asdin core curriculum for peritoneal dialysis catheter procedures

17
ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures American Society of Diagnostic and Interventional Nephrology

Upload: vuongkhanh

Post on 13-Feb-2017

222 views

Category:

Documents


1 download

TRANSCRIPT

Page 1: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

American Society of Diagnosticand Interventional Nephrology

Page 2: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

This curriculum represents the best efforts of the authors and editors at the time of publication. The judgment of the healthcare professional, taking into account all of the facts and circumstances of the presenting case, should always prevail over any procedures or recommendations in this curriculum.

Copyright © 2010 American Society of Diagnostic and Interventional NephrologyAll rights reserved.

ISBN: 1452893233ISBN-13: 9781452893235

Page 3: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

Table of ContentsChapter 1 .....................................................................................................................1Introduction Loay Salman, MD and Arif Asif, MD

Chapter 2 .....................................................................................................................3Peritoneal Dialysis Catheters Designs and Overview of Placement Techniques Stephen Ash, MD and Anil Agarwal, MD

Chapter 3 ...................................................................................................................31Definition of Peritoneal Catheter Complications and Proper FunctionStephen Ash, MD and Anil Agarwal, MD

Chapter 4 ...................................................................................................................41Surgical Placement of Peritoneal Dialysis Catheters (Dissective Placement)Amer Rajab, MD, PhD and Mitchell Henry, MD

Chapter 5 ...................................................................................................................47Laparoscopic Placement of Peritoneal Dialysis Catheters Gazi B. Zibari, MD and Hosein Shokouh-Amiri, MD

Chapter 6 ...................................................................................................................57Peritoneoscopic Placement of Peritoneal Dialysis Catheters Jeffrey Packer, DO and Rick Mishler, MD

Chapter 7 ...................................................................................................................69Fluoroscopic Placement of Peritoneal Dialysis Catheters Kenneth Abreo, MD, Bharat Sachdeva, MD, and Ivan Maya, MD

Chapter 8 ...................................................................................................................83Peritoneal Catheter Removal and Complications of Peritoneal Dialysis CathetersLoay Salman, MD and Arif Asif, MD

Chapter 9 ...................................................................................................................93CPT Coding of Peritoneal Dialysis Catheter Related Procedures Donald Schon, MD and Shouwen Wang, MD

Page 4: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

Contributors Kenneth Abreo, MDDivision of NephrologyLSU Health Sciences Center Shreveport, Louisiana

Anil Agarwal, MD Division of NephrologyThe Ohio State UniversityColumbus, Ohio

Stephen R. Ash, MDClarian Arnett HealthAsh Access Technology, Inc. and HemoCleanse, Inc. Lafayette, Indiana

Arif Asif, MD Division of NephrologySection of Interventional NephrologyUniversity of Miami Miller School of MedicineMiami, Florida

Mitchell L. Henry, MD Department of SurgeryThe Ohio State University Medical CenterColumbus, Ohio

Ivan Maya, MDNephrology Associates of Central FloridaOrlando, Florida

Rick Mishler, MDArizona Kidney Disease & Hypertension CenterPhoenix, Arizona

Jeffrey Packer, DOArizona Kidney Disease & Hypertension CenterPhoenix, Arizona

Amer Rajab MD, PhD Department of SurgeryThe Ohio State University Medical CenterColumbus, Ohio

Bharat Sachdeva, MDDivision of NephrologyLSU Health Sciences Center Shreveport, Louisiana

Loay Salman, MDDivision of Nephrology Section of Interventional NephrologyUniversity of Miami Miller School of MedicineMiami, Florida

Donald Schon, MD Arizona Kidney Disease & Hypertension CenterPhoenix, Arizona

Hosein Shokouh-Amiri, MDDepartment of SurgeryLouisiana State University Health Sciences CenterShreveport, Louisiana

Shouwen Wang, MDArizona Kidney Disease & Hypertension CenterPhoenix, Arizona

Gazi B. Zibari, MDDepartment of SurgeryLouisiana State University Health Sciences CenterShreveport, Louisiana

EditorSteven Wu, MDInterventional Nephrology Nephrology DivisionMassachusetts General HospitalHarvard Medical School

Boston, Massachusetts

Page 5: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

69

Chapter 7

Fluoroscopic Placement of Peritoneal Dialysis Catheters IntroductionThe success of a dialysis program depends on the careful evaluation of the individual patient, meticulous pre end-stage renal disease (ESRD) care/education, planning ahead to select the best long term access/modality, and transplant evaluation.

Recent data have emphasized that up to 19% of the ESRD patients in the US are using tunneled dialysis catheters (TDC) as their permanent access (1). Of particular concern is the fact that the use of TDC as permanent dialysis access is steadily on the rise, with placement rates having increased since 1996 (1). Late identification of patients with chronic kidney disease and subsequent late referral to nephrologists contributes to a high rate of catheter use in incident dialysis patients with as many as 80% of patients commencing dialysis with a TDC (1).

Peritoneal dialysis (PD) offers a number of advantages such as slow continuous daily home dialysis, preservation of residual renal function, improved middle molecule clearance, better fluid and blood pressure control, cost-effective-ness, reduced mortality, and better quality of life. However, despite these advantages, this renal replacement modal-ity remains largely ignored (2). Recent data have demonstrated that more that 50% of patients with ESRD who are informed about treatment options prefer and request PD as the modality of choice for renal replacement therapy (3, 4, 5). As many as a third of patients starting dialysis are PD candidates, provided the nephrologists taking care of these patients have the option available. (6).

Fluoroscopic peritoneal catheter placement offers an uncomplicated approach to establish a peritoneal access that is ready for use as early as within 24 hours of insertion in cases of emergency or if needed. This method has the benefit of little waiting time, a small incision, rapid wound healing, less pain/discomfort, and lower cost when compared to surgical placement methods. This procedure, first described in 1992 (7), has gained wide acceptance over the years by programs across the globe (7, 8, 9, 10, 11, 12, 13).

Preoperative EvaluationA thorough history and complete physical examination are mandatory prior to peritoneal catheter placement. Selection of the dialysis modality based on the patient’s clinical condition, co-morbidities, and preference should be addressed at every patient encounter.

Page 6: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

70

Fluoroscopic peritoneal catheter placement is the least invasive method for a long term peritoneal access but suffers from the handicap of limiting the procedure to patients free of abdominal scars/adhesions. A history of extensive abdominal surgeries in the past, or a prior failed attempt at PD, would require placement of the catheter under direct visualization using advanced procedures including adhesionolysis, omentopexy, or catheter anchoring to the anterior peritoneal wall.

Determination of the Exit SitePrior to insertion, the exit site should be identified and marked on the skin. This can be done by the physician or an experienced PD nurse. It is advisable to avoid locations where there may be pressure during daily activities.

The exit site should be:1. Above or below the belt line, should not lie on a scar, and should not be in abdominal folds. 2. Determined with the patient in an upright (seated or standing) position.3. Directed laterally and facing downwards. (A stencil can be applied to demarcate the tunnel and exit site clearly.)

(Figure 1)4. Locate to maximize self-care skills (dexterity, vision, handedness, strength, and motor skills).5. Marked laterally to midline; placement through body of rectus muscle helps avoid catheter leakage.

A complete blood count, coagulation profile (PT/PTT/INR) and basic metabolic panel help screen patients with any contraindication for the surgical procedure and/or conscious sedation. Obtaining these the day prior to the scheduled procedure would help address any abnormal finding.

Nasal SwabMethicillin resistant staphylococcus (MRSA) is seen in almost 1 in 5 dialysis patients (14) and 1 in 3 are colonized with MRSA. While the use of nasal antibiotic prophylaxis compared with placebo has not been shown to reduce significantly the risk of peritonitis (15, 16) (RR 0.94 (0.67 to 1.33), 95% CI); nasal mupirocin when compared to placebo significantly reduces the exit-site and tunnel infection rate. (15) (RR 0.58 (0.40 to 0.85), 95% CI). Routine screening and treatment of carriers should be offered to patients initiating peritoneal dialysis treatment.

Bowel PreparationThe rationale for the use of mechanical bowel preparation (MBP) is to decrease peritoneal contamination in case of bowel injury and to empty the bowel of its contents to improve the surgical field and handling of the bowel it-self (17). Bowel complications with unexpected bowel opening, although relatively rare during benign peritoneal surgery (18), nonetheless represent one of the reasons behind routine administration of MBP. Over the past three decades, several randomized control trials have proven the safety of peritoneal/abdominal surgery without MBP (18), showing no difference in mechanical complication, perforation and infectious complications post procedure. On the contrary, mechanical bowel preparation has been shown to have the potential for bacterial translocation, (19) electro-lyte disturbance, (20) and discomfort to patients (20).

Page 7: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

Fluoroscopic Placement of Peritoneal Dialysis Catheters

71

Although most surgeons continue to advocate bowel preparation and believe in its beneficial role, an impressive body of evidence points otherwise. As of now, we are at the crossroads, uncertain as to whether we are facing a paradigm shift as far as MBP is concerned.

Bladder evacuation before the procedure ensures that the pelvic gutter has open space for accommodating the perito-neal catheter. A Foley catheter during the procedure helps to ensure an empty bladder, look for any evidence of blad-der perforation (blood in urine, peritoneal fluid in the Foley bag) especially in patients with a dysfunctional bladder. However, most interventionalists place PD catheters without a Foley catheter in the bladder recommending that the patient empty the bladder prior to the procedure (10, 11, 12).

Peri-Operative Antibiotic ProphylaxisThe use of peri-operative intravenous antibiotic prophylaxis compared with no treatment significantly reduces the risk of early peritonitis (within 30 days of catheter insertion) (21, 22, 23, 24) (RR 0.35 (0.15 to 0.80) 95% CI). Gadallah et al. studied this in a randomized control trial (24). The study had three arms: placebo, vancomycin 1000 mg intravenous (single dose), and cefazolin 1000 mg (single dose) intravenous. The rate of peritonitis was 12% in the placebo arm, 7% after cefazolin, and 1% after vancomycin (p<0.05). Similarly Wikdahl et al. showed no incidence of peritonitis in the group that received cefuroxime 1500 mg intravenous prior to surgery (23).

Figure 1. Location of insertion site. (Reprinted with permission, reference 28)

Page 8: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

72

Method of PD Catheter Insertion

Location of Insertion: In most descriptions, a site 2-4 cm below (caudal) or above (cephalad) and left of the umbilicus is selected for catheter insertion (7, 8, 9, 10, 12, 25, 26). In general, the site chosen should be between the medial and lateral border of the rectus muscle (mid-rectus line). The left side is usually selected for convenience because most operators are right handed. There may be an advantage to placing the catheter on the right side rather than on the left since there is a tendency for the catheter tip to migrate to the right upper quadrant for left sided catheters. It has been hypothesized that peristaltic activity of the bowel is responsible for tip migration out of the pelvis (27). A more accurate method of determining the insertion site has been described by Crabtree (28). This can be done before the procedure as de-scribed earlier or when the patient is on the table. With the patient in the supine position, the upper border of the coiled segment of the catheter is aligned with the pubic symphysis and the catheter is laid on the abdomen along a paramedian line 3 cm lateral to the midline. The upper border of the deep cuff is the location of the insertion site as shown in Figure 1. The pubic symphysis has been recommended as a reliable landmark for the ideal location of the catheter tip in the true pelvis (29) and confirmed laparoscopically (30).

Peritoneal Entry: The aim of this step is to enter the peritoneum safely without puncturing the epigastric artery, bowel, or bladder. After infiltrating the skin and underlying tissue with 2% lidocaine with epinephrine local anesthesia, a horizontal incision of about 2-5 cm is made. Obese individuals may need an appropriately longer incision. Blunt dissection of the subcutaneous tissues and fat is performed until the shiny anterior rectus sheath is visible. Bleeding blood ves-sels are either ligated with absorbable sutures or cauterized. The rectus sheath, rectus muscle, and peritoneum are infiltrated with local anesthesia and the needle is aspirated as it is withdrawn to ascertain that the epigastric artery is not in its path. An 18-gauge needle with a blunt trocar is inserted at an angle of 45 degrees (Figure 2), directed toward the lower pelvis. The needle will be felt to puncture the anterior rectus sheath followed by a second “pop” when passing the peritoneum. The location of the needle within the peritoneal cavity is confirmed by injecting 3-5 cc of contrast. If the needle has not entered the peritoneal cavity, a smudge or stain of contrast is seen on fluoroscopy; and if it has entered, the loops of bowel are outlined giving a scalloped appearance. Using the blunt end 18 Gauge needle instead of a micropuncture needle helps decrease the risk of bowel perforation. When using a micropuncture needle, 0.018-inch wire is then inserted through the needle and its course noted under fluoroscopy. When an 18 Gauge needle is used for peritoneal entry, 0.035-inch wire will pass directly through the needle and position is veri-fied on fluoroscopy (Figure 3). After confirmation of its position in the lower pelvis, a 5-French catheter is inserted over the wire. Contrast can again be injected through the catheter to confirm its position (Figure 4). Perforation of the bowel with the micropuncure needle does not result in peritonitis. If perforation is suspected the best option is to abandon the procedure and administer broad spectrum antibiotics for 24 hours. No cases of peritonitis have occurred as a consequence to entering the bowel with a micropuncture needle (author’s personal experience). Use of blunt tipped 18 Gauge needle has been described to enter the peritoneal space (7, 26). Besides prevention of perfora-tion, a pop and give can be felt on entry into the peritoneal space with a blunt tipped needle. In addition, a larger guide wire (0.035-inch) can be passed into the abdomen precluding the use of a micropuncture needle and wire.

Page 9: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

Fluoroscopic Placement of Peritoneal Dialysis Catheters

73

Ultrasound guidance with a 10-15 MHz transducer has been used by Maya (10) and others (12) to gain safe access into the peritoneal cavity. Ultrasound measures the distance from the skin to the peritoneal cavity and color Doppler can locate the epigastric and hypogastric vessels. A skin incision followed by blunt dissection to the rectus sheath may not always be a necessary step before entry into the peritoneum. Maya has used ultrasound guidance to advance the micropuncture needle across skin, the subcutaneous tissue, the outer fascia of the rectus muscle, the muscle fibers, the inner fascia, and the parietal layer of peritoneum (10).

Figure 3: Course of the 0.035 in wire introduced through the 18 Gauge needle noted under fluoroscopy.

Figure 4: Contrast injected through the 18 Gauge needle shows it outlining the bowel wall.

Dilation, Catheter Placement, and Embedding of the Deeper Cuff: A 0.035-inch 150 cm long standard or stiff guide wire is passed through the 5-French catheter until sufficient guide wire forms a comfortable curve in the pelvis. Others have used a 0.038-inch with a 1.5 mm J-shaped end (7, 12). Dilators from 10F to 17F are advanced sequentially over the guide wire across the rectus sheath and muscle until the

Figure 2: An 18 Gauge blunt nee-dle is inserted through the rectus muscle and a 0.035-inch glide wire is then inserted through the needle.

Page 10: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

74

final 18-French dilator with a peel-away sheath (Figures 5 and 6). The PD catheter is then either advanced over the guide wire or the guide wire is removed and the PD catheter is inserted over a metal stylet through the sheath. The radiopaque line on the PD catheter allows for confirmation of its position in the lower pelvis. The catheter can be rotated and moved at this point to ensure that the “pigtail” portion is located in the pelvis. Contrast can be injected into the catheter for better visualization. One liter of PD fluid is infused into the abdomen through the catheter to evaluate its function (Figure 7). Inflow should be rapid and pain free and outflow should be a fast drip or stream that increases with deep inspiration. The catheter can be repositioned until optimum function is achieved. The deeper cuff is buried in the rectus muscle with the use of the cuff pusher (9) or with a set of forceps with the peel-away sheath in place (10, 12). The peel-away sheath is split and removed once the deep cuff is in the rectus muscle. The cuff should be held in place when the peel-away sheath is removed to prevent its dislodgement. Some operators pass an absorbable suture through the deep cuff and the outer rectus sheath and subcutaneous tissues, and tie the suture once the cuff is buried in the rectus muscle to anchor the cuff (8, 25).

Figure 5: Dilators from 10F to 17F are advanced sequentially over the guide wire.

Figure 6: Fluoroscopic view of a cath-eter being advanced over a guide wire.

Figure 7: Contrast injected into the PD catheter for better visualization.

Page 11: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

Fluoroscopic Placement of Peritoneal Dialysis Catheters

75

Exit Site and Superficial Cuff: The exit site should be placed in a location on the abdomen so as to avoid the patient’s belt line. Various exit site locations are shown in Figure 8. Typically women have beltlines above the umbilicus whereas men below. The bent intercuff segment catheter (swan neck) is best suited for women as the exit site can be located in the lower abdomen and the straight intercuff segment catheter (straight) for men as the catheter can be bent slightly to emerge above the belt. Patients who are obese, have abdominal stomas, are incontinent of urine or feces, and who desire to take a deep tub bath would benefit from an extended catheter system that will allow for an exit site located in the upper abdomen or chest (28, 31).

Figure 8: Tenckhoff catheter modifications for a variety of exit sites (Reprinted with permission from reference 28)

After selecting the general location of the exit site (upper abdomen, lower abdomen, etc.), the specific location is selected by laying the catheter on the abdominal wall and marking a point 2-4 cm beyond the superficial cuff. Using local anesthesia, a stab wound is made such that the exit site would face downward. This prevents debris and fluids collecting in the exit site. A tunneling device or a Kelly clamp is inserted into the stab incision and tunneled into the subcutaneous tissues to engage or grasp the catheter tip and the catheter is pulled through the tunnel and out of the exit site (7, 9, 10, 26). The catheter can be embedded in the subcutaneous tissues if the patient does not require di-alysis immediately. This technique was first described by Moncrief and subsequently modified by others (32, 33, 34). The technique described by Crabtree is the most straightforward (28). In brief, the catheter is brought out of a 1 cm long incision at the exit site and laid on the patient’s abdomen. A stab wound is made 0.5 cm beyond the tip of the

Page 12: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

76

catheter and the catheter tunneled so that its tip lies within the tunnel. The 1 cm scar serves as the point at which the catheter will be exteriorized when needed.

Closing the Wound: The subcutaneous tissue of the primary incision is closed with absorbable sutures and the skin is closed with non-absorbable sutures (9). The exit site should not be sutured as advocated by some authors (8), as this may cause an exit site infection. The two cuffs provide sufficient anchoring to prevent inadvertent falling out of the catheter. The catheter is flushed with saline and 7000 U of heparin are instilled in the catheter after the connectors are attached.

Postoperative ManagementA small incision to access the peritoneal cavity and a minimally invasive technique offers the advantage of fast re-covery. Patients are monitored post-operatively for a period of 2 to 6 hours and followed by the peritoneal dialysis nurse to resume peritoneal exchanges. A hemoglobin concentration is checked at 4 hours and if stable patients are discharged in some centers (10) whereas in others they are observed overnight (9).

In situations requiring immediate dialysis, low volume exchanges (≤1000 cc) can be started immediately after the catheter placement, preferably with the patient in the supine position, thereby avoiding placement of a central ve-nous catheter and all its associated complications.

If there is no urgency to start dialysis immediately after the catheter insertion, the catheter should be accessed weekly after insertion with low volume peritoneal fluid. Full volume exchanges should be withheld for 2-3 weeks after the insertion to minimize the risk of pericatheter leak.

Complications The major peri-operative complications of the fluoroscopic method are: bowel perforation, bladder perforation, early and late fluid leakage, peritonitis, exit site infections, catheter dysfunction, bleeding, muscle hematoma and death (Table 1).

Bowel and bladder perforation are rare with no bladder perforation reported by several authors and three bowel perforations mentioned of which one was a bowel puncture by the micropuncture needle, which was managed with retrieval of the needle, aborting of the procedure, and systemic antibiotic with good results (7, 10).

Early (2 weeks from implantation) peritonitis is rare and has been reported in two large series with less than a 3% complication rate (11, 12). Prophylactic antibiotics as mentioned in the pre-operative section help prevent infec-tion in the first 30 days after catheter insertion. Late peritonitis (>30 days) is not linked to the implantation of the catheter.

Early fluid leak is more common in the surgically implanted catheters by laparoscopy or open laparatomy and very rare with the fluoroscopy technique. The leakage of dialysate fluid around the catheter has been reported from 8.6%

Page 13: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

Fluoroscopic Placement of Peritoneal Dialysis Catheters

77

to 24% (35). The reason for minimal leakage with the latter technique is that the peritoneum is only punctured by an introducer or a needle without any incision of the peritoneum. Also, the inner cuff of the catheter is inserted into the abdominal wall musculature (rectus muscle) to prevent leaks. Usually PD is started between two to three weeks after placement of the catheter, to allow for wound healing and avoid leaks. Low-volume PD may be attempted within 24 hours of catheter placement, if no other dialysis access is available. The use of double cuffs, with the inser-tion of the inner cuff into the rectus muscle, and the swan-neck configuration of the peritoneal catheters has helped decreased the incidence of this complication.

Exit wound infection is low and is dependent on the local care after the implantation. The outer cuff is located in the subcutaneous tissue to create a dead space in between the two cuffs, which is believed to prevent migration of infections coming from the exit site. The subcutaneous tract and exit site face downward and laterally to avoid exit site infection. Three studies comparing the swan-neck and straight Tenckhoff catheters have demonstrated a similar rate for peritonitis and exit infection with the swan-neck design (36, 37, 38). A technique reported by Twardowsky, which modifies the Swan-Neck catheter to a pre-sternal exit site location, has shown an increase in access survival up to 95% at 2 years and also a decrease in peritonitis and exit wound infection (39). This technique is advocated to be performed in obese patients, patients with ostomies, children with diapers and fecal incontinence.

Arterial or venous bleeding with or without rectus muscle hematoma is also rare. The ultrasound technique has the advantage of visualizing the epigastric and hypogastric vessels under Doppler Color US, which helps avoiding these vessels.

Catheter dysfunction occurs most frequently weeks to months after the implantation. The intra-peritoneal portion of the catheter should be placed between the visceral and parietal peritoneum near the pouch of Douglas. The dysfunc-tion is due to tip migration to the left or right upper quadrant from the pelvic area. Tip migration is a very common complication accounting for up to 35% by different authors, and is most commonly seen after surgical implantation (40). It usually causes problems with drainage of the PD fluid. This late complication can be managed by the use of laxatives, sometimes the surgical manipulation of the catheter or radiological intervention with the use of a Fogarty catheter (40, 41).

Comparison with Surgical TechniquesSurgeons mostly use laparoscopic and surgical techniques for PD catheter placement. These procedures require gen-eral anesthesia, sophisticated expensive equipment, and specialized training. Since there is a surgical opening of the peritoneum and abdominal wall, there is a tendency to leak and the peritoneal catheter therefore cannot be used for two to three weeks.

Interventional nephrologists favor either the peritoneoscopic or the fluoroscopic technique with or without the assistance of ultrasound. The former requires the purchase of expensive equipment (peritoneoscope) whereas the latter does not but requires an interventional suite to perform the procedure. Both are performed under con-scious sedation and the catheter can be used almost immediately. These techniques are usually performed in an ambulatory setting, which benefits both patients and hospital. Patients can return home on the same day and

Page 14: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

78

hospital expense is minimized. To be proficient, the interventionist has to master either one of the techniques. The direct visualization of the peritoneal cavity can be achieved by the peritoneoscopic technique, in contrast to indirect visualization is obtained by the fluoroscopic technique. Asif et al. have shown that the incorporation of PD catheter placement in the curriculum of an established interventional nephrology program increases the utilization of this dialysis modality (42). The success of catheter placement has increased from 95 to 100% using the fluoroscopic technique (Table 1).

Table 1: Success rate and complications of the fluoroscopic placement of PD catheters.

To our knowledge there is only one study in the literature comparing the complications and long-term survival of fluoroscopically-placed versus surgically-placed PD catheters. Rosenthal et al. reported that PD catheters placed percutaneously with fluoroscopy guidance is as safe as those placed by surgical technique and although the difference was not significant, the complication rate was lower in the fluoroscopic group (25).

References1. US Renal Data System: USRDS 2008 Annual Data Report. Bethesda, National Institutes of Health, National

Institute of Diabetes and Digestive and Kidney Diseases, Chapter 5; 99, 2008.

2. Gokal R: What is the evidence that peritoneal dialysis is underutilized as an ESRD therapy? Semin Dial15: 149–150, 2002.

3. Schreiber MJ: Outcome of dialysis modality utilization after thorough patient education. J Am Soc Nephrol 12:A1254, 2001.

4. Golper TA: The impact of pre-ESRD education on dialysis modality selection. J Am Soc Nephrol 11: 1233A, 2000.

5. Prichard S: Treatment modality selection in 150 consecutive patients starting ESRD therapy. Perit Dial Int 16: 69, 1996.

Page 15: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

Fluoroscopic Placement of Peritoneal Dialysis Catheters

79

6. Asif A: Peritoneal dialysis underutilization: the impact of an interventional nephrology peritoneal dialysis access program. Semin Dial 16: 266–271, 2003.

7. Jacobs IG, Gray RR, Elliott DS, Grosman H. Radiologic placement of peritoneal dialysis catheters: Preliminary experience. Radiology 182:251-255, 1992.

8. Savader SJ, J-F Geschwind, GB Lund, PJ Scheel. Percutaneous radiological placement of peritoneal dialysis ca-theters: Long-term results. JVIR 11:965-970, 2000.

9. Zaman F, Pervez A, Atray NK, Murphy S, Work J, Abreo KD. Fluoroscopically-assisted placement of peritoneal dialysis catheters by nephrologists. Seminars in Dialysis 18:247-251, 2005.

10. Maya I. Ultrasound/fluoroscopy-assisted placement of peritoneal dialysis catheters. Seminars in Dialysis 20:611-615, 2007.

11. Moon J-Y, Sebin Song, Kyung-Hwan Jung, Mina Park, Sang-Ho Lee, Chun-Gyoo Ihm, Joo-Hyeong Oh, Se Hwan Kwon, and Tae Won Lee. Fluroscopically guided peritoneal dialysis catheter placement: Long-term re-sults from a single center. Peritoneal Dialysis International 28:163–169, 2007.

12. Vaux EC, Torrie PH, Barker LC, Naik RB, Gibson MR. Percutaneous fluoroscopically guided placement of pe-ritoneal dialysis catheters: A 10-year experience. Semin Dial 21: 459-465, 2008.

13. Abdel-Aal AK, Joshi AK, Saddekni S, Maya ID. Fluoroscopic and sonographic guidance to place peritoneal catheters: How we do it. Am J Radiol 192:1085–1089, 2009.

14. Johnson LB, Jinson J, Farah Y, Joan P, Louis DS. Prevalence of colonization with community-associated me-thicillin-resistant staphylococcus aureus among end-stage renal disease patients and healthcare workers. Infect Control Hosp Epidemiol 30:4-8, 2009.

15. Mupriocin Study Group. Nasal mupirocin prevents Staphylococcus aureus exit-site infection during peritoneal dialysis. J Am Soc Nephrol 7:2403, 1996.

16. Sesso R, Parisio K, Dalboni A, Rabelo T, Barbosa D, CendorogloM, et al. Effect of sodium fusidate and ofloxacin on Staphylococcus aureus colonization and infection in patients on continuous ambulatory peritoneal dialysis. Clin Nephrol 41:370–6, 1994.

17. Chung RS. A controlled clinical trial of whole gut lavage as a method of bowel preparation for colonic operati-ons. Am J Surg 137: 75–81, 1997.

Page 16: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

80

18. Contant CM, Hop WC, Van’t Sant HP, Oostvogel HJ, Smeets HJ, Stassen LP, Neijenhuis PA, Idenburg FJ, Dijkuhuis CM, Heres P, van Tets WF, Gerristen JJ, Weidema WF. Mechanical bowel preparation for elective colorectal surgery: A multicentre randomized trial. Lancet 370:2112-7,2007.

19. Poole GV. Spontaneous bacterial peritonitis during bowel preparation: an example of clinical translocation. South Med J 84: 1412–13, 1991.

20. Hamilton D, Mulcahy D, Walsh D, Farrelly C, Tormey WP, Watson G. Sodium picosulphate compared with polyethylene glycol solution for large bowel lavage: A prospective randomized trial. Br J Clin Pract 50: 73–75, 1996.

21. Bennett-Jones DN, Martin J, Barrett AJ. Duffy TJ, Naish PF, Aber GM. Prophylactic gentamicin in the preven-tion of early exit-site infections and peritonitis in CAPD. Peritoneal Dialysis Bulletin 4:147-50, 1988.

22. Lye WC, Lee EJ, Tan CC. Prophylactic antibiotics in the insertion of Tenckhoff catheters. Scand J Uro Nephrol 26:177–80, 1992.

23. Wikdahl AM, Engman U, Stegmayr BG, Sorenssen JG. One-dose cefuroxime i.v. and i.p. reduces microbial growth in PD patients after catheter insertion. Nephrol Dial Transplant 12: 157–160, 1997.

24. Gadallah MF, Ramdeen G, Mignone J, Patel D, Mitchell L, and Tatro S. Role of preoperative antibiotic pro-phylaxis in preventing postoperative peritonitis in newly placed peritoneal dialysis catheters. Am J Kid Dis, 36:1014-1019, 2000.

25. Rosenthal MA, Yang PS, Liu IA, Sim JJ, Kujubu DA, Rasgon SA, Yeoh HH, Abcar AC. Comparison of outco-mes of peritoneal dialysis catheters placed by the fluoroscopically guided percutaneous method versus directly visualized surgical method. J Vasc Interv Radiol 19:1202–1207, 2008.

26. Reddy C, Dybbro PE, Guest SS. Fluoroscopically guided peritoneal dialysis catheter placement: Single center experience and review of the literature. Renal Failure (submitted).

27. Twardowski ZJ, Nolph KD, Khanna R, Prowant BF, Ryan LP, Nichols K. The need for a “swan neck” perma-nently bent, arcuate peritoneal dialysis catheter. Peritoneal Dialysis Bull 5:219-223, 1985.

28. Crabtree JH. Selected best demonstrated practices in peritoneal dialysis access. Kidney Internat 70:S27-S37, 2006.

29. Twardowski ZJ. Peritoneal catheter placement and management. In: Massry SG, Suki WN (eds). Therapy of Renal Disease And Related Disorders. Kluwer Academic: Dordrecht, 1997, pp 953–979.

30. Crabtree JH, Fishman A. A laparoscopic method for optimal peritoneal dialysis access. Am Surg 71: 135–143, 2005.

Page 17: ASDIN Core Curriculum for Peritoneal Dialysis Catheter Procedures

Fluoroscopic Placement of Peritoneal Dialysis Catheters

81

31. Sreenarasimhaiah VP, Margassery SK, Martin KJ, Bander SJ. Percutaneous technique of presternal peritoneal dialysis catheter placement. Seminars in Dialysis 17:407-410, 2004.

32. Moncrief JW, Popovich RP, Broadrick LJ et al. The Moncrief-Popovich catheter. A new peritoneal access tech-nique for patients on peritoneal dialysis. ASAIO J 39: 62–65, 1993.

33. Page DE, Turpin C. A simple and inexpensive method of subcutaneous implantation of catheter distal segment using a Tenckhoff curled catheter. Perit Dial Int 20: 85–86, 2000.

34. Kubota M, Kanazawa M, Takahashi Y et al. Implantation of presternal catheter using Moncrief technique: ai-ming for fewer catheter-related complications. Perit Dial Int 21: S205–S208, 2001.

35. Ash SR: Chronic peritoneal dialysis catheters. Overview of design, placement, and review procedures. Sem Dial 16:323-334, 2003.

36. Eklund BH, Honkanen EO, Kala AR, Kyllonen LE. Catheter configuration and outcome in patients on conti-nuous ambulatory peritoneal dialysis: A prospective comparison of two catheters. Perit Dial Int 14:70-74, 1994.

37. Eklund BH, Honkanen EO, Kala AR, Kyllonen LE. Peritoneal dialysis access: Prospective randomized compa-rison of the swan neck and Tenckhoff catheters. Perit Dial Int 15:353-356, 1995.

38. Hwang TL, Huang CC. Comparison of Swan neck catheter with Tenckhoff catheters for CAPD. Adv Perit Dial 10:203-205, 1994.

39. Twardowski ZJ, Prowant BF, Nichols WK, Nolph KD, Khanna R. Six-year experience with swan neck prester-nal peritoneal dialysis catheter. Perit Dial Int 18:598–602, 1998.

40. Simons ME, Pron G, Voros M, Vanderburgh LC, Rao PS, Oreopoulos DG. Fluoroscopically-guided manipulati-on of malfunctioning peritoneal dialysis catheters. Perit Dial Int 19:544-549, 1999.

41. Gadallah MF, Arora N, Arumugam R, Moles K. Role of Fogarty catheter manipulation in management of mi-grate, nonfunctional peritoneal dialysis catheters. Am J Kidney Dis 35:301-305, 2000.

42. Asif A, Pflederer T, Vieira C, Diego J, Roth D, Agarwal A. Does catheter insertion by nephrologists improve peritoneal dialysis utilization? A multicenter analysis. Semin Dial 2005;18:157-160.