Tunnelled dialysis catheter insertions without fluoroscopy deemed safe and effective in selected patients


“The technique of inserting tunnelled dialysis catheters (TDCs) in the right internal jugular vein without fluoroscopy is a safe and effective method in selected patients”, write Zi Yun Chang (National University Health System, Singapore) and colleagues in The Journal of Vascular Access (JVA). They conclude that this finding may translate into reduced healthcare resources and hospitalisation days, which is “particularly valuable in times of limited resources, such as the current COVID-19 pandemic”.

Chang et al state that TDCs are “commonly used to provide vascular access in the intermediate or long term”. National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines recommend that when a catheter will be needed for more than three weeks, a TDC should be used, they add.

“Although we strive to initiate patients on dialysis via a permanent access (i.e., arteriovenous fistula/graft or peritoneal dialysis catheter), the TDC still plays an integral role in the care of our end-stage kidney disease (ESKD) patients”, the authors note. In addition, they stress that the universal ‘fistula first’ approach is actually being challenged as the ageing population increases and TDC is increasingly being recognised as their optimal choice of vascular access.

In their retrospective cohort study, Chang and colleagues assessed all TDC insertions or exchanges performed at the National University Health System in Singapore between January 2017 and December 2017. The investigators obtained patient demographics, laboratory results, and catheter placement information from electronic records; they collected data on immediate technical success, early and late catheter-associated complications.

In total, the research group found that 351 TDC insertions and 253 TDC exchanges were performed within the timeframe of the study. They specify that out of 351 insertions, 261 were done with fluoroscopy and 34 were done without.

Chang et al report in JVA that, for both TDC insertions and exchanges, there were no significant differences in complication rates when done with or without fluoroscopy. Furthermore, they relay that mean duration of catheter patency was longer for TDC inserted without fluoroscopy, after adjusting for site of insertion and presence of previous TDC.

The investigators acknowledge some limitations to their research. They recognise, for example, that a selection bias may have been present in view of the retrospective nature of the study—a bias they attempted to reduce by performing a subgroup analysis. In addition, they write that follow-up data could only be obtained via electronic records if these patients presented back to the centre. “There was a possibility that patients who presented with complications to other institutions were not captured and hence complication rates underestimated”, they remark.

However, they also state why their study findings are valuable. “The availability of fluoroscopy may not be sufficient to meet the demand for TDC exchanges or insertions”, they comment, noting for example that there can be a delay in TDC insertions when competing uses for fluoroscopy for other procedures take precedence.

The authors also emphasise that their findings are of particular relevance during the COVID-19 pandemic, when there is emphasis on “striving for efficient, safe, and least resource-intensive procedures”.


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