#4047 ULTRASOUND-GUIDED RIGHT INTERNAL JUGULAR TUNNELED CATHETER INSERTION FOR HAEMODIALYSIS: PRACTICES AND OUTCOMES FROM A SINGLE CENTRE
Authors: Ramgobin Chittesh , Khurshid Bilal , Rengarajan Sharmilee , Green Adele , Poulikakos Dimitrios , Raman Maharajan , New David , Lewis David , Chinnadurai Rajkumar 
Published: June 2023

Abstract

Background and Aims
Internal jugular vein tunneled catheters are important vascular access for haemodialysis (HD). In our practice, Left-sided internal jugular (LIJ) catheter insertion is performed in radiology under direct X-ray screening. Most right-side internal jugular (RIJ) catheters are inserted under ultrasound guidance in dedicated renal procedure rooms. Vascular access can become challenging with the potential for venous stenosis and thrombosis with catheter use. The aims of this study are to evaluate our practices and outcomes of non-radiologically inserted RIJ tunneled HD catheters and to investigate the predictors of procedure failure.

Method
200 successive RIJ tunnel HD catheters inserted from June 2016 under ultrasound guidance at our centre were included in this analysis. Data including demographics, co-morbidities, first or higher order insertion, outcome (success or failed attempt), and immediate complications were collated from electronic patient records. Binary logistic regression analysis was conducted to investigate the predictor for failure in catheter insertion.

Results
Of the 200 patients, 152 (76%) were first-time insertions and 48 (24%) were second or higher-order insertions. The median age of our cohort was 58 years, with a predominance of males (68%) and white ethnicity (82%). 36.5% were diabetic, with 37.5% having a history of cardiovascular disease. Nearly 30% of patients were on an antiplatelet agent, and 8% were on anticoagulants, which were appropriately managed before line insertion. Pre-operative median haemoglobin was 93 g/dl, with clotting screen and platelet counts in the target range. There was a statistically significant difference in the success of insertion, depending on the insertion being first or subsequent (96.1% vs 81.2%; p = 0.001). The reason for failure in insertion included on-table observation of a small calibre vein on ultrasound or failure to thread wire/dilator due to possible stenosis or thromboses. All line rewire (12/48) procedures were performed successfully. Immediate complication (&lt;1 week) was recorded in 9% of patients, predominantly tunnel bleeding (n = 7) and malposition (deep or high; n = 7) (Table 1). Second or higher-order RIJ catheter insertion showed a higher risk for failure in a multivariable binary logistic regression analysis. (OR: 6.4; CI: 2.1-20.5; P = 0.002) (Figure 1). Of the higher-order insertions, the longer duration between the first and subsequent catheters showed a higher risk for failure (OR:1.19; CI-1.04-1.4; p = 0.010).

Conclusion
Second or higher-order catheter insertions with a longer duration between the first and the subsequent insertion carry a significant risk of failure due to vein stenosis and thrombosis. Therefore, a careful case-to-case triaging of patients based on previous access history is warranted before listing patients for routine ultrasound-guided insertion.