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Tunneled dialysis catheters (TDCs) are an important form of hemodialysis vascular access. These devices are generally placed through the right and occasionally through the left internal jugular veins. Both ultrasound and fluoroscopy are recommended for catheter placement, ultrasound to identify and guide cannulation of the target vein and fluoroscopy to guide tip placement and positioning and to detect technical problems that can interfere with catheter function. Successful TDC placement begins with passage of a guidewire into the superior vena cava. However, occasionally this device enters the wrong vein. In these cases, it is important for the operator to recognize the errant path of the guidewire and make necessary corrections. When the vein is either the ipsilateral subclavian or the contralateral brachiocephalic, the situation is immediately recognizable because of the course taken by the guidewire. However, in some cases, especially those with central venous stenosis, the guidewire may enter the azygos vein, a left sided superior vena cava or, if the carotid was cannulated, the aorta. In these cases, the problem should be made immediately obvious by the position of the guidewire. It should also be recognized that there are occasions in which the problem is not recognized until a catheter has been inserted. This is especially true for a catheter in the azygos that is referred to the access center because of dysfunction.

LEARNING FROM IMAGES Guidewire Position as a Guide to the Appropriate Positioning of Dialysis Catheter