Bellasi A, Brancaccio D, Maggioni M, Chiarelli G, Gallieni M
Renal Unit, Azienda Ospedaliera San Paolo, Milan, Italy.
J Vasc Access. 2004 Apr-Jun;5(2):49-56. doi: 10.1177/112972980400500202.
Tunneled catheters are widely used for intermediate to long-term hemodialysis (HD) access, but are prone to several complications that can require catheter replacement. Replacing malfunctioning catheters with a new line, placed in a different access site, can lead to problems with multiple vein occlusions. This has led many nephrologists to continue using the same vein as long as possible by guidewire catheter exchanges, to preserve other veins for future use. We describe a guidewire exchange technique for the Ash-Split catheter in the internal jugular vein.
In three patients, the exchange was performed because of partial catheter removal, as evidenced by the outward dislocation of the Dacron cuff. In these patients, the guidewire was inserted through the catheter. In two additional patients, the catheter had been completely removed by accident: the replacement of the dislodged tunneled venous catheters was attempted 5 hr and 1 day after accidental removal. In these patients, the guidewire was inserted through the previous tunnel. After guidewire placement, a skin incision was made in the supraclavicular region. The metal guidewire was easily located inside the fibrous structure that had previously surrounded the catheter. The guidewire was then extracted from the subcutaneous tunnel and used to insert a new catheter safely and easily after creating a new tunnel. Patients were routinely given antibiotic prophylaxis (1 g of cefazolin) immediately before the procedure. A strict aseptic technique was used, including several sterile glove changes.
No infections developed following this procedure, which has the potential for bacterial contamination. All procedures were successful. Only in one patient did we have to convert to a different catheter: it was not possible to replace the old Ash-Split catheter with the same dual-lumen catheter because of difficulties in inserting the peel away introducer-catheter complex. In this patient, rather than forcing it with larger dilators or trying to disrupt the fibrin sheath with balloon dilatation, a single lumen Tesio catheter was successfully placed. In both patients who completely lost the previous catheter, the guidewire was readily reinserted through the subcutaneous tunnel into the vein. Catheter function was excellent in all patients, with a test blood flow rate on the 1st catheter use >350 ml/min.
We described a new method for catheter exchange, which allows the easy insertion of a new catheter and the creation of a new and safer subcutaneous tunnel. In addition, we demonstrated that in cases of complete catheter removal, it is possible to reinsert a catheter in the same vein through a guidewire, even when reinsertion was attempted up to 1 day later.
隧道式导管广泛用于中长期血液透析（HD）通路，但容易出现多种并发症，可能需要更换导管。用新导管替换出现故障的导管并置于不同的穿刺部位，可能会导致多条静脉闭塞问题。这使得许多肾病学家尽可能长时间地通过导丝导管交换继续使用同一条静脉，以保留其他静脉供将来使用。我们描述了一种在内颈静脉中对Ash-Split导管进行导丝交换的技术。
在3例患者中，由于涤纶套向外移位证明导管部分移除而进行了交换。在这些患者中，导丝通过导管插入。在另外2例患者中，导管意外完全移除：在意外移除后5小时和1天尝试更换移位的隧道式静脉导管。在这些患者中，导丝通过先前的隧道插入。放置导丝后，在锁骨上区域做一个皮肤切口。金属导丝很容易在先前围绕导管的纤维结构内找到。然后将导丝从皮下隧道中抽出，并在创建新隧道后用于安全、轻松地插入新导管。患者在手术前常规给予抗生素预防（1克头孢唑林）。采用严格的无菌技术，包括多次更换无菌手套。
该手术虽有细菌污染的可能性，但术后未发生感染。所有手术均成功。仅1例患者我们不得不更换为不同的导管：由于难以插入可撕开式导入器-导管复合体，无法用相同的双腔导管替换旧的Ash-Split导管。在该患者中，未用更大的扩张器强行插入或试图用球囊扩张破坏纤维蛋白鞘，而是成功放置了单腔Tesio导管。在2例完全丢失先前导管的患者中，导丝很容易通过皮下隧道重新插入静脉。所有患者的导管功能均良好，首次使用导管时的测试血流量>350毫升/分钟。
我们描述了一种新的导管交换方法，该方法允许轻松插入新导管并创建新的、更安全的皮下隧道。此外，我们证明，在导管完全移除的情况下，即使在尝试重新插入长达1天后，也可以通过导丝在同一条静脉中重新插入导管。
