Dialysis Catheter Tip Placement: The Purposeful Tip
The “optimum” positioning of a persistent dialysis
catheter tip has been lengthy debated, with
a myriad of conflicting suggestions
from numerous organizations such because the US
Meals and Drug Administration and the Nationwide
Kidney Basis Kidney Illness Outcomes High quality
Initiative (KDOQI).1,2 Contemplating that in 2009, an estimated
571,000 sufferers had end-stage renal illness,
and 57% of these sufferers who wanted dialysis wanted
not less than one dialysis catheter, it stands as no shock
that an settlement of optimum catheter tip place is
of paramount significance.3,4 Regardless of the preponderance
of sufferers affected, optimum catheter tip place
stays a shifting goal. In actual fact, up till 2006,
KDOQI tips advisable inserting the dialysis
catheter tip within the superior vena cava (SVC) so as
“to not trigger cardiac perforations.”5,6
The altering suggestions should not meritless.
On account of up to date practices, such because the obligatory
use of fluoroscopy and urged ultrasound
steerage for venous entry, in addition to the evolution of
catheter design and supplies, the chance of cardiac and
venous perforations has considerably decreased.7-10 In
current literary evaluations and probably the most present iteration
of KDOQI tips, the advisable catheter tip
place was within the “mid-atrium with arterial lumen
going through the mediastinum.”10,11
Nevertheless, even these suggestions are marred
by inaccuracy as a result of they make no distinction
between the completely different tip designs of the at present
accessible dialysis catheters and dynamic interaction
between catheter operate, facet gap design, and
On this article, we’ll introduce a brand new idea:
the practical tip (Determine 1). This idea is aimed
at permitting correct placement of assorted dialysis
catheters whereas bearing in mind the completely different
persistent dialysis catheter tip designs.
ACCURATE TIP PLACEMENT
Suggestion No. 1. Don’t place the catheter tip
too deep in the proper atrium, in order to keep away from touching the
flooring of the atrium. If the catheter tip touches the atrial
flooring, there’s elevated danger of atrial mural thrombus, perforation,
and arrhythmias (Determine 2).1,10
Suggestion No. 2. Don’t place the catheter
too excessive. Facet holes within the SVC could trigger suction of the
venous wall, positional occlusion, and/or malfunction.10,15
Positioning of the dialysis catheter tip throughout the SVC could
additionally result in increased recirculation charges.16,17 Injury to the
vessel wall and thrombus creation could cause delayed vascular
stenosis and occlusion (Determine 3).18
As well as, the whipping movement of the split-tip
catheter throughout high-flow dialysis could additional injury the vessel wall if the catheter terminates throughout the SVC;
thus, correct placement of split-tip catheters is of nice
The persistent dialysis catheter needs to be positioned with
the facet holes outdoors of the SVC. The anatomic location
of the cavoatrial junction is well-established; nonetheless, its
exact place on fluoroscopy and traditional chest
radiography has been far harder.19 The advanced,
three-dimensional coronary heart proves to be unfavorable to
typical anatomic landmark localization on a twodimensional
modality. A number of investigators have tried
to ascertain standards, utilizing easy landmarks such because the
carina, to permit radiologists to be extra exact when
making an attempt to put gadgets on the decrease superior vena
cava.20,21 These standards have confirmed cumbersome and
inaccurate, given the advanced anatomical variations
from one affected person to the subsequent.19 In our expertise, even
devoted chest radiologists battle to ascertain the
exact location of catheter recommendations on chest radiographs.
Putting the practical tip of the catheter inside the proper
atrium permits the interventionist increased certainty of ultimate
catheter tip place.
We see that the tip of the catheter determines how
low or how deep the catheter could also be superior. In contradistinction,
probably the most proximal facet holes decide
how excessive the catheter could also be positioned, which brings us to
the idea of the “practical tip” or “practical catheter
THE FUNCTIONAL TIP
The practical tip is the a part of the catheter from the
most proximal facet gap to the catheter tip (Figures 1,
2C, 3B, and 4). The catheter practical size or practical
tip is the a part of the catheter the place all of the motion takes place. All catheters proximal to the practical
size are, in essence, an identical and function a easy
blood conduit. Their size adjustments in accordance with the
complete catheter size. Subsequently, there needs to be solely
one tip—the practical tip.
Suggestion No. 3. Place the catheter in order that
your entire practical size is inside the proper atrium,
however not too deep to keep away from touching the ground of the proper
One other essential caveat to take into accounts
is superior migration of the dialysis catheter when the
affected person is erect or semierect, as catheters are normally
positioned within the supine place.17,22 One ought to envision
the place of the affected person throughout dialysis, as a result of it’s in
this setting that the situation of the practical size is
clinically related. Superior migration of the catheter tip
is magnified in overweight sufferers and in ladies with massive,
pendulous breasts as results of comfortable tissue motion
upon erect posture.1,22,23 In overweight sufferers, the catheter
could also be positioned deeper inside the proper atrium; nonetheless,
care needs to be maintained to not contact the proper
atrial flooring. One approach to reduce migration is to create
a shorter and extra lateral tunnel. This lateral tunnel
reduces the downward migration of the exterior a part of
the catheter when the affected person sits up.
The controversy ought to in all probability focus on the place to
place the practical tip reasonably than the place to put the bodily catheter tip. We imagine that the catheter ought to
be positioned in order that the practical size is as excessive as attainable
inside the proper atrium throughout dialysis. This enables
all of the exercise to happen inside the proper atrium,
probably bettering catheter operate, lowering thrombosis
and positional occlusion, and presumably lowering
fibrin sheath formation and delayed venous injury.
Michael Tal, MD, MBA, is Affiliate Scientific Professor.
Yale Diagnostic Radiology,Yale College College of
Medication in New Haven, Connecticut. He has disclosed
that he’s a advisor to Covidien. Dr. Tal could also be
reached at [email protected]
Tamir Friedman, MD, is with Yale Diagnostic Radiology,
Yale College College of Medication in New Haven,
Connecticut. He acknowledged that he has no monetary pursuits
associated to this text.
Hamid Mojibian, MD, is Affiliate Professor of
Radiology, Yale College College of Medication in New
Haven, Connecticut. He acknowledged that he has no monetary
pursuits associated to this text.
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