title: Alternative puncture site for implantable permanent haemodialysis catheters.
abstract: BACKGROUND
  Vascular access represents a major problem in long-term haemodialysis patients. In patients without patent internal arteriovenous fistula, the implantation of cuffed catheters to provide a temporary or permanent central venous access is often necessary. Catheterization of the subclavian vein should be avoided because of the high risk of stenosis or thrombosis. The puncture of the internal jugular vein can be impossible in cases with stenosis or thrombosis due to previous catheterization. To overcome these limitations we evaluated an alternative puncture site for implantation of permanent central venous catheters.
  
  
  METHODS
  The very low, most central jugular approach, first described by Rao et al., with the site of puncture just above the medial notch of the clavicle, was used to introduce Dacron cuffed dialysis catheters into the innominate vein in four chronic dialysis patients with impeded conventional vascular access.
  
  
  RESULTS
  In all four patients puncture of the internal jugular vein using Rao's technique was successful at the first attempt. All four catheters were introduced without any problems. Even in a case with thrombosis of the internal jugular vein and the ipsilateral subclavian vein, this technique was successfully applied. No complications such as haematoma, pneumothorax, or catheter-associated infection were observed. The catheters remained in situ for 2-12 months with excellent blood flow and without clinical evidence of venous stenosis or thrombosis.
  
  
  CONCLUSIONS
  In case of failure to cannulate the internal jugular vein by a conventional approach, the technique of Rao et al. can be used before sacrificing the subclavian vein or changing to exotic techniques such as translumbar, transfemoral or transhepatic methods.
authors.affiliation: Klinische Abteilung für Nephrologie und Dialyse, Universitätsklinik für Innere Medizin III, Universität Wien, Vienna, Austria.
authors.forename: R
authors.initials: R
authors.lastname: Apsner
authors.forename: G
authors.initials: G
authors.lastname: Sunder-Plassmann
authors.forename: M
authors.initials: M
authors.lastname: Muhm
authors.forename: W
authors.initials: W
authors.lastname: Druml
mesh_terms: D000328:Adult; D000368:Aged; D002405:Catheterization, Central Venous; D002408:Catheters, Indwelling; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000379:methods*