How does a dialysis catheter placement procedure work? [Dr. Spinowitz]

Q: How does a dialysis catheter placement procedure work?

A: There are two types of dialysis catheters. There’s a hemodialysis catheter and a peritoneal dialysis catheter. I’m going to describe the insertions of both the hemodialysis and peritoneal dialysis catheters now.

The first, the hemodialysis catheter, is a catheter that has two ports. There’s an arterial port, where the blood comes out of the catheter into the dialysis machine to clean the blood. Once the blood is clean, it’s then returned to the body through the venous port. This catheter is placed into the internal jugular vein, usually on the right side but can be placed on the left as well. The right internal jugular vein drains the blood from the head down back toward the heart in a straight fashion. The skin is anesthetized just at the base of the internal jugular vein before it connects to the brachiocephalic vein deeper in the chest. The skin is anesthetized with a small bit of lidocaine, which can cause a little bit of a pinch and burn for a few seconds. A small needle is then introduced into the internal jugular vein using ultrasound guidance. Once we are in the internal jugular vein, a wire is placed deeper into the central circulation to stabilize the system. Images are taken.

The subcutaneous tissue is then anesthetized from underneath the collar bone, all the way until the insertion point at the internal jugular vein. Once this area is anesthetized, a small incision is made just underneath the collar bone, and the catheter can then be introduced into the skin, underneath the skin, brought out from this area, where we went into the internal jugular vein, and then introduced into the internal jugular vein. When you leave here, the catheter will come out from the chest wall. Everything else is underneath the skin. You can feel the catheter underneath the skin over the collar bone just before it enters into the internal jugular vein. After that, you don’t feel it. The tip of the catheter will then be resting at the entrance into the heart.

The second type of catheter is the peritoneal dialysis catheter. This type of catheter is placed into the abdomen to perform peritoneal dialysis. (Watch the video above  for the image drawing) I’m going to draw a picture of the abdomen and how we place the peritoneal dialysis catheter to make it clear. If we were to take a picture of the patient’s abdomen and sort of cut it in half, from the top down, we would see the skin, we would see some fat or tissue underneath, some muscle under there, and underneath there, the peritoneum, which is why it’s called peritoneal dialysis. This peritoneum is a very thin lining and it goes around the whole abdomen. Inside the abdomen are the intestines. The intestines are filled and lined with a lot of blood vessels. This is the blood that is being carried to the intestine that has not yet been cleaned because the kidneys are not working. The peritoneum, this thin layer, that looks like a stocking, goes around the intestines as well. Now we have space, this peritoneal space, that is outside of the intestines but underneath the layers, we described before. This thin layer of the peritoneum can act as a filter because it’s a very thin layer on the other side of the blood vessels. In order to perform peritoneal dialysis, we will make a small incision next to the belly button, around 1-2 centimeters.

With ultrasound guidance, after numbing up this whole area, we insert a needle through this area. Once we are in the peritoneal space, between the peritoneum and the intestinal wall, we introduce a wire to go down deep into the pelvis. With this introduction of the wire, some patients can feel pressure, some patients don’t feel it at all. Once the wire is in the appropriate position, we place the catheter. Just like we did before with the hemodialysis catheter, we bury the catheter underneath the skin to prevent it from infection.

This catheter can then allow the dialysate to enter the peritoneal space. There are a lot of holes on the peritoneal dialysis catheter to allow the dialysate to go throughout the abdomen, allowing the toxins to flow from the blood across the filter, the peritoneum, into this space. This allows all the toxins to be removed just like gravity. After the exchange takes place, all the toxins then come out, and here is the waste. You will have a small incision here, which will be sutured. Underneath, those sutures will resorb by themselves. This is the exit site, where the catheter comes out.

More videos from the interview with Dr. Spinowitz of the Queens Endovascular Center as he explains the different modes of Dialysis Access Management:

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