Image-guided tunneled peritoneal dialysis catheter placement

Abstract

Patients with end-stage renal disease (ESRD) often will ultimately require dialysis to survive. One type of dialysis is peritoneal dialysis (PD), which utilizes the vessel-rich peritoneum as a semi-permeable membrane to filter blood. In order to perform PD, a tunneled catheter must be placed through the abdominal wall and into the peritoneal space, with ideal positioning of the catheter within the most dependent portion of the pelvis, represented by the rectouterine or rectovesical space in women and men, respectively. There are several approaches to PD catheter insertion, including open surgical, laparoscopic surgical, blind percutaneous, and image-guided with the use of fluoroscopy techniques. Interventional radiology (through the use of image-guided percutaneous techniques) is an infrequently utilized resource to place PD catheters, and offers real-time imaging confirmation of catheter positioning with similar outcomes to more invasive surgical catheter insertion approaches. Although the vast majority of dialysis patients receive hemodialysis instead of peritoneal dialysis in the United States, some countries have moved towards a "Peritoneal Dialysis First" initiative, prioritizing initial PD, as it is less burdensome on healthcare facilities as it can be performed at home. In addition, the outbreak of the COVID-19 pandemic has produced shortages of medical supplies and delays in care delivery worldwide, while simultaneously generating a shift away from in-person medical visits and appointments. This shift may be met with more frequent utilization of imaged-guided PD catheter placement, reserving surgical and laparoscopic placement for complex patients who may require omental periprocedural revisions. This literature review outlines a brief history of PD, the various techniques of PD catheter insertion, patient selection criteria, and new COVID-19 considerations, in anticipation for the increased demand for PD in the United States.

Keywords: End-stage renal disease (ESRD); interventional radiology; peritoneal dialysis; review.

Figure 1

Peritoneal Dialysis Catheter. In the above figure, the Dacron polyester cuffs designating the skin exit site (A) and pre-peritoneal cuff (B) are seen.

Figure 2

Post placement radiographs showing a pre-sternal tunneled PD catheter with skin exit site (black arrow) in chest (A) and coil (white arrow) in cul de sac of pelvis (B). PD, peritoneal dialysis.

Figure 3

Peritoneogram after needle placed into peritoneal cavity. Contrast media opacifies around bowel loops (arrow).

Figure 4

Peritoneogram showing opacification of the cul de sac (arrow).

Figure 5

Peritoneogram demonstrating catheter (black arrow) and guide wire (white arrow) coiled within the cul de sac.

Figure 6

Peritoneogram depicting coiled end of PD catheter (arrow) located within cul de sac. PD, peritoneal dialysis.

Figure 7

Final image showing satisfactory position of tunneled PD catheter. Skin exit site (arrow) is lateral, posterior, and inferior to insertion site. PD, peritoneal dialysis.

Figure 8

Post placement radiograph of an embedded tunneled PD catheter demonstrating the subcutaneous titanium plug and cap (arrow). PD, peritoneal dialysis.