Overview
Definition:
A Permcath, or tunneled dialysis catheter, is a type of central venous catheter specifically designed for long-term hemodialysis access
It is inserted surgically, with a portion of the catheter tunneled under the skin to exit at a remote site, reducing infection risk and improving patient comfort compared to non-tunneled catheters
The catheter has two lumens, an arterial and a venous, for blood withdrawal and reinfusion during dialysis.
Epidemiology:
End-stage renal disease (ESRD) affects millions globally, with an increasing prevalence
Hemodialysis remains a primary treatment modality, necessitating reliable vascular access
Tunneled catheters like Permcath are chosen when immediate and permanent arteriovenous access (fistula or graft) is not feasible, or as a bridge to definitive access
The incidence of catheter-related bloodstream infections (CRBSIs) remains a significant concern in dialysis patients.
Clinical Significance:
Proper Permcath insertion is crucial for effective and safe hemodialysis
A well-placed catheter ensures adequate blood flow rates for efficient toxin removal, minimizes complications like thrombosis and infection, and improves the patient's quality of life by facilitating regular dialysis sessions
For surgical residents, proficiency in this procedure is essential for managing patients with chronic kidney disease requiring hemodialysis.
Indications
Indications For Insertion:
Initiation of hemodialysis when immediate AV access is not possible
Patients awaiting creation or maturation of an AV fistula/graft
Patients with poor peripheral vasculature precluding AV fistula/graft creation
Temporary access for patients with anticipated short-term need for dialysis but requiring tunneled placement
Failure or complications of peripheral AV access.
Contraindications:
Active systemic infection or sepsis
Local skin infection at the proposed insertion site
Inability to tolerate anticoagulation if required post-procedure
Life expectancy too short to benefit from dialysis
Patient refusal
Significant coagulopathy not correctable.
Patient Selection:
Assessment of patient's renal function and need for dialysis
Evaluation of peripheral vasculature for potential AV access
Discussion of risks and benefits of Permcath versus other access modalities
Patient education and consent.
Preoperative Preparation
Informed Consent:
Detailed explanation of the procedure, risks (infection, bleeding, thrombosis, pneumothorax, air embolism, vessel damage, tunnel infection), benefits, and alternatives
Ensure patient understanding and obtain written consent.
Patient Assessment:
Review of medical history, allergies, and medications (especially anticoagulants and antiplatelets)
Physical examination, including vital signs and assessment of the proposed insertion site and contralateral side
Baseline laboratory tests: CBC, coagulation profile (PT/INR, aPTT), electrolytes, renal function tests.
Site Selection:
Typically, the internal jugular vein is preferred for central venous access due to its lower complication rate compared to subclavian or femoral veins
The insertion site is usually in the upper chest, mid-clavicular line, several centimeters below the clavicle, for tunneling to the venous anastomosis site
The exit site is typically located laterally on the chest wall.
Equipment Preparation:
Sterile surgical tray, appropriate gown, gloves, and drapes
Local anesthetic (e.g., lidocaine 1% with epinephrine)
Antiseptic solution (e.g., chlorhexidine)
Central venous catheter kit including dilator, guidewire, and the tunneled catheter itself with a Dacron cuff
Suture material (e.g., Prolene 3-0 or 4-0)
Sterile gauze and dressings
Ultrasound machine for guidance if available.
Procedure Steps
Technique Overview:
The procedure is typically performed under local anesthesia, often with conscious sedation
Ultrasound guidance is highly recommended for accurate vein cannulation.
Vein Access:
The skin over the chosen central vein (e.g., right internal jugular) is prepped and anesthetized
A small skin incision is made
Using a needle and syringe, the vein is cannulated under ultrasound guidance or anatomical landmarks
Once the vein is accessed, the introducer needle is removed, and a guidewire is advanced through the needle into the vein, extending into the superior vena cava (SVC) or right atrium.
Tunneling And Catheter Insertion:
A separate incision is made at the planned exit site on the chest
A tunneler instrument is used to create a subcutaneous tunnel from the exit site to the initial venipuncture site
The Dacron cuff is positioned within the subcutaneous tunnel
The catheter is then threaded through the tunnel and advanced through the venipuncture site, with the tip positioned in the SVC, just above the right atrium
Care is taken to ensure the catheter is not kinked.
Securing And Confirmation:
The catheter is secured to the skin at the exit site with sutures
The venipuncture site is closed
Post-insertion X-ray is mandatory to confirm catheter tip position and rule out pneumothorax or hemothorax
The catheter lumens are flushed with saline and then locked with heparinized saline to prevent clotting.
Postoperative Care
Immediate Postoperative Care:
Monitor vital signs
Observe for signs of bleeding or pneumothorax at the insertion and exit sites
Administer analgesia as needed
Chest X-ray review by radiologist
Ensure appropriate flushing and locking of catheter lumens.
Dressing Care:
Maintain sterile dressing at the insertion and exit sites until healing occurs
Strict aseptic technique during all catheter manipulations
Regular dressing changes as per institutional protocol.
Patient Education:
Educate the patient on catheter care, signs and symptoms of infection or other complications to report, activity restrictions, and importance of aseptic technique during dialysis and flushing
Teach proper flushing and locking procedures.
Anticoagulation:
For patients not on dialysis immediately, routine heparin locking is initiated
For dialysis patients, systemic anticoagulation (e.g., heparin or citrate) is used during hemodialysis sessions
The choice and duration of anticoagulation depend on institutional protocols and patient factors.
Complications
Early Complications:
Bleeding at insertion or exit site
Hematoma formation
Pneumothorax or hemothorax (especially with subclavian access)
Arterial puncture
Air embolism
Arrhythmias due to catheter tip malposition
Infection at the insertion site
Thrombosis of the catheter or vein.
Late Complications:
Catheter-related bloodstream infection (CRBSI) is the most common serious complication
Tunnel infection
Exit site infection
Catheter occlusion or thrombosis
Catheter migration or fracture
Stenosis or occlusion of the central vein
DVT of the upper extremity
Endocarditis (rare).
Prevention Strategies:
Meticulous aseptic technique during insertion and all subsequent manipulations
Use of ultrasound guidance for vein access
Optimal catheter tip positioning
Regular catheter flushing and locking
Prompt recognition and management of infection
Patient education on proper care
Use of antibiotic lock solutions in select high-risk patients
Early removal when no longer needed
Creation of permanent AV access as soon as feasible.
Key Points
Exam Focus:
Indications for tunneled catheters
Preferred vein for insertion (internal jugular)
Importance of Dacron cuff in reducing infection
Risks of pneumothorax and air embolism
Management of CRBSI
Role of chest X-ray post-insertion
Differences between tunneled and non-tunneled catheters.
Clinical Pearls:
Always use ultrasound for vein cannulation to minimize complications
Position the catheter tip in the SVC, not too high (risk of air embolism) or too low (risk of arrhythmias/endocarditis)
Ensure the Dacron cuff is placed within the subcutaneous tunnel for optimal efficacy
Strict aseptic technique is paramount for preventing infections
Teach patients thorough catheter care and when to seek medical attention.
Common Mistakes:
Failure to obtain adequate venous access on the first attempt
Incorrect catheter tip placement
Inadequate tunneling of the Dacron cuff
Insufficient sterile technique leading to infection
Delayed recognition and management of CRBSI
Not performing post-procedure chest X-ray
Overlooking contraindications.