Matthew D. Ostroff

Preservation of upper extremity vasculature in patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) is essential to maintain future arteriovenous fistula (AVF) creation options. Despite Kidney Disease Outcomes Quality Initiative (KDOQI) recommendations, inappropriate device and vein selection persists. This study evaluated adherence to KDOQI vessel preservation guidelines over a 5-year period at a single academic institution. A total of 3505 patients underwent placement of peripherally inserted central catheters (PICCs), centrally inserted central catheters (CICCs), femorally inserted central catheters (FICCs), acute dialysis catheters with venous ports (ADCwVPs), or centrally inserted tunneled catheters (CITCs) between January 2020 and January 2025, including 1433 PICCs, 1574 CICC/FICC/ADCwVP devices, and 498 CITCs. Nephrology consultation was obtained in 1464 patients (41.8%), of whom 647 (44.2%) had CKD stage 3b–ESKD. KDOQI compliance was achieved in 585 patients (90.4%); 62 patients (9.6%) were non-compliant, including 33 PICCs, 9 CICC/FICC/ADCwVPs, and 20 CITCs. Sensitivity analysis identified 22.6% (14/62) of non-compliant cases as clinically unavoidable, yielding an adjusted avoidable non-compliance rate of 7.4%. Axillary and femoral vein utilization differed significantly between renal cohorts ( p < 0.001). Twenty-five CRBSIs were identified: 13 in patients without nephrology consultation and 12 within the consultation subgroup (6 CICC/FICC/ADCwVP, 5 CITC, 1 PICC); patients with renal impairment accounted for 48% of all CRBSIs. Two-year follow-up of 33 PICC recipients with CKD stage 3b–ESKD showed progression to hemodialysis in four patients, mortality in 13, and one case of upper extremity DVT managed with anticoagulation, with removal of the PICC and placement of a CITC. A multidisciplinary bedside vascular access model achieved high adherence to KDOQI vessel preservation recommendations while maintaining low complication rates. Strategic device and vein selection may support safe vascular access management in patients with advanced kidney disease, though downstream outcomes such as AVF creation and central venous stenosis were not directly assessed.

Tunneled dialysis catheter removal is a common procedure traditionally performed in interventional radiology or the operating room. Prompt removal of unnecessary or dysfunctional catheters is important to reduce the risk of catheter-related complications, including bloodstream infection and thrombosis. We report a rare case of a retained tunneled dialysis catheter presenting with no visible external catheter and a completely healed exit site. An 80-year-old female with end-stage kidney disease requiring maintenance hemodialysis presented to the emergency department with facial swelling and concern for a previously removed dialysis catheter. Physical examination revealed no visible catheter; however, chest radiography demonstrated a retained left-sided tunneled dialysis catheter. Further evaluation identified a palpable catheter cuff despite the absence of an external catheter or identifiable exit site. Computed tomography angiography demonstrated partial thrombosis of the distal left internal jugular vein and occlusion of a previously placed left axillary venous stent, supporting significant central venous disease. Following multidisciplinary consultation, the retained catheter was successfully removed at the bedside using local anesthesia and blunt dissection. Because ongoing hemodialysis access was required, a femoral tunneled dialysis catheter was subsequently placed at the bedside, allowing continuation of dialysis while a maturing arteriovenous fistula progressed to full functionality. The patient underwent successful dialysis and had the femoral catheter removed 9 days later following successful two-needle cannulation of the fistula. The patient was discharged home without complication. This case highlights the importance of meticulous physical examination, careful imaging review, and familiarity with tunneled catheter anatomy in the recognition and management of retained catheter complications. In appropriately selected patients, bedside removal and replacement of tunneled dialysis catheters may represent a feasible management strategy that facilitates timely dialysis access. Further studies are needed to evaluate the broader clinical and operational impact of this approach.

Background: Ultrasound-guided peripheral intravenous access has transformed infusion therapy for patients with difficult venous access. While clinical tools such as the rapid peripheral vein assessment and difficult intravenous access scoring protocols assist in identifying candidates, there is no standardized triage system to guide optimal site selection between forearm and upper arm vessels. As a result, site choice often depends on individual clinician preference. Methods: This retrospective study analyzed a 10-year dataset of 29,436 ultrasound-guided peripheral IV insertions performed by 14 vascular access specialists. All operators were trained in a structured venous assessment protocol. Data collected included insertion site and catheter characteristics, ranging from distal forearm veins to deeper upper arm vessels. Results: The distal cephalic vein in the forearm was the most frequently utilized site, representing 17,617 (59.8%) of total insertions. The 22-gauge, 1.75-inch cannula was the most placed IV catheter across all procedures. Conclusion: These findings highlight the distal cephalic vein of the forearm as a practical and preferred initial site for peripherally compatible infusions when guided by structured ultrasound assessment, particularly in patients without renal impairment. Adoption of this approach may preserve upper arm vasculature for future vascular access requirements and generate meaningful cost savings by reducing the need for longer and more expensive catheters required for upper arm placement. Establishing such standardized triage practices could optimize both patient outcomes and resource utilization in infusion therapy.

Point-of-care ultrasound-guided (POCUS) venous and arterial access involves accurately guiding a needle from the skin surface through subcutaneous tissue to the target vessel. The success of this procedure relies heavily on the operator’s ability to locate and direct the needle tip, which can lead to multiple puncture attempts and iatrogenic complications. A literature review revealed a lack of comprehensive protocols addressing the sonographic details necessary for effective needle identification and vessel cannulation. This paper presents a systematic approach, the “3 Stations of the Needle” protocol, which includes: (1) identifying the needle after initial skin puncture within the subcutaneous tissue; (2) navigating the needle to the vessel’s outer wall; and (3) advancing the needle tip into the vessel lumen. This protocol offers a practical educational method for an ultrasound mastery learning program, enhancing needle identification, guidance, safety, and procedural success in venous and arterial cannulation.

Accidental vascular catheter removal (AVCR) by patients with cognitive impairment can result in loss of access for infusion therapy, significant blood loss, air embolism with large bore catheters, and withholding life-sustaining dialysis treatment. Chest-to-back (CTB) tunneling of central venous catheters is a technique described in the Rapid Assessment of Vascular Access Exit Site and Tunneling Options (RAVESTO) for patients at risk for AVCR. In this retrospective review, data was collected for all venous access devices inserted using CTB tunneling in patients requiring medium to long term intravenous access for infusion or hemodialysis, who had a history of self-removing medical devices due to an alteration in mental status, or patients with severely impaired skin integrity. Vascular access devices were placed using real-time ultrasound and intracavitary electrocardiography (ECG) guidance. In this case series, from January 2020 to October 2024, a total of 46 out of 47 patients successfully received CTB-tunneled venous access devices. There was no reported symptomatic deep vein thrombosis. CTB tunneling was unable to be completed in one case due to severe patient agitation. The mean dwell was 23 days (ranging from 1 to 130 days). Nineteen patients completed their prescribed therapy, 18 patients were discharged with the catheter but were lost to follow up, four patients self-removed their catheter, three patients developed fungal infections receiving TPN, one patient experienced a primary catheter malposition which was removed after unsuccessful attempts at repositioning, and one patient receiving dialysis had a catheter exchange on day 32 due to poor flow. CTB tunneling is useful in patients with cognitive impairment who are at risk for AVCR and require medium to long term intravenous access. This retrospective review suggests that the use of ultrasound and intracavitary ECG makes the bedside CTB tunneling a safe and minimally invasive procedure.

Background: International guidelines recommend point-of-care ultrasonography (POCUS) in neonatology for diagnostic, therapeutic, and procedural purposes. However, there are few standard protocols for using POCUS to confirm lower extremity catheter tip positioning. Methods: In this prospective study, subcutaneously tunneled femorally inserted central catheters (ST-FICCs) were placed in eligible neonates according to physician orders. In line with the Neo-ECHOTIP (NE) protocol, a subcostal longitudinal view was used to identify the catheter, and saline flush test (SFT) was performed to confirm catheter tip placement below the right atrium. During the study, a novel “retract, advance, and position (RAP)” technique was added to the existing NE-SFT protocol to improve catheter positioning. Two-view radiographs of the chest and abdomen were obtained to verify catheter tip position for all subjects. The agreement rate with post-procedural radiographs and the total number of radiographs needed to achieve proper catheter positioning were assessed. Results: The agreement rate of POCUS with radiographs for catheter terminal tip position was 75% (39/52) for the NE-SFT group compared to 100% (48/48) for the NE-SFT + RAP group ( p < 0.001). Catheters in the NE-SFT group required repositioning (25%); no malpositioned catheters were observed in the NE-SFT + RAP group. Repositioning of the catheter in the NE-SFT group resulted in 22 repeat radiographs in the NE-SFT group; none were required in the NE-SFT + RAP group ( p < 0.0001). Conclusions: This single-center study demonstrated that applying the RAP technique to the Neo-ECHOTIP protocol improved the ease and accuracy of lower extremity catheter tip position localization in neonates, thus eliminating the use of radiography.

Background: The decision to place a subcutaneously tunneled catheter is an infection prevention strategy for long term venous access allowing the proceduralist to access a vein and relocate the catheter exit site to a region on the body where care and maintenance can be safely performed. Subcutaneously tunneled centrally inserted dialysis catheter (ST-CIDC) placement is commonly performed in patients with renal disease and is traditionally performed with fluoroscopy in the interventional radiology suite or the operating theater. However, today’s interventional radiologists and surgeons perform advanced invasive procedures that can be time-consuming resulting in delays in the scheduling of elective tunneled catheter placements. Methods: In this retrospective case series, we present data from a quality improvement initiative aimed at integrating available evidence for bedside tunneled dialysis catheter placement with electrocardiograph (ECG) tip positioning, to expedite care, improve patient safety outcomes, and reduce healthcare costs associated with the procedure. Results: Most patients in the study had end-stage renal disease (59%) or acute kidney injury (37%) and were receiving placement for the first time (91%). The right jugular vein was cannulated in 84% of the placements and rates of post-insertion complications were <1%, regardless of the vessel cannulated. Performing bedside tunneled dialysis catheter placement resulted in a cost savings of $385,938.76 over a 2-year period. Conclusions: The placement of ultrasound guided tunneled dialysis catheters at the bedside following a pre-procedural evaluation of the right jugular, brachiocephalic, and femoral veins is a safe option resulting in expedited patient care, decreased resource utilization, and significant cost savings. Non-bedside techniques performed in interventional radiology, or the operating room should remain a consideration for patients requiring left sided venous access, signs of central stenosis, a history of multiple tunneled catheters, or patients requiring moderate sedation outside of the ICU.

Background: Femoral to abdomen tunneling of small-bore central venous catheters is a bedside technique for patients with contraindications to a thoracic approach, or as an alternative to a lower extremity catheter exit site. Method: A femoral to abdomen tunneling technique was implemented for patients receiving medium and long-term intravenous treatments with contraindications to the thoracic venous approach or as an alternative to a lower extremity catheter exit site. All venous access devices were inserted with ultrasound guidance under local anesthesia, and catheter tip placement assessed by post procedural radiography. Results: In this case series, from January 2020 to January 2023, a total of eight FTA-tunneled venous access devices were inserted. There were seven ambulatory patients and one bedbound patient. The median length of the subcutaneous tunnel was 20 cm, ranging from 15 to 27 cm. The median length of the intravenous catheter to the terminal tip was 31 cm, ranging from 23 to 40 cm. Tip location was confirmed by post-procedural abdominal radiograph. The catheter tip locations were interpreted to be at the level of T8-T9 (2), T12 (1), L4 (2), L2 (2), L1(1). No insertion or post insertion related complication was reported. Six patients completed the scheduled intravenous treatment. One patient was unable to be tracked due to transfer to an outside facility. One catheter initially demonstrated to be coiled over the left common iliac vessel was repositioned using a high flow flush technique. There was one reported catheter dislodgment by the nurse providing care and maintenance. The overall implant days were 961, with a median dwell time of 125 days ranging from 20 to 399 days. Conclusion: Femoral to abdomen tunneling provides an alternative exit site useful in select patients with complex intravenous access. The data of this small retrospective review suggests this a safe and minimally invasive bedside procedure.