title: Transjugular tunnelled dialysis catheter tip placement into the inferior vena cava upper segment after length overestimation.
abstract: OBJECTIVE
  The right atrium is preferred over the superior vena cava (SVC) for tunnelled dialysis catheter (TDC) tip placement as it offers the best compromise between optimal catheter performance and complications. However, clinical practice guidelines are not all unanimous on this as a universal recommendation. Right atrial tip placement may also fail due to variations in body surface area, venous anatomy or TDC designs and lengths. Moreover, the presence of recurrent long intra-cardiac fibrin sheath or cardiac rhythm management device leads serves as contraindications. Extra-cardiac tip placement in the azygous, hepatic veins and lower segment of the inferior vena cava (IVC) is an alternative but is invariably associated with poor blood flow and shortened patency.
  
  
  METHODS
  We report the concept of extra-cardiac tip placement into the larger calibre hepatic segment IVC via a transjugular approach in two diabetic haemodialysis patients with overestimated TDC length out of 380 insertions.
  
  
  RESULTS
  Blood flow was maintained above 250 ml/min for 5-6 months and no tip migration ensued.
  
  
  CONCLUSIONS
  The IVC upper segment is a reliable site for extra-cardiac tip placement in select cases but its safety and efficacy need to be further studied in larger clinical trials.
authors.affiliation: 1 Department of Medicine, Khoo Teck Puat Hospital, Yishun Central - Singapore.
authors.forename: Claude J
authors.initials: CJ
authors.lastname: Renaud
authors.forename: Ying Ying
authors.initials: YY
authors.lastname: Seow
authors.forename: Hui Siong
authors.initials: HS
authors.lastname: Teh
mesh_terms: D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D002408:Catheters, Indwelling; D062905:Central Venous Catheters; D004867:Equipment Design; D006801:Humans; D007601:Jugular Veins / Q000000981:diagnostic imaging; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010690:Phlebography / Q000379:methods; D006435:Renal Dialysis; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014682:Vena Cava, Inferior / Q000000981:diagnostic imaging