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.