Retrograde femoral vein catheter insertion. A new approach for challenging hemodialysis vascular access. As I am the author of this approach, I recommend to read the following carefully before trying to try this approach: philosophy, indications and contraindication. For full details, access the full text in Journal of Vascular Access: vascular-access.info/article/retrograde-femoral-vein-catheter-insertion--a-new-approach-for-challenging-hemodialysis-vascular-access Approach Philosophy: Normal femoral vein contains multiple competent valves. These venous valves are mobile bicuspid structures with a tiered arrangement, made of fibrous, elastic tissue and coated with endothelium. The veins are dilated at the valves, creating a sinus space to facilitate opening and closing movements. These valves, which are arranged every 4 to 5 centimeters, ensure the blood flows in one direction only from the leg towards the heart and then close preventing venous reflux. Trial to cannulate normal femoral vein in the reverse direction (from heart to leg) will fail due to the competent femoral valves. While, in case of acquired obstruction distal to the level of femoral vein (e.g. Inferior vena cava and/or iliac vein obstruction) or common femoral vein obstruction due to repeated femoral vein catheterization by hemodialysis catheters these lead to secondary varicose vein of the superficial femoral vein with its dilatation, congestion, and its valves become incompetent allowing the guide wire to pass proximally in the reverse direction i.e. from heart to leg. This new approach will give us time for preparation of those patients with poor or no vascular access to insert Tenckhoff catheter as peritoneal dialysis is the optional type of RRT or insertion of IVC catheter through translumbar or transhepatic approaches if available. On the long term, Kidney transplantation may be considered if these patients have available veins for graft implantation after vascular study and a suitable kidney donor. Indications: This is a short-term and life-saving vascular access approach until provision of an alternative option. It is applied when there are unavailable veins to insert HD catheters through the ordinary approaches including occlusion of internal jugular veins, subclavian veins, external iliac veins and common femoral veins. Preoperative Doppler ultrasound of the femoral vein should be performed to assess patency of the superficial femoral vein with stenosis/occlusion of its common femoral and/or external iliac vein from the previous HD catheters insertion. Goudas approach is indicated in the following situations: A. Patients with non-functioning AVF and have no available veins for insertion of venous hemodialysis catheters including obstructed internal jugular veins, subclavian veins, superior vena cava, and common femoral veins in addition to: Unavailability to canulate IVC through external iliac veins either due to bilateral obstruction or unavailable Doppler ultrasound and/ or Unavailability to canulate IVC through translumbar or transhepatic approaches either due to lack of skilled personnel or equipments. B. It can save chronic peritoneal dialysis patients with no vascular access who need urgent and short-term hemodialysis as in the following situations: Inefficient PD. Lack of PD fluids during disasters and unavailable fluid supply. Resistant infection necessitating PD catheter replacement. Malfunctioning PD catheters until catheter manipulation. Contraindications: Preoperative Doppler ultrasound of the femoral vein should be performed to assess patency of the superficial femoral vein. This approach is contraindicated in the following situations: A. Deep venous thrombosis (DVT) of the targeted superficial femoral vein. B. Sepsis/infection in the lower limb. This is a relative contraindication as this approach is a life-saving approach, so risk-benefit ratio will be considered by the primary physician and insertion can be done under umbrella of antibiotics.
Posted on: Sat, 12 Jul 2014 10:59:03 +0000
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