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  • ASDIN 9th Annual Scientific Meeting

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    The views presented reflect those of the author/presenter and do not necessarily reflect those of ASDIN nor serve as an endorsement of safety, efficacy or applicability of said procedure.

    Peritoneal Dialysis Catheter Insertion

    and Removal

    Indiana University Health Arnett and WellBound, Inc. Ash Access Technology and HemoCleanse, Inc.

    Lafayette, Indiana

    Clinical Associate Professor, Indiana University Medical SchoolAdjunct Associate Professor, Purdue University

    Past President of ASAIO, ASDIN2 and Secretary-Treasurer of IFAO

    Stephen R. Ash, MD, FACP

    ASDIN Advanced Course

    Washington, DC

    February 15, 2013

    Recently Available Tunneled Peritoneal Catheters

    Combinations of IP and EP designs.

    No Longer Available

  • ASDIN 9th Annual Scientific Meeting

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    In patients with panniculus the proper exit is always above anterior superior iliac spine (Dr. John Crabtree) Checklist Before Implantation

    or Removal of PD Catheter

    Off anti-platelet drugs for 5 days Off coumadin for at least 3 days and protime INR 60,000/mm3 No solid food from midnight on day of procedure NPO for 2 hours before procedure (3 hours for diabetics) but BP and

    cardiac meds should be taken on day of procedure Patient should have had normal BM in past 24 hours Patient urinates the morning of the procedure (if making urine) Patient is comfortable lying flat in bed, physiologically stable and alert Ultrasound performed in LMQ, RMQ, supra-pubic areas Prophylactic antibiotic given within one hour of starting placement

    procedure.

    Four Methods of Placement of Tunneled PD Catheters

    1.Dissection (surgical)2.Peritoneoscopic (local procedure,

    with 2.2 mm diameter scope), with ultrasound examination

    3.Seldinger technique (further developed to fluoroscopic technique

    4.Laparoscopic (general anesthesia with 5 or 10 mm diameter scopes)

    Methods of placing PD Catheters: Surgical (dissection)

    Steps of Implantation

    Y-Tec Peritoneoscopic

    System

    Peritonescopic Placement with 2.2 mm diameter scope, Single Puncture Technique

    Start with ultrasound of abdominal wall, look for fat depth, rectus border, movement visceral surface, epigastric arteries

    Video Courtesy of Dr. Rajeev Narayan, San Antonio, TX

  • ASDIN 9th Annual Scientific Meeting

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    Sometimes the ultrasound can shown some real surprises. In this patient with SVC occlusion, collateral subcutaneous veins penetrated the rectus and formed pre-peritoneal lakes, as shown in the non-contrast CTs above and to right.

    Peritoneoscopic Insertion

    Slide Courtesy of MediGroup, Inc. Slide Courtesy of MediGroup, Inc.

    Purpose of viewing peritoneum through the peritoneoscope:

    * confirm intraperitoneal position of cannula after first puncture* after air inflation, assure Quill guide is adjacent to the parietal peritoneum* find direction for Quill guide that avoids adhesions and large loops of bowel* direct catheter through Quill along previously inspected course * observe previously placed catheters to determine if there were mechanical problems* photograph unusual findings using high intensity light source

    Parietal and Visceral Peritoneal SeparationClear Space at 15 cm Distance from Deep Cuff Site

    Right or Left of Bladder

  • ASDIN 9th Annual Scientific Meeting

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    Parietal Peritoneal Adhesions Inspect Prior PD Catheters and Determine Cause of Failure

    Inspect Deep Cuff and Peritoneal Entry Sites

    Slide Courtesy of MediGroup, Inc

    Slide Courtesy of MediGroup, Inc

    Slide Courtesy of MediGroup, Inc

  • ASDIN 9th Annual Scientific Meeting

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    Slide Courtesy of MediGroup, IncSlide Courtesy of MediGroup, Inc

    Deep cuff in rectus

    Kaplan-Meier plot of Tenckhoff catheter survival according to the technique of placement, peritoneoscopic versus surgery.Gadallah et al. Am J Kidney Dis 33:120, 1999.

    Kaplan-Meier curves for catheter survival of peritoneoscopically (Scope) and surgically (Surgery) placed peritoneal dialysis catheters in patients receiving their first PD catheter.Pastan, et al. Trans Am Soc Artif Intern Organs, 1991.

    Twardowski PDI 1998Disc-ball catheters placed by dissection also do very well

  • ASDIN 9th Annual Scientific Meeting

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    Ortiz et al. Outcome of peritoneal dialysis: Tenckhoff catheter survival in a prospective study. , Adv Perit Dial. 2004;20:145-9.

    Tenckhoff catheters placed by dissection also do very well The more the scars, the

    more helpful are peritoneoscopic or laparoscopic techniques:

    Arif Asif, 2004

    Catheter Burying Procedure Also called Moncrief-Popovich Technique for burying catheters The external limb of the catheter is buried under the skin at the

    time of the implantation procedure. The external limb is exteriorized weeks to months later when

    dialysis is needed.

    Implantation Tools

    DrawingscourtesyofDr.J.H.Crabtree.

    Slide Courtesy of MediGroup, Inc

    Implantation Tools

    A

    B

    C

    D

    TheonlymedicaldevicespecificallyFDAapprovedforsubcutaneouslyburyingPDcatheters.

    AllothermethodsofburyingPDcathetersuseofflabeltools.

    Curvedhandle,plastic(A),withthreadedtip(B)Plug,titanium(C)Cap,titanium(D)

    Photographynottoscale.ImagesMedigroupInc.Usedwithpermission.

    Slide Courtesy of MediGroup, Inc

    Alternate approach: after peritoneoscopy, I reassemble the Quill, Cannula and Trocar embed the catheter through the single exit site

    NOTE: not an FDA approved use of the Y-Tec components, and catheter must be shortened, filled with heparin and plugged

  • ASDIN 9th Annual Scientific Meeting

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    Blind (needle, guidewire and splitsheath)

    Technique Survival in this retrospective study favored placement of PD catheters by blind Seldinger technique versus surgical technique. However, patients selected for surgery had a higher prevalence of: PCKD (15% vs. 3p%), Previous abdominal surgery (48% vs 9%) Previous PD catheter (33% vs 3%)

    Fluoroscopic technique can combine with Y-Tec guide for advancing catheter and implanting cuff in rectus muscle

    Needle Dye Guidewire 7 French Dilator with surrounding cannula & guide advanced over guidewireCatheter placed through dilated guide

    Normal peritoneogram through 18 gauge needle

    Photos Courtesy of Dr. Rajeev Narayan, San Antonio, Texas

  • ASDIN 9th Annual Scientific Meeting

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    Dye appearance when cannula tip is pre-peritoneal

    Photos Courtesy of Dr. Rajeev Narayan, San Antonio, Texas

    Photos Courtesy of Dr. Rajeev Narayan, San Antonio, Texas

    Sometimes the dye moves only in a restricted space due to adhesions or a limited peritoneal space.

    Guidewire advanced into peritoneum, loop crosses midline

    Photos Courtesy of Dr. Rajeev Narayan, San Antonio, Texas

    Quill Guide/cannula/7 French dilator in abdomen 0.035 guidewire

    Photos Courtesy of Dr. Rajeev Narayan, San Antonio, Texas

    Peritoneogram through properly placed PD catheter

    Photos Courtesy of Dr. Rajeev Narayan, San Antonio, Texas

    Complication rates are low with fluoroscopic technique, but in a few patients the technique doesnt allow successful catheter placement.

  • ASDIN 9th Annual Scientific Meeting

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    In a randomized study, fluoroscopic placement gave equal long term PD catheter survival as laparoscopic placement, but with fewer complications (esp peritonitis)

    Peritoneogram of PD catheter placed more deeply in the pelvis, into the recto-vesicle recess, a more complicated space than that behind the inguinal ligament

    However, in fluoroscopic placement it is necessary to understand the x-ray picture associated with various abnormal placements of the needle and catheter:

    Same catheter in recto-vesicle recess, lateral view (similar to the recto-vaginal recess in females)

    With either peritoneoscopic or fluoroscopic placement, physician must be cognizant of images representing intraperitoneal, extraperitoneal , and intraluminal placement of the cannula.

    Placement of needle into the cecum.

    Where to perform the procedures? An outpatient vascular access lab works fine for procedures done with local anesthesia or conscious sedation.

  • ASDIN 9th Annual Scientific Meeting

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    Early catheter success rate is 98% or above in published series. At one RMS center beginning placements just after training with fluoroscopic placement mostly, early success was 99%

    Laparoscopic Placement with Omentopexy, Downward Tunnel and Adhesiolysis Also Gives Excellent Results

    Slide Courtesy of Dr. John Crabtree

    Longitudinal rectus tunneling as described by Dr. John Crabtree

    Slide Courtesy of Dr. John Crabtree

    Omentopexy as described by Dr. John Crabtree, when large amounts of omentum are seen.

    Crabtree, 2010

    Incidence of Complications Over Lifespan of Catheter by Placement Method; compilation of studiesResults of 26 Studies, 1985-2001

    Mean Number of

    patients

    Mean follow-up (months)

    Infectious complication

    Outflow failure

    Subcutaneous leaks

    Blind or Seldinger Technique (9 studies)

    140 16.8 0.23 0.16 0.11

    Dissective or Surgical Technique (10 studies)

    105 17.6 0.45 0.13 0.09

    Peritoneoscopic/Laparoscopic*Technique (9 studies)

    80 18.4 0.07 0.04 0.02

    Interventional nephrologists and peritoneal dialysis access surgery. Asif and Ash, Seminars in Dialysis, 2004

    *Survival same for laparoscope and surgically placed PD caths-Cochrane Database Syst Rev. 2004

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