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Translumbar Tunneled Hemodialysis Line Placement through the Left Gonadal Vein Olivia L. Li, BSc, Maxime Noël-Lamy, MD, FRCPC, Kenneth W. Sniderman, MD, FRCPC, and Martin E. Simons, MD, FRCPC A 55-year-old woman presented with hemodialysis-dependent renal failure and required new line placement. Venography revealed bilaterally occluded internal jugular, subclavian, and brachiocephalic veins and a portion of the superior vena cava (Fig 1). The patient also had bilaterally occluded common femoral veins resulting from previous femoral lines. Computed tomography (CT) demonstrated a small, chronically occluded inferior vena cava (Fig 2, arrow). However, a left gonadal vein, enlarged by collateral flow, was identified (Fig 2, arrowhead). The patient was brought to the hybrid CT/angiography suite (Toshiba Medical Systems, Tokyo, Japan) and placed in the prone position. Using fluoroscopy and CT guidance, the left gonadal vein was successfully punctured with a 22-gauge Chiba needle (Cook Medical, Bloomington, Indiana; Fig 3) and accessed with a 0.018-inch Mandril wire (Cook Medical, Bloomington, Indiana). The AccuStick Introducer

System (Boston Scientific, Marlborough, Massachusetts) was used for access, and a 4-F GLIDECATH (Terumo Medical Corporation, Somerset, New Jersey) and wire were advanced to the right atrium. The wire was exchanged for a 0.035-inch Amplatz Super Stiff Guidewire (Boston Scientific) over which a 16-F long peel-away sheath was inserted. A 55-cm dual-floating lumen hemodialysis catheter (CardioMed, Lindsay, Ontario, Canada) was inserted, with the distal tip in the right atrium. Although the procedure was technically challenging, the result was the successful placement of a translumbar dialysis line through the left gonadal vein, which traversed the left renal vein and the suprarenal inferior vena cava into the right atrium (Fig 4). The patient was seen several times over the next 2 years for dialysis line exchanges. The catheter continues to be functional.

Figure 2 Figure 1

From the Faculty of Medicine (O.L.L., M.N.-L., K.W.S., M.E.S.), University of Toronto; and Department of Vascular and Interventional Radiology (M.N.-L., K.W.S., M.E.S.), University Health Network, Toronto Western Hospital, 399 Bathurst Street, 3mc-423, Toronto, Ontario, Canada M5T 2S8. Address correspondence to M.E.S.; E-mail: [email protected] None of the authors have identified a conflict of interest. & SIR, 2016 J Vasc Interv Radiol 2016; 27:208–209 http://dx.doi.org/10.1016/j.jvir.2015.10.007

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Translumbar Tunneled Hemodialysis Line Placement through the Left Gonadal Vein.

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