Dialysis catheter insertion with and without peel-away sheaths

Tunnelled central venous line (TCVC) as a long-term vascular access in haemodialysis patients started to be used in our unit in 1993. Although it is certainly not the optimal access type, its use is increasing because of increasing patient age associated with various comor- bidities such as compromised cardiovascular system condition, peripheral vascular disease (diabetes melli- tus, ischemic heart disease), etc. rendering creation of an AV-access practically impossible. Since 1993 until the end of 2006 we have inserted 444 lines. Conventional insertion procedure includes local anaesthesia, adher- ence to aseptic rules and use of modified Seldinger's technique, best under ultrasound guidance. The right jugular internal vein is preferred because this vessel has the lowest complication rate. First, the jugular vein is punctured with a needle. Then, a wire of about 20cm insertion length is introduced, after which the puncture needle is removed. A three to five centimetre long incision is made at the puncture site fastening up to the created subcutaneous tunnel. The tunnel leads from the fossa supraventricularis minor laterally towards the thorax and the TCVC is drawn through it. The next step is the introduction of the peel-away sheath with a dilator over the guide wire into the vein. The dilator with the wire is then removed and the catheter is inserted through the sheath. During the insertion the sheath is concurrently being taken out and peeled away.