LEARNING FROM IMAGES Oops!! Can we Prevent this Fundamental Mistake?

Abstract

Tunneled central venous catheters (TCVC) are a frequently used vascular access option to initiate hemodialysis across the globe. These TCVC are placed by resident physicians, mid-level providers and physicians from several different subspecialties. TCVC vary in their designs, including the catheter tip and their lengths, though all of them have a polyester cuff that helps secure the catheter in the subcutaneous tunnel. The tips of the TCVC used for dialysis differ widely and may be stepped, split or symmetric in design. Ideal placement of a TCVC in the internal jugular vein involves: 1) Initial venous puncture positioned as low in the neck as possible, thus providing a smooth wide curve to the catheter segment in the subcutaneous tunnel 2) The polyester cuff positioned 1-2 cm from the exit site in the subcutaneous tunnel 3) The exit site located in the infraclavicular region, avoiding the breast tissue and 4) The catheter tip positioned in the mid right atrium A standard teaching and learning process in the medical field involves peer-review and evaluation of fundamental mistakes that physicians encounter in clinical practice. The current images are examples demonstrating improperly placed TCVC providing a resource to the growing international interventional nephrology community to learn and preferably avoid duplicating them. The catheter cuff in Fig. (1) was not only placed deep in the subcutaneous tunnel, but the catheter hub was pushed in all the way up to the exit site. A deeply placed catheter cuff makes removal of these catheters difficult when the TCVC is no longer needed. The catheter in Fig. (2) was removed when it was no longer needed, revealing the trimmed off venous tip of the split-tip design. The tips are manufactured with a smooth surface to avoid endothelial trauma. Trimming of the catheter tip can lead to ragged edges that can cause endothelial trauma and potentially lead to stenosis and thrombosis. Moreover, the venous tip in a TCVC with split-tip is designed to minimize