Exit-site relocation by external splicing: A rescue therapy for damaged tunneled central venous catheter.

Abstract

Effective hemodialysis (HD) depends on efficient, durable, and safe vascular access. Despite incessant efforts to reduce the use of tunneled central venous catheter (tCVC), late referrals, poor planning, improper creation of arteriovenous fistula, and lack of appropriate blood vessels are responsible for high prevalence of tCVC in the dialysis population. Specific mechanical problems, such as cracked hubs, broken clamps, leaky connectors, and bloodline rupture, can jeopardize the tCVC integrity. In case of tCVC damage at the distal part of the extracutaneous portion, most catheters are usually fixed using specific repair kits. However, when the bloodline is cracked close to the exit-site, the catheter exchange over a guide wire or the placement at a new site are considered the only viable options. However, the preservation of patient vascular assets should be prioritized, especially in patients with limited or exhausted access possibilities. Thus, in order to rescue the catheter and preserve the patient's vascular asset, we describe an innovative technique to fix tCVC bloodline perforations located in the proximity of the exit-site. The procedure consists in creating a new exit-site through the shortening of the tunnel tract. The intervention of exit-site relocation by external splicing represents an attractive option to treat unfixable tCVC damage or tunnel erosion without the need for catheter removal or exchange. This mini-invasive procedure is rapid, safe, and optimally tolerated by the patient. However, the prerequisites for this procedure are an exit site-cuff distance of at least 5 cm and the availability of an adequate repair kit. Exposition of the device along the subcutaneous tract due to chronic erosion of the tunnel can be simultaneously resolved by this intervention.