Southern Association For Vascular Surgery

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The Inside-Out Technique: A Vascular Surgeon's Guide to Complex Catheter Placement
Brian M. Freeman, Joseph S. Tingen, Allyson L. Hale, David L. Cull, Chris G. Carsten, III
Greenville Health System, Greenville, SC

Background: Patients with multiple failed dialysis accesses and limited access sites can present as a significant challenge to vascular surgeons. The presence of central venous occlusion and the need for temporary or permanent dialysis catheter placement is especially problematic. Previous reports have described an “inside-out” technique that avoids the need for subclavian or femoral catheter placement by placing a supraclavicular catheter via a percutaneous femoral vein. However, very few reports of its use in vascular surgery exist. The purpose of this paper is to describe our version of the technique and report the results.Technique: All procedures were performed using general anesthesia or conscious sedation supplemented with local anesthesia. Ultrasound-guidance was utilized for common femoral venous access, and a superior venacavogram, anteroposterior and oblique views, was obtained to document the level of caval occlusion. An 8Fr, 81 cm length, braided transseptal sheath (Swartz Braided SL1, St. Jude Medical, St. Paul, MN, USA) was advanced until the tip of the dilator was at the level of the caval occlusion. The tip was then oriented anterior-laterally toward the clavicular head. Following this, the back end of a .014 Confianza wire (Asahi Intecc, Aichi, Japan) was passed through the dilator, forced through the vein wall, achieving a subcutaneous location, and advanced until it tented the skin at the base of the neck posterior to the clavicle. Next, a small incision was made over the wire before it was grasped with a hemostat and retrieved from the subcutaneous tissue. A micropuncture sheath was then placed over the back end of the Confianza wire and advanced into the SL1 catheter. After contrast injection was used to confirm placement, a .035 Amplatz Super Stiff guidewire (Boston Scientific, Massachusetts, USA) was advanced through the micro-sheath into the SL1 catheter. The guidewire was then advanced into an inferior vena cava while the SL1 catheter was withdrawn. The tunneled catheter was placed in standard fashion.Results: Between August 2016 and July 2017, eight patients underwent dialysis catheter placement utilizing this technique (Table). All patients had more than four prior access sites and had bilateral internal jugular vein occlusion. Technical success rate was 100% with no periprocedural complications. All procedures were successful in achieving a functioning dialysis access. One patient required catheter replacement within 48 hours secondary to inadequate tip placement proximal to the right atrium. One catheter was used as a bridge to HERO graft placement. One patient died of sepsis unrelated to their catheter.Conclusion: Our data shows the inside-out catheter placement technique to be safe and effective. This procedure allows for avoidance of subclavian or femoral catheter placement, and should be a component of every vascular surgeon’s treatment algorithm for complex dialysis patients.Table

Patients, N8
Age, mean ± SD59.8 ± 14.8
Male sex, no. (%)3 (37.5)
Technical success, no. (%)8 (100.0)
Mean patency, days (range)81 (7-370)
Procedural complications, no. (%)0 (0.0)
Mean contrast volume, cc43.1
Mean fluoroscopy time, minutes15.1

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