Minimally Invasive Tumor Therapy (MITT)

Department of Radiology, Charité – Universitätsmedizin Berlin

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References

  1. Shaldon S, Silva H, Pomeroy J, Rae AI, Rosen SM. Percutaneous femoral venous catheterization and reusable dialysers in the treatment of acute renal failure. Trans Am Soc Artif Intern Organs. 1964;10:133-5. PubMed PMID: 5878400.
  2. Hollenbeck M, Mickley V, Brunkwall J, Daum H, Haage P, Ranft J, Schindler R, Thon P, Vorwerk D. Gefäßzugang zur Hämodialyse. Der Nephrologe 2009, Volume 4, Issue 2, pp 158-176
  3. Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DA. Videos in clinical medicine. Central venous catheterization. N Engl J Med. 2007 May 24;356(21):e21. PubMed PMID: 17522396.
  4. Ortega R, Song M, Hansen CJ, Barash P. Videos in clinical medicine. Ultrasound-guided internal jugular vein cannulation. N Engl J Med. 2010 Apr 22;362(16):e57. doi: 10.1056/NEJMvcm0810156. PubMed PMID: 20410510.
  5. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol. 1953 May;39(5):368-76. PubMed PMID: 13057644.
  6. O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad II, Randolph AG, Rupp ME, Saint S; Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011 May;39(4 Suppl 1):S1-34. doi: 10.1016/j.ajic.2011.01.003.
  7. O'Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002 Aug 9;51(RR-10):1-29.
  8. Gebauer B, Beck, Wagner HJ. Zentralvenöse Katheter: Diagnostik von Komplikationen und therapeutische Optionen. Radiologie up2date 2008; 8(2): 135-154 DOI: 10.1055/s-2007-995703
  9. National Kidney Foundation KDOQI – 2006 Updates Clinical Practice Guidelines and Recommendations ,http://www.kidney.org/professionals/kdoqi/pdf/12-50-0210_JAG_DCP_Guidelines-VA_Oct06_SectionC_ofC.pdf
  10. Zieschang M, Erben B, Höffler D, Niemeyer R, Schielke DJ, Siebold G, Strack G. The Demers atrial catheter: experience with a single-lumen silicone catheter as short- and long-term access for hemodialysis. Clin Nephrol. 1995 Aug;44(2):113-7. PMID: 8529298

 

Video

Video 1 – The video shows the procedure of ultrasound-guided puncture of the vein above the right collar bone (in the video, the patient’s head is on the left). The interventional radiologist observes the needle placement on the ultrasound monitor. In the ultrasound images displayed on the monitor, the vein appears dark. A bright spot within the dark vein indicates that the needle tip has been correctly inserted. Some blood is drawn into the syringe to confirm the correct position before the procedure continues. (The video was kindly provided by Dr. de Bucourt.)

 

Demers or Atrial Catheter

 

A Demers or atrial catheter is a tunneled central venous catheter (CVC) that is mostly used for hemodialysis treatment in patients with end-stage kidney failure. Cleaning the blood outside the body requires high blood flow, which is why Demers catheters have larger diameters than central lines for other purposes.

 

Compared with non-tunneled dialysis catheters (Shaldon), a Demers catheter provides a better barrier to invading germs due to the greater distance between the insertion site and a separate exit site. Passing the catheter under the skin (subcutaneous tunneling) between these 2 sites helps to prevent infection, allowing a Demers catheter to be left in the body for a longer period of time. Demers catheters can be used for hemodialysis treatment in an outpatient setting.

 

Figure 1: Demers or atrial catheter. The tip of this central venous catheter is positioned in the right atrium of the heart to ensure high blood flow.

 

Hemodialysis catheters must enable passage of large volumes of blood. If a patient needs long-term hemodialysis, a surgeon can create a so-called dialysis shunt or fistula, which is an artificial connection between an artery and a vein in the arm. A surgically created shunt takes some time to mature before it can be used for hemodialysis. This time can be bridged by the use of a Demers catheter. The catheter is named after the person who first described it (Demers catheter) or after the position of the catheter tip (in the right atrium). A typical Demers catheter has two separate lumens (hollow channels), one for removing blood from the body for processing in the dialysis machine and the other for simultaneously returning the filtered blood to the patient’s circulation. This shortens the duration of the hemodialysis session.

 

Today, catheter tubes are most commonly made of polyurethane and less commonly of silicone. Like other central lines, a Demers catheter must be flexible without kinking and allow normal (laminar) blood flow. The material should be skin-friendly and minimize bacterial infection. A Demers catheter typically has an outer diameter of 13 – 16 French (4.5 – 5.5 mm). The catheter is secured with sutures and/or adhesive tape to prevent accidental displacement (e.g., when sleeping).

 

When Does a Patient Need a Demers Catheter?

 

A tunneled Demers or atrial catheter is most commonly placed for dialysis treatment (particularly hemodialysis), for example, in patients whose kidneys fail.

 

What is the General Procedure of Inserting a Demers Catheter and What is Special When it is Done in our Interventional Radiology Unit?

 

In general, a Demers catheter is placed under local anesthesia. In most cases, the catheter is inserted into a large neck vein above the collar bone (clavicle) and exits the body at the right chest wall. Between these two sites, the catheter is tunneled through the subcutaneous tissue (the tissue layer between the skin and muscle). Less commonly, the catheter is inserted into the vein below the clavicle. In some rare cases, there are good reasons to insert the catheter through a vein in the groin (adjusting the exit site accordingly). The procedure can be performed under near-sterile conditions using anatomical landmarks (“blind technique”) or ultrasound guidance.

 

Our interventional radiologists follow a strict set of standards when placing a Demers catheter:

  • A Demers catheter is always placed under strict sterile conditions with maximum barrier protection. This includes meticulous skin disinfection and sterile draping of the area with the personnel wearing sterile attire (sterile gown and gloves, mask, and hair cover).
  • A Demers catheter can be placed with local anesthesia, administration of additional medications, or with general anesthesia performed by an anesthesiologist.
  • To avoid complications, the interventional radiologist always uses ultrasound to guide the puncture procedure (see Figure 2 and Video 1; detailed and informative videos of ultrasound-guided vein puncture are available, for example, from The New England Journal of Medicine (3, 4)).
  • In addition, the interventional radiologist always inserts a Demers catheter using a safe and gentle catheter placement technique (the so-called Seldinger technique (5)) under X-ray guidance.
  • At the end of the procedure, with the patient still on the table, an X-ray is obtained to check for possible complications like a pneumothorax (abnormal collection of air in the pleural space that separates the lung from the chest wall).

 

 

 

Figure 2 – Depiction of the venous puncture procedure above the right collar bone (in the photographs, the patient’s head is on the left side). In the ultrasound image displayed on the monitor, the vein (indicated by the long thin arrow in the top figure) appears dark with a bright spot in the center. The bright spot is the reflection of the needle tip. Its position indicates that the vein has been accessed properly. Some blood is drawn to confirm the correct position before the procedure continues.

 

 

 

 

 

 

 

 

 

 

 

 

 

How Long Can a Demers Catheter Stay in Place and What are Possible Alternatives?

 

A Demers catheter can typically stay in the body for 3 to 12 months. In some patients, if no alternative option is available, it may become necessary to leave the catheter in place beyond this period.

 

For further information please feel free to contact us. We will be happy to answer any questions you may have.