be avoided. The
purse-string suture has to be placed around the catheter strictly below the cuff
and is completed by passing the suture through the Dacron velour of the
cuff at 12 hours; three additional single sutures are passed through both, the
peritoneum and the cuff at three, six, and nine o'clock, thus forming a collar of
peritoneal membrane around the base of the cuff to keep the cuff well attached
and to create a watertight seal of the abdominal cavity (figure 19-3). We use
absorbable and atraumatic suture material (3/0 Dexon or Vicryl).
A subcutaneous tunnel is created by the stab technique using a Faller- or
Redon-type stylet (Charr. 18) with the catheter attached to its end. This
instrument is pierced through the abdominal skin at the exit point indicated
earlier and marked on the skin (figure 19-4). Up until the time of complete
323
healing, the catheter is fixed at the skin exit site by means of a holding suture
placed at some distance from the catheter exit.
Smears are taken from the peritoneal cavity and the subcutaneous tunnel for
bacterial culture when the abdominal cavity is opened and closed.
After the operation is finished, the catheter is connected to the bag. For this
purpose, the surgeon (after glove exchange) connects the catheter side of the
sterile draining line with the catheter adaptor and hands the bag side connector
of the draining line to the assisting pediatric nephrologist, who connects it to
the dialysis fluid bag (500 ml), which is hung on the hook of a spring balance
on a post. After filling the line with dialysis fluid, the connection between the
line and the catheter is established by the surgeon. Peritoneal dialysis fluid is
infused in an amount of20 mllkg body weight with heparin (200 units) added
to the bag. The rate of the infusion, generated by gravity from a height of 1 m
above the abdomen, should not be less than 100 ml per 30 seconds. After
completion of abdominal filling, two thirds of the intraabdominal fluid are
drained passively without any suction; this can be achieved by placing the bag
not more than 10 cm below the abdomen. A specimen of the drainage fluid is
cultured for bacteria; after adding Cefotaxime (1 g), the dialysis is reinfused
in the same manner as described above. Following another drainage, the
abdomen is carefully filled with no more than 10 mllkg body weight to avoid
leakage. The catheter is taped tightly onto the skin.
High inflow and outflow rates are mandatory to allow an appropriate
dialysis. The patient should not leave the operating theater if there is any
deficiency of inflow or drainage [8]. There is no further drainage procedure or
bag exchange before the child has reached the ward and dialysis has been
introduced, with one exception, that bag exchange might be necessary in the
operating theater if the dialysis fluid is sanguinolent. We feel, in agreement
with other authors [10], that radiographic control of the catheter placement is
not necessary. In selected cases where hernias are suspected, the use of
peritoneography might help in establishing the diagnosis and might allow an
indication for herniotomy [9].
3. DIALYSIS AFTER CATHETER INSERTION
Various procedures have been described for starting dialysis after catheter
insertion [8, 35]. As a general rule, filling volumes should be kept small in the
first few days in order to allow an undisturbed healing process. In our unit, the
dialysis procedure is usually started two hours after catheter insertion by
means of a closed dialysis fluid distributing system called stag antlers [49] or
octopus (RN Fine, personal communication). In the first hours of dialysis,
we prefer the use of this system (Fresenius Inc.) to that of a cycler because
flow and turbidity of the dialysate can be monitored more closely. Even an
untrained pediatric nurse is able to manage the fluid balance without opening
the tubing system, after adequate information. With the stag antlers system the
bags have to be replaced only once a day by an expert dialysis nurse.
324
In the initial phase of dialysis, we usually apply slightly hypertonic dialysis

fluids (350 mOsm/L) and add heparin (200 lUlL) and Cefotaxime (250 mg/L)
during the first day. In the average case, the dialysate is initially exchanged
every 4 to 6 hours. If more efficient blood purification and fluid removal is
needed or if the effluent contains blood, the dialysis fluid is exchanged at more
frequent intervals. During the first week of dialysis, the exchange volume
should not exceed 10 mllkg body weight. In case of an urgent need for
efficient blood purification or fluid removal, it is preferable to combine CAPD
with hemodialysis through a subclavian venous catheter rather than suddenly
increasing the peritoneal exchange volume or using dialysis fluid of a higher
osmolarity.
In the second week ofCAPD, the exchange volume is gradually increased to
the final amount of25 to 50 ml/kg body weight, and in infants up to 60mllkg,
accompanied by training the patient or caretaker for home treatment. The
described procedure usually allows discharge of the well-trained patient three
weeks after catheter insertion.
4. RESULTS AND COMPLICATIONS
In our experience with 44 cumulative treatment years in 49 patients aged 0.1 to

17 (median 9) years, the rate of modality survival with CAPD is greatly
influenced by the catheter survival, which is best expressed by an estimate of the
cumulative probabitity of survival. Following the introduction of an improved
standardized technique of catheter insertion in 1983, as described above, we
have observed a significant increase in modality survival from 50% at one year
in 19 pediatric patients from 1979 to 1982 (group A) to 97% at one year in 30
patients from 1983 to 1986 (group B), while 75% had been reported in 137
EDTA children on CAPD [16] and 73% in adult patients of the U.S. CAPD
register.
Parallel to this, catheter survival in group Breached 82% at one year in
comparison to 70% in 50 pediatric patients observed by Alexander and
coworkers in 1985 [8]. The number of catheters used in our group B averaged
1.4 per year of treatment. The duration of catheter life was up to 33 months.
This prolonged modality survival was accompanied by a decreasing incidence
of peritonitis, mainly of those forms originating from tunnel infections.
Indeed, peritonitis was the most frequent complication in our children
treated by CAPD, with a current incidence of1.3 per year (group B) compared
to 0.9 [12] and up to 2.5 per year [47] in other centers. In 78% of our cases
observed in group B, peritonitis appeared to be a self-limited event followed
by cure after adequate antibiotic treatment without further complications
or recurrence with the same germ. This sporadic form of peritonitis may
originate from failing hygiene during bag-exchange procedures and may
spread out by an intracanalicular mode of infection. Another group of peritonitis is characterized by relapses after adequate antibiotic therapy within one
month after the onset of peritonitis with the same germ as found in the
325
previous episode of peritonitis, without clinically apparent tunnel infection.

We have reasons to assume that in such cases the peritoneal infection was
catheter related. In each of these cases and in other cases of peritonitis originating in obvious tunnel infections not responding to antibiotic treatment,
or in cases of obvious tunnel infection without peritonitis, only the removal of
the catheter (with one exception) was able to induce a cure. These results
correspond to those of other investigators [9, 10, 12]. In patients continuing
with CAPD, the catheter was always reinserted successfully after CAPD was
transiently replaced by intermittent hemodialysis over 1 to 2 weeks. The
reintroduction of CAPD was not successful in two cases when the catheter was
exchanged for a new one during the same operation.
It is our feeling that catheter-related infections can be reduced in number by
a skillful implantation technique. The number of catheter removals has been
reduced from 23 in our group A to 9 (7/30 children) in group B.
Exit-site infections are relatively frequent in children on CAPD. They may
occur independently of the presence of a subcutaneous cuff [48, 53]. The
predominant germs observed in both exit-site and tunnel infections are Staphylococcus aureus and Staphylococcus epidermidis, in about equal parts. In infants,
gram-negative bacteria are predominant. Sometimes no germs can be found
[54].
In the majority of children suffering from single or recurrent exit-site
infections, conservation therapy with regular showers with mild fatty soaps
followed by careful drying using an electric hairdryer and loose dressings
without disinfectants is successful. In infants, care should be taken that the exit
site remains free from the moisture of diapers. In contrast to reports in the
literature [9, 12, 55], we do not feel that prolonged systemic antibiotics, such
as rifampicin, ampicillin plus clavulanic acid, clindamycin, or gyrase inhibitors
are helpful. Antibiotics may, however, be useful as an initial treatment given
over a few days to manage severe purulent skin infections with exophytic
granulations until surgical treatment is possible.
A surgical procedure is indicated in a minority of cases. In our experience,
catheters never had to be removed, although in three cases the tunnels in the
abdominal wall became very short following destruction and retraction of the
dermal tissues after prolonged infection. In the case of protrusion of the
catheter, we removed the subcutaneous Dacron cuff, if not placed correctly
(two cases) or, if the latter was not involved and was deeply fixed in the tissue
(one case) or was absent (one case), we excised the purulent, granulomatous,
or necrotic tissue areas, as reported in the literature [56-58]. The subcutaneous
cuff, if placed correctly, seems to not be involved in exit infections. In the
literature, results with two-cuff catheters are reported to not be worse [59] or
to be even better [48, 53] than with one-cuff catheters.
Noninfectious complications in CAPD treatment have become relatively rare in
children. In earlier years, we saw two complete obstructions of the peritoneal
catheter combined with severe peritonitis. A further complete obstruction of a
326
catheter that had not been used for three months was surgically corrected.
Two one-way obstructions were due to transverse malposition of the catheter
because of short intramuscular tunneling in the beginning of our CAPD
programme. In group B, two one-way obstructions were associated with
intraabdominal strictures and another with extreme obesity. Two of them
were corrected following a surgical incision of the peritoneal cavity far from
the insertion site in order to change the position of the catheter coil. In our
experience, omental obstruction of the catheter, as observed by other authors
[8, 11,41,42], occurred only exceptionally with curled catheters. The straight
and sagittal tunnel across the rectus muscle guarantees that the catheter coil is
well positioned behind the bladder [50]. In addition, the bidimensional shape
of the curled catheter provides a good inflow and outflow, even if the position
is not deep in the pelvis [8].
Traumatic lesions or dislocations of catheters may occur by the inadvertent
use of scissors or by sudden stress. They usually require the removal of the
catheter. The use of double cuffs allows a tighter fixation than one-cuff
catheters and therefore a better protection against exogenous insults. Leakage
of fluid from the insertion site can be prevented by the suture technique
described above. Alexander recommends an additional purse-string suture of
the anterior rectus sheath [8]. The risk of leaks is also lessened by trans rectal
access instead of midline access [59, 60]. In babies, the tender peritoneal
membrane can be sealed successfully by liquid fibrin [51]. Perforation of the gut
has not been reported in children to date. Disconnections and cracks of the
catheter may be caused by material fatigue or production failures and require
instantaneous repair [61, 62].
Hernias are well-known complications of CAPD treatment. Inguinal hernias
are found most frequently and are reported in 7% [63] to 10% [10] of children
on CAPD treatment. Three of our four cases with inguinal hernias (8% of our
CAPD patients) were corrected surgically without interrupting dialysis. One
umbilical hernia did not need surgical therapy. The one incisional hernia
(access related) we observed was cured only after catheter removal. The
number of incisional hernias in general seems to have decreased since the
trans rectal access was introduced to replace the midline access [64]. The use of
CCPD might diminish the risk of acquiring hernias, since the abdominal
cavity eventually remains empty for a longer period of time [12]. Hydroceles
sometimes need surgical treatment. Hydrothorax is very rare in children on
CAPD; the incidence is 1% to 2% [10, 12, 65].
An overall evaluation of catheter-related complications in CAPD noted
above may be made by analyzing the frequency of cather removal (table
19-1). Our results appear to demonstrate that the curled type of catheter is
superior to the straight one in preventing the above mentioned complications.
At the same time the number of patients who switched from CAPD to
hemodialysis, mainly due to peritonitis, decreased from ten in our group A to
four in group B.
a Column
47 (36%)
65%
61 (20%)
80%
78%
4 (13%)
Not recorded
8 (6%)
1 (3%)
14(11%)
2 (7%)
1 (1%)
0
0
1 (3%)
0
31
27
Not recorded
1 (0%)
37 (12%)
Not recorded
adults
11 (8%)
5 (4%)
8 (6%)
disc catheter used in 14%_
Total number of
catheter removals
One-year catheter
survival
Hernia
Omental obstruction
Leakage
Wrong catheter
position
Peritonitis
Exit-site/tunnel infection
Other
134
88
Not recorded
3 (12%)
2 (8%)
64%
9 (37%)
58%
18 (70%)
Not recorded
1 (4%)
6 (23%)
8 (33%) 7 (27%)
Not recorded
0
0
24
27
children
26
Straight
Alexander et aI.,
1985 [8]
Straight
Curled
Single cuff Double cuff
Diaz-Buxo and
Geissinger, 1984 [531
Not recorded
12 (4%)
11(4%)
247
adults
315
Numberofpts
Number of catheters used
Straight
Slingeneyer et al. ,
1981 [70]
Catheter type
Authors
50%
25 (33%)
2(3%)
Not recorded
6(8%)
1 (1%)
1 (1%)
13(17%)
2(3%)
55
children
78
Straight
Balfe and Watson,

1986[10]
Table 19-1. Reasons for removal of catheter in various pediatric and adult populations treated by CAPD/CCPD
(2%)
(19%)
(13%)
(3%)
Not recorded
74 (45%)
3
32
22
5
1 (1 %)
6 (4%)
5 (3%)
93
children
167
Straight a
v_ Lilien et al. ,
1987 [12)
1 (3%)
5 (13%)
7 (15%)
1 (3%)
0
0
0
15%
82%
38 (100%) 14 (33%)
2(5%)
8 (21 %)
16 (42%)
5 (13%)
1 (3%)
0
6 (16%)
19
30
children
38
40
Curled
1979-82
1983-86
Present study
:l
"
'"
-...J
'"
g:
0:
,..,
Q.
:l
'"
iJl
5
5
f.
tJ
;:;-
:c
328
5. RENAL TRANSPLANTATION FOR CHILDREN ON CAPD
CAPD does not seem to be a risk factor for renal transplantation in adults [52,
66] or in children [10,67-69]. Various procedures have been suggested for the
preparation of CAPD children for renal transplantation [67].
From our point of view, the indications for transplantation are essentially
the same as in pediatric patients on hemodialysis. Care should be taken to not
perform a graft during or soon after an episode of peritonitis. We and most
other authors [67] suggest permitting transplantation, at the earliest, two
weeks following termination of antibiotic therapy for peritonitis. Grafting
should also be delayed in the presence of purulent skin infections, whereas a
minor irritation of the catheter exit is not an absolute contraindication for
grafting.
Usually, there is no need to remove the catheter during the grafting procedure, even if this is preformed on the side ipsilateral to the exit site [68].
The catheter may also remain in situ if transplantation is performed with the
transperitoneal route, as in very small children [10]. Most pediatric centers
leave the catheter in situ for 2 to 4 months following kidney transplantation in
order to allow continuation of dialysis if needed or to drain a postoperative
ascites [9, 66-69]. The incidence of peritonitis is not increased after transplantation [67] and its treatment follows the same rules as before [68, 69]. In
order to avoid infections, it is important to keep the catheter clamped and
capped unless in use. In the case of a prolonged course of peritonitis under
immunosuppressive therapy post-transplant, or in the case of tunnel infection,
the catheter should be removed immediately.
6. CONCLUSION
The technique of peritoneal access for acute or chronic peritoneal dialysis in

children on CAPD has improved in recent years, which can be documented by
a longer cather survival and by a decreasing frequency of catheter replacements
due to a lower incidence of complications. We prefer the curled type of
Tenckhoff catheter, which appears to yield similar or better results in CAPD
treatment than the straight type. This catheter is easy to insert, the same size
fits in older children and infants, and it guarantees an excellent dialysate flow
by its bidimensional shape. Whatever form of catheter is used, the technique
of insertion and postoperative management remains critical to obtain good
catheter function. The main points to be observed in creating an efficient and
persistent peritoneal access for CAPD are: 1) careful tissue handling during
operation by an experienced and devoted surgeon, 2) access through the rectus
muscle, 3) small incision of the parietal peritoneal membrane, 4) purse-string
suture of peritoneal membrane and additional single sutures to attach the
peritoneum securely to the Dacron cuff, 5) fixation of the catheter within the
abdominal wall by a straight upward tunnel across the rectus muscle and
attachment of two Dacron cuffs, and 6) small initial filling volumes.
It is hoped that future technical development will allow a safer peritoneal
access with improved sealing of the abdominal wall and better biocompatibility.
329
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(ed) Continuous Ambulatory Peritoneal Dialysis. Amsterdam: Excerpta Medica, 1980, pp
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parameters in continuous ambulatory peritoneal dialysis for infants and children. In: Moncrief
jW, Popovich RP (eds) CAPD Update. New York: Masson, 1981, pp 195-209.
3. Bonzel KE, Diekmann L, Koch H, Liitkenhaus C: Erfahrungen mit der chronischen Peritonealdialyse (IPD und CAPD) beim Kind. Nieren- und Hochdruckkrankheiten 10:61-67,
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4. DeSanto NG, Capodicasa G, DeSimon V: Experience of CAPD in children - a pilot study.
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513-518, 1987.
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Selwood NH, Wing AJ: Combined report on regular dialysis and transplantation of children
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children. 2 Congresso nationale della Societa Italiana di Nefrologia Pediatrica, Abetre Ed,
1987, pp 59-72.
15. Kohaut EC, Alexander SR, Mehls 0: The management of the infant on CAPD. In: Fine RN,
Scharer K, Mehls 0 (eds) CAPD in Children. Berlin: Springer, 1985, pp 97-105.
16. Broyer M, Rizzoni G, Brunner FP, Brynger H, Challah S, Faflbinder W, Oules R, Selwood
NH, Wing HJ: Combined report on regular dialysis and transplantation of children in Europe,
1984. Proc Eur Dial Transpl Ass 22:55-82, 1985.
17. Meadow SR, Cameron jS, Ogg CS, Saxton HM: Children referred for acute dialysis. Arch
Dis Child 46:221-227, 1971.
18. Day RE, White RHR: Peritoneal dialysis in children. Review of8 years' experience. Arch Dis
Child 52:56-61, 1977.
19. Levin S, WinckelsteinjA: Diet and infrequent peritoneal dialysis in chronic anuric uremia. N
Englj Med 277:619-624,1967.
20. Fejdman W, Balisk T, Drummond K: Intermittent peritoneal dialysis in the measurement of
chronic renal failure in children. Am j Dis Child 116:30-36, 1968.
21. Weston RE, Roberts M: Clinical use of stylet-catheter for peritoneal dialysis. Arch Intern
Med 115:659-662, 1965.
22. Boen ST, Mion C, Curtis PK, Shilipetar G: Periodic peritoneal dialysis using the repeated
puncture technique and an automatic cycling machine. Trans Am Soc Artif Intern Organs
10:409-413, 1964.
23. Boen ST, Mulinari AS, Dillard DH, Scribner BH: Periodic peritoneal dialysis in the manage-
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ment of chronic uremia. Trans Am Soc Artif Intern Organs 8:256-265, 1962.
24. Jacob GB, Deane N: Repeated peritoneal dialysis by the catheter replacement method:
Description of the technique and a replacable prosthesis for chronic access to the peritoneal
cavity. Proc Eur Dial Transplant Ass 4:136-140, 1967.
25. Stephen RL, Atkin-Thor E, Kolff WJ: Recirculating peritoneal dialysis with subcutaneous
catheter. Trans Am Soc Artif Intern Organs 22:575-584, 1976.
ArtifIntern Organs 14:181-183,1968.
27. Counts S, Hickman R, Garbaccio A, Tenckhoff H: Chronic home peritoneal dialysis in
children. Trans Am Soc ArtifIntern Organs 19:157-163, 1973.
28. Sakai T, Kasai N, Shinagawa I: Treatment of chronic renal failure by peritoneal dialysis with
Tenckhoff indwelling catheter in childhood. Third International Symposium of Pediatric
Nephrology, Washington, Sept, 1974 p 19A.
29. Brouhard RH, Berger M, Travis LB, Cunningham III RJ, Carvajal HF: Chronic peritoneal
dialysis in children. Texas Medicine 72:84-89, 1976.
30. Gagnadoux MF, Hernandez MA, Broyer M, Vacant J, Royer P: La dialyse peritoneale
chronique: Alternative de I'hemodialyse iterative chez l'enfant. Arch Franc Ped 34:860-875,
1977.
31. Brouhard BH, Berger M, Cunningham III RJ, Petru sick T, Allen W, Lynch RE, Travis LB:
Home peritoneal dialysis in children. Trans Am Soc Artif Intern Organs 25:90-94, 1979.
32. Baluarte HJ, Grossman MB, Polinsky MS: Experience with intermittent home peritoneal
dialysis in children. Pediatr Res 14:994(A), 1980.
33. Lorentz WB Jr, Hamilton RW, Disher B, Crater C: Home peritoneal dialysis during infancy.
Clin Nephrol 15:194-197, 1981.
34. Potter DE, McDaid TK, Ramirez JA: Peritoneal dialysis in children. In: Atkins NM,
Thomson PC, Farrel PC (eds) Peritoneal Dialysis. New York: Churchill Livingstone, 1981,
pp 356-361.
35. Balfe WJ: Peritoneal dialysis. In: Holliday MA, Barratt TM, Vernier RL (eds) Pediatric
Nephrology, Baltimore: Williams and Wilkins, 1987, pp 814-827.
36. Diaz-Buxo JA, Walker PJ, Farmer CD, Chandler JT, Holt KL, Cox P: Continuous cyclic
peritoneal dialysis. Trans Am Soc Artif Intern Organs 27:51-53, 1981.
37. Scharer K, Miiller-Wiefel DE: Dialyse im Kindesalter. In: Franz HE (ed) Blutreinigungsverfahren, Technik und Klinik. Stuttgart: Thieme, pp 298-318.
38. Mauer SM: Pediatric renal dialysis. In: Edelman CMJr (ed) Pediatric Kidney Disease. Boston:
Little, Brown, 1978, pp 487-502.
39. Khanna R, Oreopoulos DG: Complications of peritoneal dialysis other than peritonitis. In:
Nolph KD (ed) Peritoneal Dialysis. Boston: Martinus Nijhoff, 1985, pp 441-524.
40. Palmer RA, Quinton WE, Gray JE: Prolonged peritoneal dialysis for chronic renal failure.
Lancet 1:700-702, 1964.
41. Rottembourg J, Dominique J, Von Lanthen M, Issad B, El Shahat Y: Straight or curled
Tenckhoff peritoneal catheter for continuous ambulatory peritoneal dialysis. Perit Dial Bulletin 1:123-124, 1981.
42. Duffy DP, Dart RA, Kuehner HD, Parker JP, Swanson MK, Winemiller HD: Advantages of
CAPD with the curved Tenckhoff catheter. Perit Dial Bulletin 4:S21(A), 1984.
43. Leumann EP, Knecht B, Dangel P, Mieth D, Duc L: Peritoneal dialysis in newborns:
Technical improvement. In: Bulla M (ed) Renal Insufficiency in Children. Berlin: Springer,
1982, pp 147-151.
44. Oreopoulos DG, Zellerman G, Izatt S: The Toronto Western Hospital permanent peritoneal
catheter and continuous ambulatory peritoneal dialysis connector. In: Legrain M (ed) Continuous ambulatory Peritoneal Dialysis. Amsterdam: Excerpta Medica, 1980, pp 73- 78.
45. Ash SR, Johnson H, HartmanJ, Granger J, KoszuiaJ, Sell L, Dhein C, Blewins W, Thornhill
JA: The column disc peritoneal catheter - a peritoneal access device with improved drainage.
Trans Am Soc Artiflntern Organs 3:109-115,1980.
46. Bozkurt F, Keller E, Schollmeyer P: Swan neck peritoneal dialysis catheter can reduce catheter
complications in CAPD patients. Perit Dial Bulletin 7:S9(A), 1987.
47. Hogg RJ, Coin D, Chang J: The Toronto Western Hospital catheter in a pediatric dialysis
program. AmJ Kidney Dis 3:219-223, 1983.
48. Smith C: CAPD: One cuff vs. two cuff catheters in reference to incidence of infection. In:
Maher JF, Winchester JF (eds) Frontiers in Peritoneal Dialysis. New York: Field, Rich and
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Assoc, 1986, pp 181-182.

49. Bonze! KE, Miillcr-Wiefel DE, Roth H, Benz G, Wartha R, Rascher W, Mehls 0: Wahl des
Katheters, Kathetereinpftanzung und Komplikationen bei der kontinuierlichen ambulanten
peritonealdialyse (CAPD) im Kindesalter. Aktuelle Nephrologie 18: 151-169, 1985.
50. Colombi H, Rosenthal GL: Kontinuierliche ambulante Peritoneale Dialyse - eine neue
dialysemethode. Aktuelle V rologie 11:97-102, 1980.
51. Roth, H, Bonzel KE, Benz G: Implantationstechnik des Peritoneal dialysekatheters im
Sauglings- und Kindesalter. Z Kinderchir 41 :355-359, 1986.
52. Veitch P: Surgical aspects of CAPD. In: Gokal R (ed) Continuous Ambulatory Peritoneal
Dialysis. Edinburgh: Churchill Livingstone, 1986, pp 110-144.
53. Diaz-Buxo ] A, Geissinger WT: Single cuff versus double cuff Tenckhoff catheter. Perit Dial
Bull 4:S100-S106, 1984.
54. Amair P, DeCamejo 0, Dominguez O. Boissiere M: Skin reactions against the catheter. An
explanation for exit site infection in CAPO. In: Maher ]F, Winchester]F (eds) Frontiers in
Peritoneal Dialysis. New York: Field, Rich and Assoc, 1986, pp 207-209.
55. Vas SI: Peritonitis. In: Nolph KD (ed) Peritoneal Dialysis. Boston: Martinus Nijhoff, 1985,
pp 403-439.
56. Andreoli SP, West KW, Grosfeld]L, Bergstein]M: A technique to eradicate tunnel infection
without peritoneal dialysis catheter removal. Perit Dial Bull 4:156-158, 1984.
57. He!frich G, Winchester ]F: Letter to the editor. Perit Dial Bull 2:183, 1982.
58. Nichols WK, Nolph KD: A technique for managing exit site and cuff infection in Tenckhoff
catheters. Perit Dial Bull 3:94-95, 1983.
59. Kim 0, Burke 0, Izatt S, Mathews R, Wu G, Khanna R, Vas S, Oreopoulos DG: Single- or
double-cuff peritoneal catheters? A prospective comparison. Trans Am Soc Artif Intern
Organs 30:232-243, 1984.
60. Helfrich GB, Pechan BW, Alijani MR, Barnard WF, Rakowski T A, Winchester ]F: Reduction
of catheter complications with lateral placement. Perit Dial Bull 3:S2-S4, 1983.
61. Roman], Gonzales AR: Tenckhoff catheter repair by the splicing technique. Perit Dial Bull 4:
89-91, 1984.
62. Zappa costa AR, Perras ST: Replacement of cuff and extraperitoneal section of Tenckhoff
catheter in single cuff catheters. Perit Dial Bull 4:S73(A), 1985.
63. Leichter HE, Salusky IB, Davidson D, Hall T, Jordan SC, Ettenger RB, Fine RN: Long-term
mechanical complications in children undergoing CAPO Per Dial Bull 4:S36(A), 1984.
64. O'Connor B, Rigby R], Hardie ]R, Wall DR, Strong RW, Woodruff PWH, Petrie ]]B:
Abdominal hernias complicating continuous ambulatory peritoneal dialysis. Am] Nephrol6:
271-274, 1986.
65. Lorentz VB: Acute hydrothorax during peritoneal dialysis.] Pediatr 94:417-419, 1979.
66. Cardella CJ: Renal transplantation in patients on peritoneal dialysis. Perit Dialysis Bull
1:12-14, 1981.
67. Scharer K, Fine RN: Renal transplantation in children treated by CAPD: A report on a cooperative study. In: Fine RN, Scharer K, Mehls 0 (eds) CAPO in Children. Berlin: Springer,
1985, pp 212-220.
68. Miiller-Wiefel DE, Dreikorn K, Bonzel KE, Horsch R, Dippell], Mehls 0, Opelz G, R6hl L,
Scharer K: Nierentransplantation bei Kindern unter CAPO. Nieren- und Hochdruckkrankheiten 16:289-293, 1987.
69. Stefanidis CJ, Balfe ]W, Arbus GS, Hardy BE, Churchill BM, Rance CP: Renal transplantation in children treated with continuous ambulatory peritoneal dialysis. Perit Dial Bull
3:5-8, 1983.
70. Slingeneyer A, Mion C, Charpiat A, Balmes M: Is an alternative to the Tenckhoff catheter
necessary? In: Gahl GM, Kessel M, Nolph KD (eds) Advances in Peritoneal Dialysis.
Amsterdam: Excerpta Medica, 1981, pp 179-184.
20. PREVENTION OF PERITONITIS DURING CAPD:

SPECIAL PRECAUTIONS AND USE OF
CONNECTION SYSTEMS
ROSARIO MAIORCA, GIOVANNI C. CANCARINI and CORRADO CAMERINI
Peritonitis in CAPD is multifactorial, with bacterial entry into the peritoneal

cavity being the most important, but not the only, cause. Factors such as daily
peritoneal losses of macrophages and opsonins [1, 2], defect in complementmediated opsonization [3], inhibition of polymorphonuclear leucocyte phagocytosis by low pH and high osmolality of peritoneal fluid [4], and bacterial
ability to form biofilm-encased adherent micro colonies resistant to antibiotics
[5] are all involved, especially in patients prone to peritonitis. Permanently
activated peritoneal macrophages with sustained release of interleukin 1, prostaglandins, and leukotrienes have also been demonstrated [6-9]; the role of
these factors, if any, in favoring peritonitis is unclear, but they may well be
important in favoring ultrafiltration loss or peritoneal sclerosis.
However, the fact that it has been possible to reduce the peritonitis rate,
from one episode every 5-10 weeks at the beginning to one episode every 50
or even 88 patient-months (p-m) in some current studies, just by reducing
bacterial contamination of the connector is clear evidence of the preeminence
of external contamination in producing peritonitis.
1. CONTAMINATION ROUTES
Bacteria can reach the peritoneal cavity transluminally, extraluminally,

through the blood, transmurally, or ascending from the uterus.
1.1. Transluminal route
Contamination occurs during a bag exchange. At this moment the system

peritoneal cavity-catheter-connector-bag is briefly open to bacterial entry.
333
334
Bacteria colonize the fluid filling the connector and subsequently spread to the
peritoneal cavity. Since bag exchanges take place 3-5 times a day, the risk of
trans luminal contamination is high and can account for the extraordinarily
greater incidence of peritonitis in CAPD than in intermittent peritoneal
dialysis (IPD).
1.2. ExtraluDlinal (or periluDlinal) route
Contamination occurs through infection of the cutaneous exit site and of the
subcutaneous tunnel that lodges the catheter. Since the risk of transluminal
infection has been reduced, this has become a major source of peritoneal
infection. There are still questions regarding how to prevent this infection. Is it
better to leave the exit site uncovered or to keep it covered with sterile or
antiseptic gauze? What is the best treatment for initial exit-site infection local disinfectants, local antibiotics, systemic antibiotics, or surgery?
1.3. TransDlural route
Bacteria enter the peritoneal cavity through the intestinal wall, especially in
cases of diverticulosis or diverticulitis, or after intestinal perforation.
1.4. Blood route
This is a less frequent route and is involved in peritonitis due to Mycobacterium

tuberculosis, Streptococcus viridans, or Pneumococcus.
1.5. Ascending route
This is specific for women and is the consequence of diffusion to the peritoneum of a vagina-uterus-fallopian tube infection. It IS more frequent in
patients with contraceptive intrauterine devices (IUD).
2. PREVENTION OF CONTAMINATION
During bag exchange, some general precautions are necessary to prevent

bacterial contamination, particularly in those connection systems that exclude
flushing and in-line disinfection (see below).
2.1. The operating rOODl
It is advisable that the bag-exchange operation be performed in a clean, well-lit

room with closed doors and windows and without unnecessary persons. No
domestic animals, plants, or flowers should be in the room. A wash basin in
the room is necessary to avoid the operator opening the doors or going to
another room after washing the hands.
2.2. The working surface
The working plane must be smooth and washable, and not subject to
deterioration by the disinfectants, with which it must be washed at least once a
day. It should be in suitable position that allows all bag-exchange maneuvers
20. Prevention of peritonitis during CAPD
335
with the patient remammg seated. It must be distant from heat sources, to
avoid the arrival of dust particles moved by convective drafts. All needed
materials must be easily at hand to facilitate the operation.
2.3. Clothes
It is advisable to wear simple clothes and to avoid long or large sleeves, ties,
scarfs, shawls, or any other swinging ornament that might touch the connection points during the aseptic procedure of bag exchange. Long hair must
be collected in a cap, for the same reason. A mask will prevent contamination
by coughing, sneezing, or saliva droplets.
2.4. Hand care
Nails must be cut short and should be very clean. Hand washing is important
to reduce bacterial contamination. We teach our patients or their helpers to
wash their hands for two minutes with chlorexidine-containing compounds or

with a neutral soap before beginning the bag-exchange operation and again
just before connecting the tubing to the new bag. The usefulness of sterile
gloves is matter of controversy, since the patient has to touch nonsterile
material. In our opinion they may even reduce the attention level in patients
not fully aware of the precautions necessary when operating in asepsis. With
in-line disinfection, we consider sterile gloves unnecessary. If any skin wound
is present on the operator's hands, however, gloves are mandatory.
2.5. Bag care
Bags must be stocked in a clean and dry room and only for a limited period
of time. It is good policy to control the expiration date and to use the oldest
bags first. Piling many bags may damage them and may favor bacterial contamination. Integrity of the bag's envelope must be checked before any bag
exchange. After opening the envelope, maximum attention must be paid to
checking the bag's limpidity, integrity of tubing and the connections, and
looking for fluid leakage at tubing insertion points or the injection port during
bag compression. Dry heating of the bag at a temperature close to 3TC should
be used. Higher temperatures may enhance plastifier release or damage the
bag.
3. CONNECTION SYSTEMS
In parallel with CAPD growth, a new technological branch called connectology

has developed, whose purpose is to find new connection systems, that are as
simple, safe and reliable as possible.
After the early days, in which sterility of connection was thought to be
guaranted by the aseptic procedure, bacteriologic filters were inserted in-line
into the connector. Later, flushing of tubing with fresh fluid and effluent dialysate was proposed to wash out bacteria suspended in the fluid filling the
tubing system. A further step has been sterilization of the connector just before
336
or after the connection. Disinfection of the ends when connecting them, disinfectants filling the connector, heat, and ultraviolet-rays (UV) are the sterilizing methods proposed by different investigators.
The results obtained with each system have often been very different from
one group to another, due to several factors: initial selection of patients, their
training, the number of patients included in the program, the presence of
devoted personnel, the percentage of patients switching to hemodialysis (with
consequent maintainance in the CAPD program of patients with a low peritonitis incidence only) and all the other factors that characterize the wellknown "center-effect." Unfortunately, very few prospective, controlled studies
have been reported (table 20-1), so that, in most cases it is difficult to assess
the validity of the method proposed. In the majority of cases, authors compare
the results achieved with one method with the historical results they formerly
obtained with the standard Toronto Western Hospital system (standard
system); the validity of such a comparison is questionable.
3.1. Standard systent
These are the first connectors introduced for peritoneal dialysis. The connection to the bag is made with a spike (figure 20-1) or with a Luer-Lock.
In the spike system [10], in order to reduce the number of connection procedures, the bag is kept folded on the abdomen during the dwell time and is
subsequently filled with the effluent dialysate.
For the bag exchange, the patient unfolds the empty bag and puts it below
the abdominal level while opening the clamp to allow fluid drainage by
Table 20-1. Efficacy of connectors in reducing
peritonitis incidence. Results of clinical randomized studies.
Control connector
(pts, FU, PI)
Authors
Year
Reference
Maiorca R et al.
1983
15
Pascoe et al.
1984
Ogden et al.
1984 36
Ryckelynck et al.
1987 64
Spike
NR
75
117
O-set soaked in disinfectant
Fenton et al.
1987
Spike
V iglino et al.
1987 79
Spike
30
Spike
10
24
351
57
199
1/11
1/4
1/25
14
NR
117
Y -solution transfer set
(Travenol conventional
system)
28
188
1/62
Experimental connector
(pts, FU, PI)
Y -solution transfer set
32
Spike
363
1/33
+ antisepsis
52
1/3
Sterile connection device

NR
58
1119
O-set
25
217
1/43
o-z connector'
1120
14
NR
Travenol advanced system
28
176
FU = Followup (patient-months); PI = peritonitis incidence (episode/p-m); NR = not reported.

'High-risk patients only.
1/88
o
L-
337
ProtectIve
covering
~~port
.....-Spike
Titanium
adaptor
Catheter
Figure 20-1. Setup for CAPD, using a spike (standard system). Once the protective port
covering has been removed, the tubing set is connected to the bag by a spike.
gravity. Then he places a povidone-iodine (Betadine) soaked sterile gauze

over the spike-outlet port area, wears a mask, and washes his hands. At the
end of the drainage, the patient clamps the tube, pulls out the spike from the
old bag, and inserts it into a new bag previously suspended on a stand.
This system has been subsequently modified by substituting a Luer-Lock for
the spike. The results have been different in different centers, with the
incidences of peritonitis ranging from 4 to 0.5 episodes/year (1/3-1/24 p-m)
[10-25].
In order to reduce the risk of touch contamination due to a patient's manual
disability or visual impairment, mechanical devices have been introduced that
allow the connection to be made without touching the tube ends. With the
Compact Exchange Device, the peritonitis rate has been reported to have
dropped from 117.5 p-m to 1/32 p-m [13].
Another way to reduce touch contamination is to disinfect the connector
end just before connection. The disinfectant used is usually povidone-iodine.
In 22 patients followed for 294 p-m, Parsons et al. [26] observed a reduction
in peritonitis incidence from one episode/4.4 p-m to 1/85.4 p-m. Similarly,
Cavagna et al. [27] obtained a reduction to 1118.2 p-m by performing connection during immersion in a chloroxidizer (Amuchina). Gluck et al. [28]
employed one automatic exchange device (Trav-X-change II device) and
disinfection, and obtained a reduction of peritonitis incidence to 1157 p-ll)..
The disinfectants used have improved and have led to the design of special
connectors and connecting procedures.
338
3. 1. 1. Beta-cap (ann ector
The beta-cap connector [29, 30] was first introduced for IPD and was later
applied to CAPD. It includes four components: 1) beta-cap: a cap of resistant
plastic that closes the catheter end; 2) beta-cap adapter: placed in the peritoneal
catheter for connection with the beta-cap; 3) finger grip: facilitates handling of
the catheter while protecting its end; and 4) catheter-clamp: placed on the
distal part of the catheter, about 5 em from its end. Bag-exchange is performed
as follows: the spike on one end of the connector is inserted into a drainage bag
and the other end is connected to the beta-cap adapter, after removing the beta
cap. The clamp is opened so that peritoneal fluid drainage begins. At the end of
drainage, the connector spike is pulled out from the drainage bag and inserted
into a new bag. When fresh dialysate has entered the perioneal cavity, the
catheter and connector are clamped and disconnected. With a special capillary
tube, the distal part of catheter (from its end to the clamped point) is filled with
povidone-iodine. The beta cap (which has been stored in disinfectant) is again
placed on the adapter: with this maneuver, the disinfectant fills up the space
completely, including the internal surface of the beta cap. Using this system,
McMahon and Moriarty [30] obtained a peritonitis incidence of 1/9 p-m.
3.1.2. Oreopoulos-Zellerman connector
The Oreopoulos-Zellerman connector [31] is a silicone rubber tubing that is

connected to the catheter by a standard adapter. The spike at the other end is
surrounded by a cylinder with a bell-shaped end, which prevents accidental
touch contamination and facilitates the connection. During the dwell time, the
spike is covered by a cup filled with povidone-iodine.
For bag exchange, the spike cup is removed and the spike is connected to the
drainage bag through a special adaptor that prevents contamination. After
drainage, the spike is inserted into a new bag and the peritoneal cavity is filled
with fresh dialysate.
In a controlled trial with this method in high-risk patients (more than three
peritonitis episodes/year or more than two episodes in three months), the
peritonitis incidence was reduced from 117 p-m to 1/20 p-m [14]; the results
were even better in unselected patients (from 1/9 to 1136 p-m) [15].
3.1.3. Fuchs' connector
The Fuchs' connector [32] (figure 20-2) has two parts, one containing a deepseated cone and another with an elastic barrier that functions as a slit valve.
Both elements are surrounded by a cylinder that protects them from touch
contamination. Before connection, the two parts are sprayed with an alcoholic
solution of povidone-iodine. During connection, the cone penetrates the
elastic barrier (slit-valve, see figure 20- 2) and the two parts are then fixed in a
bayonet joint. The incidence of peritonitis with this method was reduced to
1/16 and 1/13 p-m [29, 33].
339
Slit-valve
===~~WZZ'=???=~ r=
O-ring
Figure 20-2. Sections of Fuchs' connector. In the upper drawing, the two parts are
disconnected; the part on the left side has a deep-seated cone surrounded by a cylinder; the part on
the right side has an elastic barrier (slit-valve). In the lower drawing, the two parts are connected:
The cone has penetrated the slit valve, while the external cylinder of the part on the left side
surrounds the whole system to protect it from touch contamination .
Bag
U-"""
Povidone-Iodine
sponge
(II
l'
Catheter
Figure 20-3. Sections of Becker's connector@ In the upper drawing, the two parts of the LuerLok connector are disconnected. The male (disposable) part (on the left side) is fixed to the bag
and contains a povidone-iodine-soaked sponge within the protective sleeve; the female part (on
the right side) is attached to the catheter by a connecting line and is changed every two weeks. In
the lower drawing the two parts are connected; during the connection, the povidone-iodinesoaked sponge is compressed within the sleeve so that povidone-iodine moistens the inner part of
the connector during the dwell time.
3.1.4. Becker's connector
Becker's connector [34] (figure 20-3) is a Luer-Lock connection with both the
parts protected by a sleeve. The male part, fixed on the bag and containing a
povidone-iodine-soaked sponge, is disposable; the female part is attached to
the catheter by a connecting line and is changed every two weeks. During the
connection, the povidone-iodine-soaked sponge is pressed within the sleeve so
that the disinfectant can moisten the inner part of the connector during the
dwell time. As far as we know, no clinical results with this method have been
published.
340
....
--
C.,he."
.>
b)
c)
d)
. )
Figure 20-4. Schematic drawing of Hong Kong connection system and connecting procedure.
a: bag tube and catheter, both capped; b: the capped ends of bag tube and catheter have been
inserted, through small incisions, in a sterile, transparent polyethylene bag, containing two gauzes
soaked into a disinfectant solution (povidone-iodine or chlorexidine); c: the capped ends are
wrapped with the two gauzes for five minutes; d: the uncapped ends are wrapped with the two
gauzes for five more minutes; e: the ends are connected and drainage performed. All these steps are
carried out by the patient who handles the ends of the bag tube, and catheter from the exterior of
the sterile polyethylene bag.
3.1.5. Hong Kong connector
The connecting tube and the catheter with its adaptor of the Hong Kong
connector [35], both capped (a in figure 20-4), are inserted through small
incisions into a previously prepared sterile, thin, transparent polyethylene bag
containing two gauzes soaked with povidone-iodine or chlorexidine. The incisions are sealed with tape. The ends are then wrapped with gauze (c in figure
20-4) for five minutes, after which the caps protecting the end of the tubes are
removed and the gauze is wrapped around the uncapped ends (d in figure
20-4) for another five minutes. Then the connection can be made (e in figure
20-4) and the bag emptied. Finally, after emptying, the tube and catheter can
be disconnected. All the steps are carried out by the patient from the exterior
of the sterile polyethylene bag. The sterile polyethylene bags are prepared by
the patient once a week.
The incidence of peritonitis reported with this method was 1/20 p-m, which
341
was further reduced, with some modifications to 1170 p-m (0.17 episodes per
year).
3.2. Heat sterilization
Several connectors have been proposed that are sterilized by heat just before or
after the connection. The parts of some of these connectors that are to be
heated contain no dialysis fluid, in order to avoid caramel formation during
sterilization.
3.2.1. Sterilization by flame
The part of the connector fixed to the bag is ceramic, and the part fixed to the
line is nickel. A screw nut reinforces the connection. They are sterilized by
heating the connecting parts to 200C over an alcohol stove for two minutes.
The system may create problems, such as tube or ceramic breaking or tube
fusion. The incidence of peritonitis in 60 patients, with a followup of 651 p-m,
was 1117 p-m [36].
3.2.2. Microwaves
With this method, proposed by Bielava et al. [37], temperatures of 138 Care
reached, together with an increase in the pressure of the fluid entrapped in the
connector.
3.2.3. Infrared rays
The connector [38] (after the humidified male part has been joined to the
female part) is sterilized under an infrared lamp to a temperature of 124C. The
procedure requires 7.5 minutes (2 minutes for heating, 3.5 minutes for
sterilizing, and 2 minutes for cooling).
3.2.4. Heat welding and sterilization (Sterile connection device, Sterile weld)
This method was described by Hamilton et al. [39]. The chief working components are a microprocessor control system; two tubing carriers, one fixed
and one movable; and a heated, blunt copper sterilizing wafer (figure 20-5).
The bags used in this system have an air-filled extension tube. After drainage,
the residual air in the old bag is allowed into the tube by the patient. The
administration set and the extension tube are put in the holders. The wafer heats
and melts the tubes killing bacteria and spores. As the melted polymer cools a
seal is formed. After in-vitro experiments that showed good results [39, 40],
conflicting results were obtained in two clinical studies, one with an incidence
of peritonitis of 1/19.3 p-m (vs. 117.5 p-m) [41], and one with only 1/10 (vs.
1/9 p-m with the standard system) [17].
3.2.5. Thermal sterilization
Both the catheter and the tubing have a steel adaptor which, after connection,
is heat-sterilized at 360C for one minute [42, 43].
342
A)
To the
catheter
:=~!!!!!!!!!~~~~~=:::
New bag
: : Old bag
Tubing carriers
B)
To the
cathete,-
:=:::==::::~=::=::====
_~~IIiIIIIIIIIIC====:===::
::
New bag
Old bag
Figure 20-5. Schematic drawing of 'sterile connection device'@ A: The tubes of both the new
and old bag arc lodged in the tubing holders; one holder is mobile. B: A heated welding wafer (not
drawn) melts the tubing, then the tubing holder shifts and aligns the two tubes. Their molten ends
are now merged to form a weld.
3.3. UV sterilization
Proposed by Eisinger [44] for IPD, the use ofUV sterilization was subsequently
extended to CAPD by Popovich et al. [45]. However, the original method,
which appeared in in-vitro studies to be highly efficient [46, 47] did not seem
to be able to reduce the incidence of peritonitis when tested in vivo in some
open studies [19, 48, 49] and in a multicenter study [18]. Therefore, the method
has been modified. The system now consists of a plastic box with a drawer in
which the connector and the the outlet port, permeable to ultraviolet rays, are
located. When the drawer is closed, an ultraviolet lamp is lit and a control
system assures that the ultraviolet irradiation is adequate for sterilization, even
when the lamp loses power over time. After ultraviolet irradiation, a connection is obtained with a mechanical device that inserts the spike into the
outlet port within the box. Good results have been reported with this device
by some investigators (1117 p-m) [50, 51].
3.4. Connectors with bacteriological filters
To prevent peritonitis, addition of a bacteriological filter between the bag

and the catheter has been proposed [52] (figure 20-6). This method was
initially employed for IPD [53] and is now used for CAPD. The filter has
some cellulose membranes that are able to retain particles larger than 0.22
micrometers. The connector is made of two parallel tubes, one for drainage
(bypass for drainage in figure 20-6) and one for infusion (infusion line in
figure 20-6). The two tubes join at their extremities, forming a single tube at
each end: One of these is connected to the catheter (down in Figure 20-6), the
other to the bag (up in figure 20-6). The bag used to fill the peritoneal cavity
343
........ Clamp
Bacteriological
filter -----...
Cath.t.r~
Figure 20-6. Schematic drawing of a connector with a bacteriological filter. The connector is
made of two parallel tubes, one for drainage (bypass for drainage) and one for the infusion
(infusion line). The two tubes join at their extremities, forming a single tube at each end: One of
these is connected to the catheter (down in the figure), the other one to the bag (up in the figure).
The bag used for filling the peritoneal cavity with dialysate may also be used for draining it. The
bacteriological filter is placed in the infusion line in which a unidirectional valve prevents peritoneal dialysate from refluxing through the filter. Another similar valve in the outlet tube also
ensures unidirectional flux for drainage (antirdlux valve).
with dialysate may also be used to drain it. The bacteriological filter is placed in
the infusion line, in which a unidirectional valve prevents peritoneal dialysate
from refluxing through the filter. Another similar valve in the outlet tube also
ensures unidirectional flow for drainage (antireflux valve in figure 20-6).
The results [52, 54-62] have varied according to many factors, such as
modifications of the filter, the aseptic procedure followed, patient selection,
etc. In the best series, one peritonitis episode every 24 months was observed
[52, 56]. The effectiveness of these filters in preventing contamination has been
questioned. Tranaeus et al. [63] have demonstrated bacterial growth on both
sides of the filter, and a positive limulus test (indicating the presence of
bacterial endotoxins) in the fluid after the filter. Endotoxins in the bacterial
colonies growing within the filter will enter the peritoneal cavity, damaging
the mesothelium and stimulating peritoneal macrophages [6]. One of the
dangerous effects is a sustained production of interleukin-l, which may have a
role in developing life-threatening "sclerosing encapsulating peritonitis" [6,
64].
344
3.5. Connectors utilizing flushing
The rationale for these devices is that the physical action of flushing is effective
in washing out all or most of the bacteria from the connecting lines. They are
Y -shaped, and one of the three branches is for connection to the catheter,
another for connection to the fluid inlet, and the third for dialysate drainage.
Y -connectors have been registered with different names: O-set, Safe-Iock-Osystem, and Y -set.
Verger and Luzar [65], in in vitro studies of experimentally contaminated
systems, demonstrated that flushing 100 ml of fluid in the first five minutes
after contamination washed out 100% of Staphylococcus epidermidis, 60% of
Staphylococcus aureus, but only 30% of Pseudomonas aeruginosa. The same flushing, nine hours after contamination, was able to completely eliminate Staphylococcus epidermidis but not Staphylococcus aureus or Pseudomonas aeruginosa. A
two-liter flushing was also ineffective for washing Pseudomonas from the catheter. They consider this different behavior to be due to differences in bacterial
adherence to the connector, due to the presence or not of pili or polar flagella
(Pseudomonas) .
Donald et al. [66], using the O-set in 89 patients and following them for 765
p-m, achieved an incidence of peritonitis of 1/23 p-m. Better results were obtained by adding a disinfectant. Using the O-system, good results (1 episode
every 33 p-m) were obtained by Uttley et al. [67].
Schmid et al. [68], in an in-vitro study with the Fresenius "O-system,"
found that after washing a line that had been contaminated with an aqueous
bacterial suspension, only 0.2% -2% of bacteria reached the peritoneal cavity.
They also pointed out that this washing was not as effective after touch contamination, due to greater bacterial adherence.
The in-vivo effects of flushing a Y -connector have been examined by Rottembourg et al. [16] in 27 patients (followup 277 p-m), compared to 28 others
(followup 344 p-m) on a standard system: The results were one peritonitis
episode every 23 p-m for the V-connector against 1/12 for the controls. In 16
patients, the incidence of peritonitis was reduced from 1/10 p-m on the
standard connector to 1/24 with the Y -connector and flushing. A controlled
study of the combined effect of flushing plus connector end disinfection versus
flushing alone in a Y -set was carried out by Ryckelynk et al. [69]. Surprisingly,
they had better results with flushing alone (1/43 vs. 1125 p-m). However, in
their study, only the connector end was soaked in the disinfectant and the
duration of disinfection is not indicated. The disinfectant used by the authors
was povidone-iodine, which requires a long time (at least five minutes) to be
effective.
An innovative method has been introduced by Bazzato et al. [70]. The catheter has an adaptor divided into two branches, in order to allow a greater
number of punctures so that it can be changed only every two weeks (figure
20-7 A). Each branch, when not in use, is covered by a cap. In every cycle a
"double-bag" disposable system is used. This consists of a bag containing
345
CD::
~
Toth.
~~catheter
Figure 20-7. Double-bag system@ A: adaptor for the peritoneal catheter with two branches;
each of them can be punctured by the needle C; B: disposable double bag, one filled with dialysis
fluid and the other one empty. The two bags are connected to the catheter adaptor with a needle on
the free branch (C).
dialysis fluid and an empty bag (figure 20-7B). They two bags are connected
by a Y -tube, whose free branch has a needle (figure 20- 7C). At the time of
drainage, the needle is inserted into one of the free branches of the catheter
adaptor and peritoneal dialysate drains into the empty bag. This results in a
two-liter washing of the connector. Then the new dialysate from the other bag
is allowed to fill the peritoneal cavity. At the end of this phase, the needle is
pulled out and the double-bag system is thrown away. During the dwell time,
the patient enjoys freedom from the bag. In a first variant, the distal parts of
the two branches of the catheter adaptor were provided with a povidone-iodine
chamber to sterilize the spike entering the connector lumen (figure 20-SA).
Subsequent modifications were: 1) a Closter-system [71] (figure 20-SB), in
which the needle is covered by a cap to be pushed back during connection; 2) a
Sayfter -cap [72, 73] (figure 20-SC), a sterile disposable capping-off chamber
filled with disinfectant, replacing the catheter adaptor. A further modification
of this method, in which the connection is made through an adaptor without a
needle (CAPO system with integrated closure) has been proposed by others
[74]. The results obtained with these different systems vary from 1/19-1/22
p-m (double bag) [71, 75, 76], to 1/20-1/24 p-m (closter) [77, 7S], to 1/27
(integrated closure) [79]. There are no data available for the Sayfter-cap system.
The Take-off System is another two-bag system that utilizes a specifically
designed safe-lock connector. There are five steps in using this system, each of
them allowing only one phase of the entire bag-exchange cycle (figure 20-9).
This prevents patients error. Before connection, the two parts of the connector
arc sprayed with povidone-iodine.
346
II. Peritoneal access for dialys is
Figure 20-8. Modifications of the double-bag system. A: Distal part of the tw o branches of the
catheter adaptor (A in fi gure 20-7) provided with a povidone-iodine chamber; B: double-bag
with a Closter-system: the needle is covered by a cap that is pushed back during connection;
C: Sayfter-cap, a sterile disposable cappin g-off chamber fill ed with disinfectant.
3.6. Y -systems with in-line disinfection
These systems combine three procedures in order to obtain an effective asepsis:

1) filling oflines with a disinfectant that is left there for the entire dwell time; 2)
washing out of the connector with 100-200 ml of fresh dialysate and, subsequently, with the peritoneal draining fluid; this eliminates killed bacteria and
their toxins; and 3) disinfection of conn ecting ends before making all connections. During the dwell time the patient does not wear the bag that is
disconnected and thrown away just after filling the connector with the disinfectant. The disinfectant used is an electrolytic chloroxidizer (Amuchina),
which differs from hypochlorite in having a less alkaline pH, being less
damaging to tissue, and having a greater stability. At the concentration used
(6000-12,000 ppm offree available chlorine), it is able to completely disinfect
in one minute.
Accidental introduction of disinfectant into the peritoneal cavity is a rare
risk. If this occurs, the patient complains of a sudden acute pain that disappears
after 2-3 peritoneal flushings. In our experience [80], this accident has not
caused any biochemical abnormalities or ultrafiltration loss or reduction of
peritoneal clearance.
TO THE
CATHETER
='1=iiiiiiilllll
347
NEW BAG
DRAINAGE
Figure 20-9. Connector of the Take-off system SF. The connection is made by a safe-lock (SF
safe-lock), which integrates five functions through five subsequent steps: 1) rinsing of the
connection with dialysis fluid going from the new bag to the drainage (empty) bag; 2) drainage of
the peritoneal fluid; 3) fresh solution flows into the peritoneal cavity; 4) dialysis fluid inflow can be
regulated; and 5) automatic closure of the safe-lock when the system is removed.
3.6.1. Perugia CAPDsystem@
The original connector of Buoncristiani et al. (Perugia CAPD System) [81]

has three short branches that connect to the peritoneal catheter, to the long
outflow tube of the new bag, and to a drainage tube (figure 20-10). The
connector is fixed to the catheter and is replaced every eight weeks by a skilled
nurse.
At the beginning of the bag-exchange procedure, the distal end of the bag's
outlet tube, provided with a valve, is filled with disinfectant and is then
connected to one branch of the connector; the other branch is joined to a
drainage tube. While the branch of the connector fixed to the catheter is
clamped, the valve is broken and 100 ml of fresh dialysate are allowed to flush
out the disinfectant from the distal end of the bag's outlet tube, the two
branches of the connector, and the drainage tube. Then the peritoneal fluid
drains through the drainage tube after unclamping the branch to the catheter
and clamping the branch to the new bag. At the end of drainage, the fresh
dialysate enters the peritoneal cavity after clamping the branch to the drainage
348
~ Inlel brarlCh
To lI1e
~ - c'lnater
...... OUU.t brafICh
~
... -
Cap
Drainage
tube
Figure 20-10. Perugia CAPD system. This system consists of a Y -connector with three short
branches for connection with the peritoneal catheter, the long outflow tube of a full bag, and a
drainage tube. This connector is fixed to the catheter. The distal end of the bag's outlet tube is
provided with a valve (enlarged and circled in the figure) and is filled with disinfectant before
connection.
tube and unclamping the branch to the new bag. The final step is filling the Yconnector with disinfectant by a syringe while the catheter branch is clamped.
The empty bag can be disconnected and discarded. Thus, during the dwell
time, the Y -connector is full of disinfectant.
With this method, Buoncristiani et al. obtained incidences of peritonitis of
1/33 [82] and of 1/42 p-m [83] in open studies.
3.6.2. Y-solution transfer set (Y-set)
Maiorca et al. [20] have used a modified Y -connector (Y -solution transferset) in order to use standard bags. The Y has a long inlet branch that is conected directly to the bag's outlet port by a spike during the exchange and is
protected by a spike-cap between exchanges (figure 20-11). The outlet branch
of the Y -connector is also long, so that a drainage tube is not necessary. The
short branch of the Y -connector is fixed with a Luer-Lock to the catheter
through a titanium catheter adaptor. The Y -set is changed at the hospital every
eight weeks by a skilled nurse. Maiorca et al. [20] have carried out a controlled,
prospective, two-center study comparing this so-called Y -system (Y -connector
349
.--New bag
L-
~__
protective
port covering
~Spjke
......- Inlet tube
~_Tothe
catheter
..-....- Outlet tube
Figure 20-11. Y -solution transfer set@ This set contains a modified Y -connector, which allows
the use of standard bags. The Y -connector has a long inlet branch, which is connected directly to
the bag's outlet port by a spike during the exchange and is protected by a spike cap between
exchanges. The outlet branch of the Y -connector is also long, functioning as a drainage tube.
The short branch of the V-connector is fixed by a Luer-Lok to the catheter, through a titanium
catheter adaptor.
with disinfectant) with the standard system. The incidence of peritonitis was
1/33 p-m with the Y-system and 1III p-m with the standard system. These
results were improved in subsequent studies [21, 80], with a peritonitis
incidence of 1/50 p-m. The overall results of this group are reported in figure
20-12, including patients transferred from hemodialysis.
The same system was used in a multicenter open study [24] with results that
significantly differed for the Y -system (1/23 p-m) and the standard system (1/9
p-m). The latter study also showed that there are large differences in different
centers, even though the validity of the Y -system is beyond question.
The Y -systems have had widespread use in Italy: The Cooperative Study
Group on CAPD, which joins 34 centers, has extended its use between 1983
and 1985 from 35% to 80% of the patients [25].
A new modification of the Y -set (Travenol Advanced System, is now being
used in a multicenter, prospective, controlled study. Preliminary results show
an incidence of peritonitis of 1/88 p-m with the new version of the Yconnector against 1/62 with the old version (controls). For these preliminary
data, however, the difference is not statistically significant [84].
350
1000
800
..
600
~----------------------------------------~
f------------------------
40
"'0
30
20
"'C
ill Z 400 +------------a:;

0
~~
en
or-
OlD
~=
10
200 +---------7~
~~
0
ZZ
32
en ...
+------------------
.c
~!
9!~
gm
az
:r
~
0
7980
1981
1982
1983
1984
1985
1986
1987
* 1st
quarter
--
peritonitis
incidence
bSl
Slandard set
Vset
Figure 20-12. Mean interval (in patient-months, scale on the right-hand side, line) between
peritonitis episodes after the introduction of the Y -system in our center over the years. Bars
represent annnal experience (in patient-months; scale on the left-hand side); solid bars represent
use of the Y -system; diagonal bars represent use of the standard system (spike). The mean interval
increases with the increasing use of the Y -system.
4. CONCLUDING REMARKS
We are thoroughly convinced that the future of CAPD is closely linked to the
control of peritonitis, since peritonitis is the main cause of drop-out from
CAPD programs, reduces patients' acceptance of this type of dialysis, impairs
their well-being (and perhaps their survival) when on CAPD, and heavily
increases the rate of hospitalization, center load and, consequently, the overall
cost of treatment.
The drop in peritonitis incidence obtained with the use of Y -systems with
in-line disinfection is consistent with a major role of touch contamination in
causing peritonitis. Other causes, such as the extraluminal, transluminal, or
blood circulation routes of infection, or the immunological defense status of
the patient, undoubtedly play lesser roles.
Weare therefore convinced that significant reduction in the incidence of peritonitis can be obtained only by improving connection devices and techniques.
An ideal connector should have the following characteristics:
1. Extreme simplicity of use, so that it can be used by any patient (even

patients with visual or manual impairment)
2. The smallest number of components, in order to reduce the risk of
contamination during disconnection of stuck parts.
3. No release of microparticles, or materials used for adherence
4. A safe catheter-connector connection, not accidentally disconnectable
351
5. The least encumbrance, with empty bag removable after bag exchange
6. Long-term resistance to the chemical or physical agents used
7. The method for its use should protect from touch contamination but
should also ensure against bacterial growth and colonization during the
dwell time; wash-out of killed bacteria and their toxins must be ensured
8. If a chemical disinfectant has to be used, this must be highly effective and
nontoxic to the patient; the accidental introduction of disinfectant into the
peritoneal cavity should be made impossible, but, if it occurs, there should
be no danger to the peritoneum
9. It must allow a minimum filling and draining time
10. It must be superior to any other method for reducing the peritonitis rate
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42. Di Paolo N, Buoncristiani U, Frigato C, DeMia M, Rubegni M: A new system for
continuous ambulatory peritoneal dialysis. In: Gahl GM, Kessel M, Nolph KD, (eds)
Advances in Peritoneal dialysis. Amsterdam: Excerpta Medica, 1981, pp 105-110.
43. Buoncristiani U, Di Paolo N: Autosterilizing CAPD connection system. Nephron 35:
244-247, 1983.
44. Eisinger Aj: A simple method of lessening the incidence of peritonitis in peritoneal dialysis
using a photochemical reactor. Clin Nephrol 14:42-44, 1980.
45. Popovich RP, Moncrief J,Sorrel-Akar P: An ultraviolet germicidal system to alleviate touch
contamination in CAPD. Proc Am Soc Nephrol 16:123A, 1983.
46. Holmes CJ., Miyake C, Kubey W: In-vitro evaluatin of an ultraviolet germicidal connection
system for CAPD. Perit Dial Bull 4:215-218, 1984.
47. Popovich RP, Moncrief JW, Sorrels-Akar AJ, Mullins-Blackson C, Pyle K: The ultraviolet
germicidal system: The eliminatin of distal contamination in CAPD. In: Maher JF, Winchester
JF (eds) Frontiers in Peritoneal Dialysis. New York: Field, Rich and Assoc, 1986, pp 169-175.
48. Boeschotcn EW, Southwood J, Struijk DG, Krediet RT, Arisz L: Prevention of peritonitis:
Filter or UV system? Contr Nephrol 57:158-166, 1987.
49. Iravani A, Fennel RS, Mack C, Richards GA: Peritonitis and continuous peritoneal dialysis:
With and without the use of the ultraviolet germicidal exchange system. Perit Dial Bull 6
(SuppI4):Sll, 1987.
50. Tapson JS, Hepplewhite PM, Wilkinson R: Experience with the Travenol ultraviolet
germicidal exchange system. Contr Nephrol 57:167-171, 1987.
51. Zappacosta R, Perras ST: Reduction of CAPD peritonitis rate by the Travenol CAPD
germicidal exchange device (UV-XD). Perit Dial Bull 6 (Suppl 4):S24, 1987.
52. Slingencyer A, Leindo-Liendo C, Mion C: Continous ambulatory peritoneal dialysis with a
bacteriological filter on the dialysate infusion line. In: Legrain M (ed) Continuous Ambulatory
Peritoneal Dialysis. Proc Intern Symp CAPD. Amsterdam: Excerpta Medica, 1980, pp
59-68.
53. Sarles HE, Lindley JD, Fish JC, Biggers JA, Cottom DL, Cottom JR, Mader JT, Dunaway
JE, Remmers AR JR: Peritoneal dialysis utilizing a millipore filter. Kidney Int 9:54-56, 1976.
54. Slingeneyer A, Mion C, Despaux E, Perez C, Duport J, Dansette AM: Use of bacteriologic
filter in the prevention of peritonitis associated with peritoneal dialysis: Long term clinical
results in intermittent and continuous ambulatory peritoneal dialysis. In Atkins RC, Thomson
NM, Farrel PC, (eds) Peritoneal Dialysis. Edinburgh: Churchill Livingstone, 1981, pp
301-312.
55. Slingeneyer A, Mion C: Peritonitis prevention in continuous ambulatory peritoneal dialysis:
Long term efficacy of bacteriological filters. Proc. Eur Dial Tansplant Assoc. 19:388-396,
1983.
56. Slingeneyer A, Mion C, Ponsot JF, Rossi P: Peritonitis prevention in CAPD: A comparison
of 3 models of connecting devices with an in-line bacteriological filter. Perit Dial Bull 4
354
(Suppl 2):S60, 1984.

57. Winchester JF, Ash SR, Bousquet G, Rakowsky TA, Barnard WF, Heeter EM, Haley S:
Successful peritonitis reduction with an unidirectional bacteriologic CAPD filter. Trans Am
Soc ArtifIntern Organs 29:611-615,1983.
58. Ash SR, Horswell R, Heeter EM, Block R: Effect of the Peridex filter on peritonitis rates in a
CAPD population. Perit Dial Bull 3:89-93, 1983.
59. Ash, SR, Winchester JF: Effect of the Peridex filter on peritonitis rate in a CAPD population.
Perit Dial Bull 4:S118-S120, 1984.
60. Rotellar C, Winchester JF, Ash SR, Rakowski TA, Barnard WF, Heeter E: Long-term use of
unidirectional bacteriologic filters to reduce peritonitis frequency in CAPD. In: Maher JF,
Winchester JF (eds) Frontiers in Peritoneal Dialysis. New York: Field, Rich and Assoc, 1986,
pp 203-206.
61. Morgan B, Dale A, Foulks C, Singh S: Efficacy of the Peridex filter in reducing peritonitis
rates in CAPD patients. In: Khanna R, Nolph KD, Prowant B, Twardowski ZJ, Oreopoulos
DG (eds) Advances in Continuous Ambulatory Peritoneal Dialysis. Proc Fifth Annual CAPD
Conference, Kansas City. Toronto: Peritoneal Dialysis Bulletin, 1985, pp 73-76.
62. Boeschoten EW, Southwood J, Struijk DG, Krediet RT, Arisz L: Prevention of peritonitis:
Filter or UV system? Contr NephroI57:158-166, 1987.
63. Tranaeus A, Lindholm B, Myrback KE, Flink 0:' Bacteriological filter in CAPD unfavourable clinical and laboratory results. Perit Dial Bull 7 (Suppl 2):S77, 1987.
64. Carozzi S, Nasini MG, Lamperi S: Lympho-mvnokine disorders and peritoneal fibroblast
proliferation in CAPD. Perit Dial Bull 6 (Sup pi 4):S3, 1987.
65. Verger C, Luzar MA: In vitro study of CAPD Y-line system. In: Advances in Continuous
Ambulatory Peritoneal Dialysis 1986. Khanna R, Nolph KD, Prowant B, Twardowski ZJ,
Oreopoulos DG (eds) Toronto: Peritoneal Dialysis Bulletin, 1986, pp 160-164.
66. Donald CM, Eastway A, McMillan M, Alcock S, BriggsJD, Junor BJR: Peritonitis in CAPD
with a disconnect system. Perit Dial Bull 7 (Suppl 2):S24, 1987.
67. Uttley L, Marsden A, MoonJ, ManosJ, Gokal R: '0' set experience; reduction in peritonitis.
Perit Dial Bull 6 (Sup pi 4):S21, 1987.
68. Schmid E, Augustin R, Kuhlmann U, Machleidt C, Bartz V: Quantitative in vitro
contamination and recovery studies: The flush principle in CAPD. Contr Nephrol
57:185-190, 1987.
69. RyckelynckJPH, Verger C, Com G, Faller B, Pierre D: Role of the antiseptic in the efficacy of
disconnect systems: A prospective controlled trial. Perit Dial Bull 7 (Sup pi 2):S66, 1987.
70. Bazzato G, Landini S, Coli U, Lucatello S, Fracasso A, Moracchiello P: A new technique of
continuous ambulatory peritoneal dialysis (CAPD): Double-bag system for freedom to the
patient and significant reduction of peritonitis. Clin Nephrol 13:251-254, 1980.
71. Bazzato G, Coli U, Landini S, Fracasso A, Genchi R: Closter: A new connection for a
double-bag system to prevent exogenous peritonitis. Perit Dial Bull 6:138-140, 1986.
72. Seveso M, Galato R, Brando B, Brunati C, Minetti L: Sayfter-cap: A new connection in the
double-bag system. Perit Dial Bull 7 (Suppl 2):S68, 1987.
73. Strippoli P, Civiello F, Orbello G, Scatizzi A: Sayfter-cap device versus biconnector in
double-bag-closter system for CAPD. Perit Dial Bull 7 (Suppl 2):S73, 1987.
74. Koenig P, v Dittrich P: CAPD system with integrated closure. Dial Transplantation
15:78-82, 1986.
75. Bazzato G, Coli U, Landini S, Lucatello S, Fracasso A, Moracchiello M: Continuous
ambulatory peritoneal dialysis without wearing a bag: Complete freedom of patient and
significant reduction of peritonitis. Proc Eur Dial Transplant Assoc 17:266-275, 1980.
76. Bazzato G, Coli U, Landini S, Fracasso A, Moracchiello P, Righetto F, Scanferla F: Six years'
experience of CAPD with double bag system. Abstracts of the III International Symposium
on peritoneal dialysis. Perit Dial Bull 4(Suppl 2):S4, 1984.
77. Bazzato G, Coli U, Landini S, Fracasso A, Morachiello P, Righetto F, Scanferla F, Del Turco
M, Genchi R: II Closter: Una nuova connessione per il sistema a doppia sacca nella
prevenzione delle peritoniti esogene. In: Lamperi S, Cappelli G, Carozzi S (eds) Dialisi
peritoneale. Atti del III Convegno Nazionale sulla Dialisi Peritoneale. S. Margherita Ligure,
20-21 Settembre 1985. Milano: Wichtig Editore, 1985, pp 183-189.
78. Giordano C, De Santo NG, Capodicasa G, Scatizzi A, Bazzato G, Siciliano A, Sparano A,
Cicchetti T, Gianni S, Strippoli A, Daidone G, Fracasso A, Aulisio M, Capasso G, Cirillo D:
355
A multicenter study with the double-bag closter system. Perit Dial Bull 7 (SuppI2):S34, 1987.
79. Koenig P, v Dittrich P: Diminution of drop-out and peritonitis episodes by using a CAPD
double-bag system with integrated closure. Perit Dial Bull 7 (Suppl 2):S42, 1987.
80. Maiorca R, Can carini GC, Brasa S, Colomb rita D, Manili L, Camerini C: Y-system with
disinfectant in the prevention of peritonitis in CAPD. Contr Nephrol 57:178-184, 1987.
81. Buoncristiani U, Bianchi P, Cozzari M, Carobi C, Quintaliani G, Barbarossa D: A new safe
simple connection system for CAPD. IntJ Nephrol Urol AndroI1:50-53, 1980.
82. Buoncristiani U, Cozzari M, Quintaliani G, Carobi C: Abatement of exogenous peritonitis
risk using the Perugia CAPD system. Dial Transplan 12:14-45, 1983.
83. Buoncristiani U, Carobi C, Cozzari M, Di Paolo N: Clinical application of a miniaturized
variant of the Perugia CAPD connection system. In: Maher JF, Winchester JF (eds) Frontiers
in Peritoneal Dialysis. New York: Field, Rich and Assoc, 1986, pp 193-197.
84. Viglino G, Colombo A, Scalamogna A, Cavalli PL, Guerra L, Renzotti G, Gandolfo C, De
Vecchi A, Barzaghi W, Cantaluppi A, Balteau P, Peluso P: Confronto prospettico
randomizzato tra due connettori a Y. Abstracts IV Convegno Nazionale di Dialisi Peritoneale.
Stresa, Italy, 1987, p. 54.
LIST OF MANUFACTURERS
Abbott Renal Care

D-Rl0 AP6B
Abbott Park, IL 60064, USA
Peritoneal dialysis
CAPD connection system (for prevention of infection): Standard system
CAPD fluid bags and lines
Accurate Surgical Instruments Corp.
590 Richmond St. W.
Toronto, Ontario, Canada M5V 1Y9
Peritoneal dialysis
Tcnckhoff catheters (straight)
Permanent Toronto Western Hospital catheters (straight) (OroupoulosZellcrman catheters)
Swan Neck (Tenckhoff, Oroupoulos, Missouri, Coil Missouri) peritoneal
dialysis catheters
Pcdiatric catheters
CAPD connection systems (for prevention of infection): OreopoulosZeller man connector
357
358
Amicon Division, W.R. Grace & Co.

24 Cherry Hill Dr.
Danvers, MA 01923, USA
Hemodialysis
Femoral catheters
Argon Medical Corp.

1445 Flat Creek Rd.
Athens, TX 75751, USA
Hemodialysis
Single- and double-lumen subclavian catheters (Teflon, polyurethane)
Asahi Medical Co., Ltd

The Imperial Tower
1-1, U chisaiwaicho 1-chome
Chiyoda-ku, Tokyo, Japan
Asahi Medical GmbH

Lyoner Strasse 44-48
D-6000 Frankfurt/Main 71
Fed. Rep. Germany
Hemodialysis
A V fistula needles
Baxter Healthcare Corp.

1425 Lake Cook Rd.
Deerfield, IL 60015, USA
Hemodialysis
A V fistula needles
Peritoneal dialysis
Stylet disposable catheter
CAPD connection systems (for prevention of infection): Standard system,
UV system, 0 system
"Y"-solution transfer set (Travenol Advanced System)
Bellco S.p.A.
Via Camurana 1
P.O. Box 92
1-41037 Mirandola, Italy
Hemodialysis
A V fistula needles
359
Bernas Medical
55, rue Stephenson
75018 Paris, France
Peritoneal dialysis
Column disc catheter: Lifecath
Dacron cuff (Ref 11 308-00)
Silicone glue type A (Ref 10 807-001)
Bieffe Biochimici S.p.A.

Via Nuova Provinciale
1-23034 Grosotto (Sd), Italy
Peritoneal dialysis
CAPD fluid bags and line
CAPD double-bag system with "closter" and "Sayfter-cap"
Bionic GmbH
Max-Planck-Str. 21
D-6382 Friedrichsdorf, Fed. Rep. Germany
Hemodialysis
Implantable right atrial catheter (central venous catheter for permanent
vascular access)
B. Braun Melsungen AG
Postfach 110 & 120
D-3508 Melsungen, Fed. Rep. Germany
Peritoneal dialysis
Stylet disposable catheter for children
CAPD connection systems (for prevention of infection): Fuchs' connector
CD Medical, Inc.
P.O. Box 9308
Miami Lakes, FL 33014, USA
Hemodialysis
A V fistula needles
Double-lumen catheters
Cobe Laboratories, Inc.

1185 Oak St.
Lakewood, CO 80215, USA
360
Hemodialysis
A V fistula needles
Peritoneal dialysis
Tenckhoff catheter with two Dacron cuffs (Cat No 008173-000)
Cook Critical Care, Division of Cook Inc.

P.O. Box 489
Bloomington, IN 47402, USA
Hemodialysis
Single-lumen subclavian/femoral catheters (Teflon)
Double-lumen subclavian catheters for adult and pediatric patients (polyurethane)
Peritoneal dialysis
Acute and chronic peritoneal dialysis catheters
Cordis Inc.
P.O. Box 025700
Miami, FL, USA
Peritoneal dialysis
Cerebral ventricular drainage catheter for newborns and premature infants
Corpak/Thermedies Inc.
100 Chaddick Drive
Wheeling, IL 60090, USA
Peritoneal dialysis
Tecoflex (polyurethane peritoneal dialysis catheters) for adult (straight and
coiled) and pediatric patients (straight)
Dermaport peritoneal dialysis catheter
Davol Inc.
100 Sockanossett Crossroads
P.O. Box 8500
Cranston, RI 02920, USA
Hemodialysis
Single-, dual-, and triple-lumen catheters for central venous access (Hickman
hemodialysis catheter)
361
Peritoneal dialysis
Tenckhoff catheters (straight) for adult and pediatric patients
Modified Hickman-Tenckhoff catheter (straight) for premature infants
Delmed, Inc.! American Medical Products Corp.

P.O. Box 190
Freehold, NJ 07728, USA
Peritoneal dialysis
PD-cycler AMP for CCPD
Drake Willock Division

CD Medical Inc.
13520 S. E. Pheasant Ct.
Portland, OR 97222, USA
Hemodialysis
A V fistula needles
Double-lumen catheters
Evermed
Medina, W A, USA
Hemodialysis
Hickman catheter (silastic right atrial, surgically implantable catheter)
Peritoneal dialysis
Tenckhoff catheters
Fish Laboratories
BP 22
72320 Vibraye, France
Peritoneal dialysis
Albuclair, waterproof plastic cloth for catheter protection
Fresenius AG
Bad Homburg, Borkenberg 14
6370 Oberursel Ts. 1, Fed. Rep. Germany
Peritoneal dialysis
Berlin catheter
"Stag antlers" ("Octopus"), closed dialysis fluid distributing system
362

CAPD connection systems (for prevention of infection): Fuchs' connector,
O-system, 5F safe-lock
Galtier
66, A v. Charles Flahault
34100 Montpellier, France
Peritoneal dialysis
Special needle "Aiguille de Tenckhoff' (Ref. 01 208 04)
Gambro AB
Box 10101
S220 10 Lund, Sweden
Hemodialysis
Vas-cath vascular access devices
A V fistula needles
Peritoneal dialysis
CAPD connection systems (for prevention of infection)
Genetic Laboratories Inc.
1385 Centennial Drive
St. Paul, MN 55113, USA
Hemodialysis
Biological vascular prostheses: Human umbilical vein grafts (Bioflow graft)
W.L. Gore & Associates, Inc.
2401 Singerly Rd., P.O. Box 1220
Elkton, MD 21921, USA
Hemodialysis
Gore-Tex vascular graft (e-PTFE vascular graft)
Peritoneal dialysis
(Gore-Tex peritoneal catheter is no longer manufactured)
Hospal Medical Corp.
21 Northfield Ave.
Raritan Center
Edison, NJ 08837, USA
Hospal Ltd
15 Manderwell Road
Oadly, Leicester LE2 5LQ
England
363
Hemodialysis
A V fistula needles
Impra, Inc.
2445 W. 10th PI.
Tempe, AZ 85281, USA
Impra Medica S.A.

277, Route d'Annecy
1257 Croix-De-Rozon
Geneva, Switzerland
Hemodialysis
Impra vascular graft (e-PTFE vascular graft)
Single- and double-lumen subclavian/femoral catheters (polyurethane)
Peritoneal dialysis
Johnson & Johnson Products Inc.

Patient Care Division
501 George St.
New Brunswick, NJ 08903, USA
Hemodialysis
Vita graft (e-PTFE vascular graft)
Biological vascular prostheses: Extracorporeal artegraft (Bovine heterograft)
Joka Kathetertechnik GMBH

1m Weiher 19
D-7450 Hechingen, Fed. Rep. Germany
Hemodialysis
Single- and double-lumen subclavian/femoral catheters
A V fistula needles
Lifemed of California
2059 Del Amo Blvd.
Compton, CA 90220, USA
Peritoneal dialysis
Tenckhoff (straight) catheters for adult and pediatric patients
Lifecoil (coiled) catheters for adult and pediatric patients
Lucas Medical
Bradley Electronics Ltd.
Electral House
364
N easden Lane
London, England NWlO 1RR
Hemodialysis
A V fistula needles
3M
40, rue Gabriel Erie
92245 Malakoff Cedex, France
Peritoneal dialysis
Tegaderm (Ref. 1629), waterproof plastic cloth for catheter protection
McGaw/Baxter Inc.
Evanston, IL, USA
Peritoneal dialysis
Stylet disposable catheter for children ("Trocath")
Meadox Medicals, Inc.

112 Bauer Dr.
Oakland, NJ 07436, USA
Hemodialysis
Biological vascular prostheses: Human umbilical vem grafts (Meadox
biograft, Dardik biograft)
Synthetic vascular prostheses
Medcomp - Medical Components Inc.

1499 Delp Drive
Harleysville, P A 19438, USA
Hemodialysis
Jugular vein catheter
Single- and double-lumen subclavian/femoral catheters (polyurethane)
Peritoneal dialysis
Pendlebury catheter for newborns
Medigroup, Inc.
Division of Janin Group, Inc.
350 Smoke Tree Plaza
North Aurora, IL 60542, USA
365
Peritoneal dialysis
Y -Tec system, needles cope for peritoneoscopic peritoneal catheter Implantation
Millipore Corp.
80 Ashby Rd.
Bedford, MA 01730, USA
Peritoneal dialysis
CAPD connection systems (for prevention of infection): Bacteriological
filter
Miramed, S.p.A.
Via Morandi 6
P.O. Box 43
41037 Mirandola, Italy
Peritoneal dialysis
Valli catheter (Ref M 822)

Medical Products Division
22 Paris Ave.
Rockleigh, NJ 07647, USA

Cloverhill Ind. Est.
Clondalkin
Dublin 22, Ireland
Hemodialysis
Single- and double-lumen subclavian catheters (Teflon, polyurethane)
A V fistula needles
Peritoneal dialysis
CAPD connection systems (for prevention of infection): Safe-Lock connection systems
Nissho Corp.
3-9-3 Honjo Nishi, Oyodoku
Osaka, Japan
Hemodialysis
A V fistula needles
Quinton Instrument Co.

2121 Terry Ave
Seattle, WA 98121, USA
366
Hemodialysis
Quinton-Scribner arteriovenous shunts
Hickman catheter (silastic right atrial, surgically implantable catheter)
Raaf catheter (single-lumen silastic right atrial, surgically implantable,
catheter with a Dacron cuff)
Perm-Cath (double-lumen silastic right atrial, surgically implantable,
catheter with a Dacron cuff) for internal jugular vein cannulation
Mahurkar dual-lumen catheter (central venous catheter for permanent
vascular access)
Double-lumen subclavian/femoral catheters (polyurethane)
A V fistula needles
Peritoneal dialysis
Stylet disposable catheter

LifeCath catheter (straight, with implantable disc)
CurlCath (curled) catheters for adult and pediatric patients
CAPD connection systems (for prevention of infection): Beta-cap connector
Renal Systems Inc.-Minntech Corporation

14905 28th Avenue North
Minneapolis, MN 55441, USA
Hemodialysis
Hemasite no-needle vascular access system
Shiley, Inc.
17600 Gillette Ave
Irvine, CA 92714, USA
Shiley Europe
158-162 High Street
Staines, United Kingdom, TW 184 AZ
Hemodialysis
Femoral vein catheter

Single- and dual-lumen subclavian catheters (Teflon)
Flexicath, subclavian catheter (silicone)
Single- and dual-lumen central venous catheters for pediatric vascular access
Tetraflex PTFE vascular graft
Sifra S.p.A
Via Camagre, 41/43
1-37063 Isola della Scala (Verona), Italy
Peritoneal dialysis
CAPD connection systems (for prevention of infection): Perugia CAPD
system
367
Sil-Med Corp.
700 Warner Blvd.
Taunton, MA 02780, USA
Peritoneal dialysis
Peritoneal straight silicone catheters for adult and pediatric patients
Bent catheters
Coil catheters
Sister S.p.A.lCrinos International S.p.A.

Via Belvedere, 1
1-22079 Villa Guardia, Como, Italy
Hemodialysis
A V fistula needles
Solco
Basel AG
CH-4127 Birsfelden, Switzerland
Hemodialysis
Biological vascular prostheses: Solcograft (bovine heterograft)
Sorin Biomedica S.p.A.

1-13040 Saluggia, Italy
Hemodialysis
A V fistula needles
Terumo Corporation
1045 Centennial Ave.
Piscataway, NJ 08854, USA
Hemodialysis
A V fistula needles
Vas-cath Inc.
2380 Tedlo St.
Mississauga, Ontario, Canada L5A 3V3
Hemodialysis
Single lumen subclavian/femoral/jugular vem catheters (Teflon, polyurethane)
FLEXXICON, double lumen subclavian/femoral/jugular vein catheters
368
(Bodysoft Polyurethane)
SOFT-CELL, permanent double lumen catheter for either subclavian or
jugular cannulation (Bodysoft plus Polyurethane with Dacron Cuff)
Peritoneal dialysis
Peritoneal catheters (Tenckhoff and curled catheters)
Vygon
BP 7, 5-21, rue Adeline
Ecouen, France 95440
Hemodialysis
Canaud cath (double-silas tic percutaneously implantable jugular vem
catheter)
Richard Wolf Medical Instrument Co.

Rosemont, IL, USA
Peritoneal dialysis
Gas insuffiator machine for peritoneoscopic peritoneal catheter implantation
INDEX
Page numbers followed by the letter "T" refer to tables;

page numbers followed by the letter "F" refer to figures.
Acetate, 237
Acidosis, 3, 10
Acute renal failure, 139
AIDS, 10
Albuclair, 235
Alfentanil, 8
Alkalosis, 3, 5
Aluminum, 2
Aluminum hydroxide,S
Amides,6
Ampicillin, 325
Amuchina, 337, 346
Anemia, 2, 158
Anesthesia, 1-12,219,283
Anesthesia, epidural, 6- 7
Anesthesia, general, 7-10, 219, 283
Anesthesia, local, 5-6, 175, 176,219,227,
244,247
Anesthesia, regional, 5- 7
Anesthesia, spinal, 6- 7
Aneurysm, 40, 41, 46, 46F, 50, 51, 58, 60, 61,
86F, 120, 145, 206T,210
Angiogram, 101F, 124F, 125F
Angiography, 83, 83F, 111-128, 113F, 115F,
116F, 117F, 118F, 119F, 120F, 121F,
122F, 123F, 124F, 125F, 181, 182F, 186,
188F
Angioplasty, 70, 81, 87, 111, 121-126, 125F
Antacids,S
Antecubital vein (see also Median cubital

vein), 114, 130
Antibiotics, 159, 161, 162,278,312,324,325
Anticholinergics, 4
Antihistamines, 4
Arrhythmia, 3, 8, 187
Arteriogram, 51, 82, 87
Arteriography, 24, 111
Arteriovenous fistula, 23-44, 84F, 197T,
199-204, 200F, 201F, 202F, 203F, 204F,
205F, 212
Aspergillus, 243
Atracurium, 9, 10
Atrial catheters, 171-173, 172T, 173, 175F,
176F, 177F, 178F, 179F, 180F, 184T
Atropine, 4
A VF (Arteriovenous fistula), 23-44, 84F,
197T, 199-204, 200F, 201F, 202F, 203F,
204F,205F,212
A VF complications, 40-42
A VF in the lower extremity, 36-39
Axillary artery, 77
Axillary vein, 47, 77, 206, 209
Axillary-axillary PTFE fistula, 78F
Bacteriological filters, 342-343, 343F
Barbiturates, 4
Basilic vein, 24, 35, 76, 77, 201, 202, 203,
369
370
206, 209
BCA (Bovine carotid artery), 205, 206, 209,
210,212
Becker's connector, 339, 339F
Benzodiazepine, 4, 9
Berlin catheter, 226
Beta-blockers, 3
Beta-cap connector, 338
Beta dine (see Povidone-iodine)
Biocompatibility, 301-302, 302T
Biofiow graft, 61-63, 61F, 62F, 64, 68
Bladder perforation, 221
Bleeding, 62, 143, 144, 144T, 146, 146T,
148T, 186,222-223,236,266, 293T
Bovine heterograft, 56-58, 58F, 61F, 62F,
66F, 83, 84F, 106, 107, 197T, 198,205,
206T, 208T, 208F
Bowel perforation, 221-222, 241, 293T, 300,
326
Brachial artery, 34, 42, 46, 47, 48, 96, 203,
206, 209
Brachial vein, 206, 209
Brachial-antecubital PTFE fistula, 78F
Brachial-basilic A VF, 35
Brachial-basilic PTFE fistula, 76F
Brachial-cephalic AVF, 34, 202, 204F, 208T
Brescia-Cimino fistula, 23-44, 84F, 197T,
199-204, 200F, 201F, 202F, 203F, 204F,
205F,212
Bupivacaine, 6
Butyrophenones, 4
Calcium, 3, 5
Calcium carbonate,S
Candida albicans, 159
Carbohydrate, 2
Cardiac failure, 11, 41
Cardiac output, 41, 50
Carpal tunnel syndrome, 42
CA VH (Continuous Arteriovenous
Hemofiltration), 130, 146T
Cavography, 181, 182F
Cefotaxime, 323, 324
Cephalic vein, 23, 24, 34, 44, 46F, 76, 77,
119, 123, 199, 201, 203F
Cephalothin, 262
Children, peritoneal access in, 315-331
Children, vascular access in, 195-214
Chlorhexidine, 236
Chlorine, 236
Chloroprocaine, 6
Chloroxidizer, 337, 346
Cholinesterase, 6, 9
Cimetidine, 5
Clindamycin, 325
Closter system, 345
Clotting, 157
Coagulopathy,2
Column disc catheter, 226, 231, 236, 294,
297,298,318
Comitantes venae, 35, 36, 42, 48
Compact Exchange Device, 337
Computer tomography, 141,249
Congestive hearth failure, 219
Connection systems, 333-355
Curvularia lunata, 243
Dacron (cuff, cloth, etc), 20, 61, 92, 96, 99,
103,104, 171F, 172T, 173, 176, 176F,
182,189, 191,212,225,226, 226F, 227,
228, 228F, 229, 230, 231F, 233, 234,235,
238,241,245,258,259,261,263,273,
274, 276, 278, 282, 287, 298, 300, 307,
318, 320, 322, 325
Dardik graft, 58-61
Deep A VF in the upper arm, 35-36
Dementia, 2
Dermaport (peritoneal dialysis catheter),
307-313,308F
Desilet, 178
Diabetes, 10,87,159,234-235
Diazepam, 4, 96, 219, 283
Digital subtraction angiography, 113-120,
113F, 114F, 115F, 116F, 117F, 118F,
119F, 120F, 121F, 122F
Digitalis, 2
Diphenhydramine, 4
Disequilibrium syndrome, 2
Doppler, 40, 164
Double silastic right artrial catheter, 171F,
172T, 173, 177F, 178, 178F, 179F, 184T
Double-bag system (for peritoneal dialysis),
344, 345F, 346F
Double-cuff catheter (for peritoneal
dialysis), 274-275, 275F, 276F, 279,
287T
Double-lumen catheters (cannula, for
vascular access), 130, 131, 131F, 156,
156F, 157, 170, 171F, 173, 174, 175F,
176, 176F
Dreschlera spicifera, 243
Droperidol, 4, 9
Edema, 42
Embolism, 142, 144T, 146T, 147, 148T, 149,
161, 163, 187, 187T
Endocarditis, 161
Enfiurane, 7, 8
Erythropoietin, 2
Esters, 6
Etidocaine, 6
Etomidate, 8
Expanded PTFE graft, 73-89, 75F, 76F,
Index
77F, 78F, 79F, 80F

External arteriovenous shunt, 15-21, 18F,
19F, 43-44, 198-199, 208T, 209, 211
Femoral artery, 36, 38, 38F, 39, 39F, 77, 78,
130, 138, 207, 209
Femoral catheter, 129-152, 133F, 134F,
135F, 136F, 138F, 139T, 140T, 144T,
146F, 146T, 148T, 149T
Femoral vein, 129, 130, 137, 137F, 140, 142,
211
Femoral vessel cannulation, 129-152
Femoral-saphenous PTFE fistula, 78F, 212
Fentanyl, 8, 9, 75
Fistula, arteriovenous, 23-44, 84F, 197T,
199-204, 200F, 201F, 202F, 203F,204F,
205F, 212
Flow meter, 48
Flumazenil, 4
Fluorocytosine, 243
Fluoroscopy, 249
Fogarty catheter, 101, 199
Frekaderm, 236
Fuchs' connector, 338, 339F
Fungi,243
Fusarium, 243
Gallamine, 9
Glycopyrrolate, 4
Goldberg's catheter, 293
Gore-Tex (peritoneal) catheter, 274, 295T,
300
Gore-Tex (vascular graft), 57T, 83, 84F,
121F
Halothane, 7, 8
Heart failure, 102
Heat sterilization, 341
Heat welding, 341
Hemasite device, 91-110, 92F, 93F, 94F,
95F, 100F, 101F, 102F, 103F, 104F,
106F, 107F, 108F, 109F, 209
Hematoma, 48, 50, 62, 78,85, 120, 142,
144T, 145, 146, 146T, 148T, 186,211,
236
Hemodiafiltration, 191
Hemofiltration, 191
Hemoperfusion, 139, 145
Hemoperitoneum, 240
Hemorrhage, 11,40,103,198, 210T,
236-237,266,300
Hemothorax, 140, 147, 148T, 158, 158T,
162, 186
Heparin, 15,63, 126, 131, 141, 142, 155, 158,
176,179,181,222,235,236,240,262,
371
268, 285, 324

Hepatic coma, 139, 145
Hepatitis, 10
Hernias, 233-234, 241-242, 326, 327T
Hexamidine, 236
Hexomedine, 236
Hibitane, 236
Hickman, 212
Hickman catheter, 146T
Hong Kong connector, 340, 340F
HTL V -3/LA V infection, 10
Hydration, 2
Hydroceles, 326
Hydrothorax, 326
Hydroxyzine, 4
Hyperkalemia, 2, 3, 9, 10, 149
Hyperparathyroidism, 2, 3
Hyperphosphatemia,3
Hypocalcemia, 3
Hypochlorite sodium, 236
Hypokalemia, 3
Hyponatremia, 3
Hypotension, 3, 6, 9, 10
Hypoxia, 10
Iliac vein, 140
IMPRA,57
Infants (peritoneal access in), 315-331
Infections, 40, 43, 50, 58, 84-85, 98-99,
100F, 109, 109F, 142, 143, 144T, 145,
146T, 147, 148T, 156, 159-162, 161F,
183T, 189, 198, 206T, 210, 21OT, 211,
238-239,242-243,269,274,278,293,
293T, 295, 297, 299T, 300, 312, 324,
325,327T
Inhalation anesthetics, 7-8
Insulin, 2, 3
InternalJugular Vein (IJV) cannulation
(Atrial cannulation), 169-194, 171F,
175F, 177F, 178F, 179F, 183T, 184T,
187T
Internal Jugular Vein catheters, 170-173,
171F, 172T, 174, 184T, 187T, 188F
Iodine, 236
Ion-exchange resin, 3
Ischemia of the extremity, 41
Isofiurane, 7, 8
Jugular catheterization, 146F, 147, 148T
Jugular vein, 130, 146F, 169-194
Kanamicin, 238
Kayexalate,3
Ketamine, 7, 8, 9
Ketoconazole, 243
372
Lactate, 237
Leakage (of dialysate), 223, 237-238, 242,
326,327T
Lidocaine, 6, 96, 283
Lifecath, 294, 295T, 300, 302
Magnesium hydroxide, 5
Mannitol, 237
Meadox graft, 58-61, 66, 68
Median cubital vein, 76, 77
Median nerve, 6
Meperidine, 4, 96
Mepivacaine, 6
Merfene, 236
Metoclopramide, 5
Metocurine, 9
Midazolam, 4, 9, 75
Missouri catheter, 279, 280F, 281, 282-286,
282F,283F, 284F,286-287,287F
Morphine, 4
Muscle relaxants, 9-1
Mycobacterium tuberculosis, 243
Narcotics, 4, 5, 7, 9
Neuroleptanalgesia, 9
Neuromuscular abnormalities, 2
Neuropathy, 2, 7, 9, 143
Nitrous oxide, 7
O-set (connector), 344
Obese patients, 219, 233, 234, 283
Obesity, 107
Octopus, 323
Op'site, 181
Oreopoulos-Zellerman catheter (see also
Toronto Western Hospital catheter),
257-270,258F,260F, 293,296,296T,
297, 298F,299T,302
Oreopoulos-Zellerman connector, 338
Osteodystrophy, 3
Osteomyelitis, 161
Pain, 223-224, 237, 269
Painful syndrome, 42
Pancuronium, 9
Pediatric patients (peritoneal access in),
315-331,317F,319F,320F,321F,322F,
327T
Pediatric patients (vascular access in),
195-214
Pelvic vein, 140
Percutaneous transluminal angioplasty (see
Angioplasty)
Peri Patch technique, 248

Pericardial effusion, 50
Pericarditis, 2
Peritoneal dialysis access, 215-355
Peritoneoscopic implantation (of peritoneal
catheter), 232
Peritoneoscopy, 295, 295T
Peritonitis, 240, 241, 269, 293, 293T, 297,
298, 299T, 301, 307, 312, 317, 324, 425,
327T, 333-355, 350F
Perugia CAPD system, 347-348, 348F
Phenylmercure, 236
Phlebitis, 40, 50
Phlebography, 181, 188
Phlebothrombosis, 140, 140T, 142, 144T,
162
Plasmapheresis, 139, 145, 154
Plethysmography, 86
Pneumoperitoneum, 241
Pneumothorax, 11, 140, 148T, 158, 158T,
186,211
Polycystic kidney, 222, 240
Polypropylene glycol, 104
Polytetrafluoroethylene, 278
Polyurethane, 131, 155, 155T, 156, 163, 170,
171F,274
Polyvinyl chloride, 162
Povidone-iodine/polyvidone-iodine
(Betadine), 93, 94F, 96, 97, 98, 154,
174,180,211,219,227,235,236,246,
283, 286, 337
Premedication, 3-5
Prilocaine, 6
Procaine, 6, 219, 220,221,224
Promethazine, 4
Prosthetic A VF, 51
Prosthetic graft fistulas, 73-89, 75F, 76F,
77F, 78F, 79F,80F
Proteus mirabilis, 159
Pseudoaneurysm, 85-86, 86F, 87F, 120,
120F
Pseudomonas aeruginosa, 159,239,243,
344
PTA (Percutaneous transluminal
angioplasty). (see Angioplasty)
PTFE (Polytetrafluoroethylene), 51, 53F,
54, 57, 68, 73-89, 75F, 76F, 77F, 78F,
79F, 80F, 83, 83F,92, 93, 95, 99,103,
104, 105F, 106, 107, 120, 121F, 126, 198,
205,206, 206T, 207F, 208T, 209, 210,
212
Pulmonary edema, 2, 10,219
Pulmonary embolism, 142, 144T, 146T, 147,
148T, 149, 161, 163
Quinton-Scribner shunt, 15-21, 18F, 19F,
43-44,198-199, 208T, 209, 211
Index
Radial artery, 23, 44, 46, 76, 119, 123, 199,

203F
Radial nerve, 6, 24
Radial-antecubital PTFE fistula, 76
Radial-cephalic AVF, 24-32, 25F, 26F,
27F, 28F, 30F, 31F,32F, 199-201,
200F,202,208T
Radiography, 249
Resin, ion-exchange, 3
Reverse A VF, 35
Rifampicin, 325
Safe-lock-O-system (connector), 344
Saphenous vein, 36, 37F, 38, 38F, 39, 39F,
46,47,77,204, 205,205F, 207, 209
Saphenous vein grafts, 45-54, 47F, 49F,
49T, 50F, 52F, 53F, 54F
Sayfter cap, 345
Scarpa triangle, 38, 39, 39F
Scopolamine, 4, 5
Seizures, 8
Seldinger technique, 132, 136, 154, 170, 174,
211,316
Sepsis, 159, 160T, 161, 161F, 183T
Septicemia, 142, 187T, 211
Seroma,88
Shunt, external arteriovenous, 15-21, 18F,
19F, 43-44,198-199, 208T, 209, 211
Silastic catheter, 171-173, 171 F, 172T, 175F,
177F, 178F, 179F, 180F, 184T, 212, 225,
247,273,317,320
Silicone, 18, 19, 155T, 162, 170, 171, 173,
175,178,186,190,232,238,257,276,
287
Silicone rubber tubing, 131, 170, 171, 173,
232,238,257,317,320,338
Single-cuff catheter (for peritoneal dialysis),
274-275,275F,276F,279F
Sodium citrate,S
Sonography, 48
Sorbitol, 237
Spike, 336, 336T, 337F
Stag antlers, 323
Staphylococcus aureus, 159, 189, 239, 243,
245, 297, 325, 344
Staphylococcus epidermidis, 159,239,241,
243, 245, 325, 344
Steal syndrome, 11,50,51,63,68,76,86-88
Stenosis, 120F, 123F, 125F, 147, 148,
162-164,210
Sterile connection device, 341, 342F
Sterile weld, 341
Streptokinase, 123F, 126, 186,223,240
Stylet catheter, 217-224, 218F, 316, 317
Subclavian catheterization (cannulation),
146F, 147, 148T, 152-168, 155T, 156F,
158T, 164F, 170, 190
373
Subclavian catheters, 146F, 147, 148T,

152-168, 155T, 156F, 160T, 190
Subclavian vein, 130, 146T, 152-168, 158T,
164F,211
Succinylcholine, 2, 9
Sufentanil, 8
Swan Neck Missouri catheter, 279, 280F,
281,282-286, 283F, 286-287, 287F
Swan Neck peritoneal dialysis catheters,
271-289,272F, 273F, 279F, 280F, 281F,
282F, 283F, 287T, 295T, 300, 318
Swan Neck Tenckhoff catheter, 279, 279F,
281, 281F,282F, 283F
Swan Neck Toronto catheter, 278-279,
280F, 281,281F,282-286
Sympathetic blockade, 6
Take-off system, 345, 347F
Teflon, 17, 18, 18F, 19, 19F, 20, 44,131,155,
155T, 156, 163, 170
Tegaderm, 235
Tenckhoff catheter, 225-255, 226F, 228F,
250F, 271, 273, 274, 279, 281, 281F,
282F, 283F, 286, 292-293, 294, 295,
296, 296F, 297, 298, 298F,299F, 300,
302,315,316,317, 317F, 318, 319F,
320F, 321F, 322F
Tetracaine, 6
Thermal sterilization, 341
Thiopental, sodium, 8
Thrombectomy, 81,82, 82F, 83, 88, 99,
101, 102, 102F
Thrombophlebitis, 140, 140T, 142, 144T,
147
Thrombosis, 40, 41, 46, 58, 60, 62, 80-84,
99-102, 109F, 120, 123F, 126, 142, 144,
145,146,147,148, 148T, 162-164,
183T, 186, 187T, 188, 189, 198, 206T,
21O,21OT
Tibial artery, 36, 37F, 205F
Toronto Western Hospital catheters (see also
Oreopoulos-Zellerman catheter),
257-270, 258F, 260F, 278-279, 280F,
281,282-286,318
Transfusion, blood, 2, 10
Transplantation, renal, 328
Trav-X-change II device, 337
Travenol advanced system, 336, 349
Tubocurarine, 9
TWH (Toronto Western Hospital).
(See Toronto Western Hospital
catheters)
Ulnar artery, 24, 77, 201
Ulnar nerve, 6
Ulnar-antecubital PTFE fistula, 76F
374
Ulnar-basilic A VF, 32-33, 201-202, 202F,

208T
Ultrasonography, 141
Ultrasound imaging, 74, 75F, 83, 86
Umbilical vein graft, 58-63, 205
Uremic lung, 2
Urokinase, 186,240,243
UV sterilization, 342
Valli catheter, 226, 297, 299T
Vancomycin, 95, 238, 239, 245, 246, 283
Vascular access for hemodialysis, 13-214
Vecuronium, 9, 10
Vena cava, 138, 142, 154, 162, 173, 181,
182F, 187T, 188, 188F

Venogram, 164
Venography, 24,111-112, 112F
VitaminD,3
Xylocaine, 126, 175, 176,237
Y-connnector, 344, 348, 348F, 349F
Y-set (connector), 344, 348-349
Y-solution transfer set, 336T, 348-349, 349F
Y -system (connector), 344, 346, 350, 350F
Y-Tecsystem, 232

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VASCULAR AND PERITONEAL ACCESS FOR DIALYSIS

TOPICS IN RENAL MEDICINE

VE Andreucci, The Kidney In Pregnancy. ISBN 0-89838-741-8

VASCULAR AND PERITONEAL ACCESS

KLUWER ACADEMIC PUBLISHERS

Distributors for North America:

Library of Congress Cataloging-in-Publication Data

1989 by Kluwer Academic Publishers

Softcoverreprint of the hardcover I st edition 1989

To my wife Gabriella and to my children Michele and Maria Vittoria

1. Anesthcsia for vascular and pcritoncal access for dialysis

I. VASCULAR ACCESS FOR HEMODIALYSIS

2. External arteriovenous shunt: The first permanent vascular access device

3. Thc arteriovenous fistula

ENRICO DI SALVO, STEFANO FEDERICO, VITTORIO E. ANDREUCCI

4. Autogenous saphenous vein grafts as vascular access for hemodialysis

JOHN P. HARRIS, JAMES MAY

5. Bovine heterograft and umbilical cord graft for arteriovenous fistulas

6. Prosthetic graft fistulas: The expanded PTFE graft

8. Angiography for studying hemodialysis vascular access

9. Percutaneous femoral vessel cannulation for hemodialysis

VANHOLDER, SEVERIN M. RINGOIR

10. Subclavian vein cannulation for hemodialysis

11. Internaljugular vein cannulation for hemodialysis

BERNARD JEAN-MARIE CANAUD

12. Vascular access for hemodialysis in children

WOLF D. BRITTINGER, WOLF D. TWITTENHOFF, GOTTFRIED WALKER

II. PERITONEAL ACCESS FOR PERITONEAL DIALYSIS

STEFANO FEDERICO, GIORGIO FUIANO, VITTORIO E. ANDREUCCI

14. The permanent Tenckhoff catheters

15. The permanent Toronto Western Hospital catheters

RAMESH KHANNA, DIMITRIOS G. OREOPOULOS

16. Swan Neck peritoneal dialysis catheters

ZBYLUT J. TWARDOWSKI, RAMESH KHANNA

17. The choice of access for long:-term peritoneal dialysis

18. Dermaport peritoneal dialysis catheter

BENEDICT D. T. DALY, KURT A. DASSE

19. Peritoneal access for dialysis in infants and children

KLAUS-EUGEN BONZEL, HELGA ROTH, KARL SCHARER

20. Prevention of peritonitis during CAPO: Special precautions and use of

Dimitrios G. Oreopoulos, MD, PhD, FRCP, FACP

When the external Quinton-Scribner arteriovenous shunt was developed in

prevention and treatment of any complications occurring in relation to access

VASCULAR AND PERITONEAL ACCESS FOR DIALYSIS

1. ANESTHESIA FOR VASCULAR AND

ALEC R. HOVAGIM and PAUL]. POPPERS

Clinical manifestations of ischemic heart disease in uremic patients include

1. Anesthesia for dialysis

2.1. Routine medications

The routine medications taken by the uremic patient should be continued

The goal of successful anesthetic premedication is to make a patient free

1. Anesthesia for dialysis

Monitoring for access surgery should allow prompt recognition of potential

4.1. Local anesthesia/anesthetics

Local anesthesia is a popular choice of anesthesia for access surgery. Although

monitoring must remam the same, irrespective of the mode of anesthesia

1. Anesthesia for dialysis

times which might cause a hematoma in a vascular shealth or within the

5.1. General considerations

1. Anesthesia for dialysis

Neuroleptanalgesia, combining droperidol and fentanyl, is acceptable in

Succinylcholine is the only commonly used depolarizing muscle relaxant. It is

Atracurium, an analog of d-tubocurarine, is metabolized both by Hofmann