Placement and Maintenance of Tunneled Hemodialysis Catheters

Hemodialysis remains the most common treatment modality for end-stage kidney disease. In the US, the majority of patients use central venous catheters for hemodialysis initiation, and a significant percentage remain dependent on tunneled hemodialysis catheters (TDC) for a variable length of time. This makes appropriate TDC placement and maintenance important in achieving adequate blood flow rates and consequently effective dialysis. Ideally TDC to be inserted in the right internal jugular vein, the subclavian vein to be avoided since it may result in central stenosis, limiting future ipsilateral AV access creation. The insertion site on the neck in relation to the clavicle is vital, the closer it is to the clavicle the less likely the catheter will kink and result in malfunction. Ultrasound guidance accessing the target vessel, and post catheter insertion radiographic imaging confirming the location of the catheter’s tip in the right atrium is standard of care. Also, ultrasound and radiographic guidance will not only ensure proper placement, but will help avoid complications. Post placement, proper catheter maintenance to ensure adequate hemodialysis is paramount, since catheter dysfunction is associated with increased risk of both infection and mortality. Catheters have a two- to three-fold higher risk of infection related hospitalization compared to any other AV access. This chapter will discuss in depth a step by step approach for central catheter placement, complications, maintenance, malfunction and troubleshooting.