Necessity is the mother of invention, and in the field of surgery vascular access is surely the best example of this truism, for a whole specialty has grown to meet the requirements of new fields such as dialysis and chemotherapy. The earliest vascular access was achieved by the introduction of intravenous glass cannulae in the early 1900s; these were replaced in the 1950s by plastic cannulae which allowed prolonged intravenous infusions. Attempts to extend the duration of infusion and to use more concentrated (and therefore irritant) solutions for intravenous feeding in the 1950s led to the development of central venous cannulation, made possible by the development of longer catheters and less thrombogenic plastics. This technology advanced in the 1970s with the introduction of Teflon and Silastic coated catheters, new tunnelling techniques, and the use of porous cuffs to anchor the catheters beneath the skin and perhaps provide a bacteria-proof seal. The central veins can now be used for long-term, high flow access sufficient for intravenous feeding, chemotherapy, and even haemodialysis, although their frequent use for haemodialysis is relatively recent.

The advent of haemodialysis, pioneered by Kolff in 1944, introduced a new requirement for repeated high volume blood flow both into and out of the circulation. Initially this was obtained by adapting the technique of intravenous cannulation to allow repeated catheterization of the femoral artery and vein, made safer by the introduction of the Seldinger guide wire technique. However, this approach rarely allowed dialysis for more than a few weeks. Permanent cannulation of arteries and veins always resulted in thrombosis, until the introduction of the Quinton– Scribner shunt using silastic tubing in association with Teflon coated vessel tips. The Quinton–Scribner shunt was the mainstay of haemodialysis for many years, but required relatively frequent revision and was prone to thrombosis and sepsis. A major advance was the realization that the formation of an artificial arteriovenous fistula resulted in massive enlargement of veins sufficient to allow repeated cannulation, and the Brescia–Cimino forearm fistula, first described in 1966, remains the mainstay of haemodialysis access today.

Vascular access is only ever required to allow some form of medical treatment, and the surgery should be performed in such a way as to make the medical treatment as simple as possible. The first requirement of good access is prolonged patency or absence of thrombosis. The factors important in preventing thrombosis are the use of high flow vessels, non-thrombogenic materials and reduced blood clotting factors. The second requirement is minimal morbidity including a low rate of infection, and lack of disability caused by subsequent loss of the vessel.

For many patients these requirements are best met by using cannulae placed in large veins. Catheters inserted into the subclavian and internal jugular veins, with the catheter tip in the superior vena cava or right atrium, have high flow rates, and thrombosis of the vessel usually causes relatively little disability. Furthermore the good blood supply of the skin of the neck helps minimize infection. The leg veins and inferior vena cava have a slower flow and so thrombose more easily. Thrombosis often causes leg swelling or embolization and cannulae are at greater risk of infection.

In other patients a form of arteriovenous fistula is the best solution. Here the connection of the radial artery to the cephalic vein in the forearm is the preferred technique, giving high blood flow, low infection rate, and low thrombosis rate, with little morbidity if the vessels are lost. One arm is disabled during cannulation of the fistula, but this drawback is slight compared to the higher thrombosis and infection rate seen when leg vessels are used. Similar arguments apply to the use of cannulae (shunts) to connect arteries to veins.

It is now possible to keep patients in end-stage renal failure alive and well for many years, reliant on vascular access for regular therapy. The strengths and limitations of various forms of access in different patient groups have been learnt over the years, allowing the adoption of a flow diagram, which varies somewhat depending on the procedure planned and from unit to unit. A typical flow diagram for dialysis access is shown in Fig. 1 381. Forward planning is the key to good access surgery, allowing procedures to be performed on routine lists with sufficient time for fistulae to mature before use is required. The object of access surgery should be to avoid using all of the ‘easy’ access sites during the lifetime of the patient. Provision of a lifetime of access has been a particular problem for the young dialysis patient, but the recent success of renal transplant programs has meant that many patients can be relieved of the need to dialyse for large portions of their lives, and judicious planning of access is possible so as to maximize this benefit. Thus a patient who is likely to gain a rapid transplant should be given an early transplant rather than a fistula which is likely to thrombose if the transplant is successful. One of the most difficult messages to get across is the importance of preserving the cephalic veins, particularly because so often patients arrive via other services.

Patients with renal failure, both acute and chronic, are often a daunting prospect for a general anaesthetic when they first present. Fortunately local anaesthesia is adequate for most access procedures, although general anaesthesia is recommended for open internal jugular vein exposure in nervous patients. Administration of 1 per cent xylocaine with adrenaline is recommended to minimize oozing.

It is important that patients are neither fluid overloaded nor dehydrated. There is a tendency to dehydrate recently dialysed patients, and it is best to have a drip running, dextran being a good choice because of its added anticoagulant properties. If a limb is to be used it should be shaved preoperatively, painted with betadine solution, and wrapped in cotton wool to keep it warm. A light premedication is often helpful to calm the nervous patient.

The danger time for all forms of vascular access is during anaesthesia for another procedure, when dehydration, hypotension and inadvertent local pressure may result in thrombosis. Great care should be taken to avoid these risk factors. Patients with long-term indwelling cannulae must be scrupulous about covering the exit site and cannula ends with a sterile dressing, careful sterilization of the cannula prior to connection, and regular flushing of the cannula if not in use.

The subclavian veins or internal jugular veins can be used to provide access for central venous monitoring, intravenous feeding or chemotherapy, when a single lumen catheter is usually adequate, or for haemodialysis, when a double lumen catheter is required (Fig. 2) 382. In either case the catheter can usually be placed under local anaesthesia, with or without a short subcutaneous tunnel. The subclavian veins have the advantage of convenience, since neck lines tend to be obtrusive, but jugular line insertion is safer and also avoids the risk of later subclavian vein stenosis, which may create problems for forearm fistula formation. A number of commercial catheters are available. Most now use a smaller bore needle and syringe to locate the vein initially, followed by introduction of a flexible guide wire into the vein, withdrawal of the needle, and then advancement of the final catheter over the guide wire (Seldinger technique). There are several variations of techniques for the catheter insertion: those most commonly used are illustrated in Fig. 3 383 and described in Table 1 207.

The femoral vein is now normally used only to provide access for single haemodialysis in the emergency situation and for veno-venous haemofiltration. In this circumstance the femoral approach has the advantage over subclavian vein catheterization since the patient does not need to be placed head down (which can be difficult in fluid overloaded patients) and is more easily performed at the bedside, with less risk of complications, provided prolonged repeated dialysis is not attempted. The actual technique of cannulation is very similar to that employed for the subclavian vein, namely a Seldinger technique using a guide wire and double lumen catheter (Table 2) 208. If arterial pressure is required for haemofiltration then the femoral artery can be cannulated using a similar technique.

The catheter can usually be removed by simple withdrawal followed by local pressure to the puncture site for 5 min. Prolonged bleeding may sometimes necessitate longer pressure. Occasionally a large haematoma or false aneurysm formation may require exploration.

The Quinton–Scribner shunt was once the anchor of dialysis access, and can be used for both acute and long-term access, with the vessels of one limb lasting many years in some cases. Unfortunately, minor revisions are frequently required and in addition the device is inconvenient to dress and keep covered. However, the technique still has advantages for the patient with acute renal failure since it allows reliable access with less risk than subclavian puncture, particularly in patients with a bleeding tendency (as is often the case). In addition the arterial pressure can be used to ‘drive’ diafiltration systems. Either the radial artery/cephalic vein (Fig. 4) 384 or posterior tibial artery/saphenous vein can be used, but the forearm cannula is usually more practical once the patient is more mobile. This can also be converted to a fistula if needed later. Separate arterial and venous cannulae are placed which are joined together by a teflon connector when not dialysing (Figs. 5, 6 (a,b,c)) 385,386. Local anaesthesia is usually adequate, and a so-called ‘straight’ silastic cannula is preferred (Fig. 5) 385 since it allows simple thrombectomy using a short Fogarty-type embolectomy catheter. The largest possible Teflon vessel tip should be used to cannulate the vessel ( Table 3 209, Fig. 6 386 (a,b)). Another variety of cannula that has gained some popularity is the Buselmeier shunt, which has the advantage of keeping the shunt loop intact during dialysis, taking the flow to the machine off a side access port. In the event of clotting occurring in the dialyser the shunt will then keep working. The basic principles of insertion are similar.

Removal of cannulae may be required because of repeated thrombosis, sepsis that cannot be cleared, or when the shunt is no longer required. Provided clotting is normal and in the absence of sepsis the shunt can simply be clamped off for a period of at least 4 and preferably 7 days. Local anaesthetic is then infiltrated around the catheter tips and the cannulae removed by avulsion. In the presence of clotting disorders or sepsis it is wiser to remove the cannulae under direct vision and ligate the vessels with an absorbable ligature such as polyglycolic acid.

The connection of an artery to a vein results in steady widening of the vein and its tributaries, with increased rates of flow. Veins which were originally difficult to cannulate and unable to deliver the rate of flow sufficient for dialysis become ideally suited for repeated cannulation (Fig. 7) 388. Once developed fully the fistula can remain patent indefinitely and provide permanent access. The ideal site, originally described by Brescia et al. is the radiocephalic fistula, but other sites are possible. Most fistulas can be formed under local anaesthesia, but maintenance of adequate hydration and a warm limb are particularly important for successful fistula formation. A recent innovation has been the use of a glyceryl trinitrate patch on the distal limb to encourage vasodilatation. For patients with a particular fear of needles, especially children, the use of EMLA (eutectic mixture of local anaesthetic) cream can allow painless cannulation.

For the creation of a radiocephalic fistula the incision and dissection should follow guidelines 1–5 (Table 3) 209 outlined for shunt formation, although a slightly longer incision is needed (Fig. 4) 384 and enough vessel should be dissected free to bring the two vessels side by side over approximately 2 cm without tension ( Fig. 8 387 (a,b); Table 4 210). The cephalic vein is usually the best to use but occasionally other nearby tributaries will have suffered less trauma from previous infusions. Soft Silastic slings are used to control and approximate the vessels. The vessels are opened for a distance of 7 to 10 mm side by side, and the vein patency and size tested by injecting heparinized saline. The vessels are then anastomosed using continuous 6/0 or 7/0 Prolene suture, taking particular care not to narrow the lumen at the proximal end. A more precise anastomosis can be achieved using magnification loupes, but adequate anastomosis is possible without. Some surgeons prefer to tie off the distal vein or perform an end-to-side anastomosis in order to prevent the possibility of distal venous hypertension, but this is an uncommon complication that is relatively simple to deal with and leaving the distal vein initially may allow better run-off in the critical postoperative period. On releasing the slings a palpable thrill should be evident. The expected patency rate is variously reported at between 60 and 90 per cent at 1 year and 60 to 75 per cent at 5 years.

The general rule in fistula formation is that the non-dominant arm and the most distal site possible are used. It is possible to locate the radial artery distally in the anatomical snuffbox and at this point the artery lies close to the cephalic vein. However, the access for the anastomosis is more limited, making the procedure technically demanding, and should the cephalic vein prove to be unsuitable alternative veins are not available. If the radial artery is occluded or absent the ulnar artery can be used, together with a cephalic tributary or the basilic vein (less ideal as it tends to lie deep in an awkward position), but an occlusion test and Doppler studies should be used to confirm another arterial supply to the hand in case of thrombosis. If a forearm fistula fails it is possible to make a fistula between the cephalic (or median cephalic) vein and the brachial artery at the elbow, and still have sufficient dilated veins develop in the upper arm to allow satisfactory dialysis. In addition to the complications mentioned for radiocephalic fistula, the major complications of using this site are distal ischaemia due to stealing of blood and the development of cardiac failure due to massive fistula development. Both these complications can be minimized by limiting the diameter of the anastomosis to 6 mm.

In general a functioning fistula should not be closeed, even if a kidney transplant makes the fistula unnecessary, since it can never be certain that later dialysis will not be required. In fact many fistulae thrombose after successful transplantation. Indications for fistula closure include cosmetic appearance, extremely large flows leading to heart failure (see above) and, occasionally, sepsis and distal embolism. It is usually possible to dissect the fistula free, control the feeding vessels and take down the anastomosis. Often the artery can be reconstituted using fine Prolene suture, but the veins are best ligated.

Although a forearm fistula is the procedure of choice for long-term dialysis access it does have disadvantages (Table 4) 210 and (Fig. 9) 389. The fistula cannot be used for dialysis for at least 4 weeks and often longer, since time is required for dilatation of the veins to occur. However, in some cases full development of the veins does not result, and thus a fistula may be a less attractive option in patients who present in renal failure and who require early dialysis. The waiting period can be covered by temporary dialysis via a subclavian line (see above), but the insecurity of this access makes most clinicians prefer inpatient treatment, and subclavian thrombosis and sepsis becomes more frequent with prolonged subclavian cannulation using temporary lines. In elderly patients with a limited life expectancy this waiting period may be a significant proportion of their remaining life. Some patients also have a horror of needles or have a phobia of needling themselves. Lastly, connection of an indwelling catheter is certainly less technically demanding than the insertion of two dialysis catheters into a fistula, and this may be an important factor in considering home dialysis in some patients.

The development of more efficient membranes has meant that venovenous dialysis can now be a long-term option, even though recirculation of 7 to 15 per cent of the blood may occur, and hence dialysis via a long-term central venous catheter represents another chronic access option (Table 5) 211.

Although it is possible to use the subclavian vein, stenosis or occlusion is a common eventual outcome. The jugular veins are a better option, since loss of the external jugular veins or one internal jugular vein leads to no disability, and both internal jugular veins can be occluded with surprisingly little disability, provided there is a gap of some months between procedures.

The catheter must be robust and made of Silastic or other non-thrombogenic material with a cuff to allow tissue ingrowth; most have a double lumen with well designed caps and temporary occlusion clips (Fig. 10) 390, although a single lumen (Francis) catheter based on an adapted peritoneal dialysis catheter, has also been used with success. Although the catheter can be placed in the external jugular vein of some patients, this vein is often too small and even if cannulation is successful malposition is common. The internal jugular vein is more certain to allow satisfactory cannulation. The internal jugular vein is approached at the lower end of sternomastoid, separating the sternal and clavicular heads (Fig. 11) 391. Care must be taken in mobilizing the vein as small tributaries may be present, and avulsion may cause haemorrhage. The internal jugular vein must be carefully separated from the vagus behind and medial to it. The vein can be controlled by two double-looped slings and a purse-string suture of 4/0 Prolene inserted. The catheter is prefilled with saline, tunnelled to the wound, and the patient tipped head-down; the catheter is then inserted into the vein via an incision in the centre of the purse-string, which is then tied snugly around the catheter. A radiograph to check the position of the catheter should always be taken immediately and ideally the tip should be placed at the entrance to the right atrium. After closing the wound the patient should be nursed as upright as possible to minimize haematoma formation. Patency rates of 60 per cent at 2 years are claimed.

Catheter removal is usually required for intractable thrombosis or sepsis (Table 5) 211, and involves reopening of the original wound to free the Dacron cuff by sharp dissection. It is usually best to locate and divide the purse-string suture. The catheter is removed with the patient in the head-down position; bleeding can be controlled by a finger, whilst the track is closed with absorbable sutures.

Expertise in the more complex access salvage techniques is not a skill that should be acquired easily, since it represents failure of the simpler procedures. Nevertheless, despite the greatest care, some patients eventually exhaust the simple access sites. This problem is most common in small women, where the vessels are naturally tiny, patients with vascular disease or Raynaud's phenomenon, diabetics, and patients with abnormal susceptibility to sepsis for some reason. A large number of ingenious techniques have been described for more complex access: only those that are commonly used will be described.

A fistula may be functioning but unusable due to the deep-seated position or inaccessibility of the veins, for example the basilic vein. Mobilization of the vein to a more superficial position may prevent loss of an access site.

A vascular graft (either vein or prosthesis) inserted subcutaneously between a suitable artery and vein will allow repeated vascular access. Autologous saphenous vein is probably the conduit of choice, since extensive experience in vascular surgery has shown this to have a lower natural thrombogenicity and infection rate with repeated needling. However, saphenous vein is sufficiently strong to usually resist dilatation by persistent arterial pressure, a feature that is advantageous for vascular bypass grafts, but not ideal for access where needling of the graft is required. For this reason autogenous saphenous vein should only be used if a large vein is available. Patency rates of 70 per cent at 1 year and 65 per cent at 5 years are quoted. The alternative is a synthetic graft, with purpose-made Gore-Tex (using a tapered arterial end and loop reinforcement) probably being preferred over other synthetic grafts such as Dacron. Patency rates of 58 to 95 per cent at 1 year and 40 to 80 per cent at 2 years are claimed by various authors. Alternatives such as human umbilical vein, bovine artery, and human saphenous vein allografts have shown a higher complication rate from sepsis and aneurysm formation. An interesting technical modification is the addition of a connection port to the conduit to allow simple connection for dialysis without the need for cannulation (Haemasite). Two-year patency rates of 50 per cent with low infection rates are claimed for this prosthetic graft and thrombosis is easily cleared by opening the port.

In most patients the forearm and lower leg vessels have been used previously for either shunt or fistula formation, and the jugular veins may also have been used. The first requirement is location of a suitable artery and vein for anastomosis. In most patients a number of options are open: the radial artery may be patent, but since there are no suitable veins in the forearm a longitudinal graft needs to be run from the radial artery and connected to a cubital vein. In other patients the brachial artery and cubital veins are available and a forearm loop can be performed (Fig. 12) 392. It is possible to cross the elbow joint to anastomose to the cephalic vein above the elbow, provided a reinforced graft is placed with the rings across the joint line. If these options are not possible a loop can be formed in the thigh, most simply by connecting the mobilized long saphenous vein as a loop anastomosed directly on to the common femoral artery. Other grafts are usable if anatomically possible: axillary artery to femoral vein and grafts between femoral vessels of opposite legs have been used. In these cases the basic technique is similar. The points of importance are listed in Table 6 212.

Although the general principles outlined for adults also apply to children, the problems are increased by the small size of vessels available and the importance of psychological factors such as needle fear. Fortunately the introduction of EMLA cream allows the painless insertion of needles, making a fistula a far more attractive option than was previously the case. Since one must plan for a lifetime of renal replacement therapy decisions regarding the use of access sites are particularly important. General anaesthesia is recommended for all access-forming procedures.

Acute access for dialysis is a particular problem in children, since the subclavian veins are relatively difficult to cannulate percutaneously and tend to thrombose once cannulated. In neonates and many older children the best option may be peritoneal dialysis, which is discussed elsewhere. If this option is not available the best solution is usually to insert an internal jugular line under direct vision, using a cannula of as large a bore as can be inserted, with the tip of the cannula in the right atrium. The principles of insertion are similar to those described for adults. In many children the next option chosen would be early transplantation rather than fistula formation, in order to preserve the forearm site for future use.

In children in whom early transplantation is not an option the procedure of choice is again a radiocephalic fistula. Although the surgical principles are similar to the technique used in adults, experience of microsurgical techniques and special instruments are required.

The requirements of access for parenteral nutrition differ from those of haemodialysis in that only a single line is required, and the flow rates needed are relatively small. However, the nutrients being delivered are highly irritant to vessels and it is thus not possible to use peripheral veins. The haemoglobin level of these patients is often near normal, as is platelet function, and so formation of an arteriovenous connection is contraindicated because of the likelihood of thrombosis, although this is a technique that has been used occasionally for total parenteral nutrition. The best solution is to use central venous cannulation, where the concentrated nutrients can be diluted rapidly enough to prevent vessel inflammation. The catheter used can be small bore, but must be made of non-irritant material such as silicone and in the case of permanent nutrition must be sufficiently robust for long-term use. Inclusion of a Dacron cuff is felt to be an advantage for prevention of track infection. A number of commercial catheters are now available (Fig. 13) 393 and a major advance has been the recent development of totally implantable catheters with ports containing self-sealing membranes that allow intermittent cannulation (Fig. 14) 394. The number of cannulations possible is still rather limited for the purposes of long-term total parenteral nutrition but it is certainly an option that is worth considering in children and for relatively short-term outpatient management, since the sepsis rate is low.

Percutaneous insertion of the catheter into the subclavian vein under local anaesthesia is the usual approach because the catheter can then be conveniently kept out of the way by strapping to the chest. The cannulation technique is similar to that described earlier for haemodialysis catheter insertion, but the proximal line should also be tunnelled out from the puncture site for a distance of about 5 cm. The complications include those noted for subclavian dialysis catheter placement, but sepsis is the most frequent problem. This usually arises from poor connection technique, particularly if the catheter is used for any purpose other than total parenteral nutrition; since many of these patients are in an intensive care unit the temptation to allow use of the line for blood sampling and drug delivery must be firmly avoided. Delivery of the daily requirement premixed in one bag also limits the number of bag changes and reduces the chance of infection.

Lines suspected of being infected may be cultured by taking blood from the line: a negative result is reliable, provided the patient has no antibiotics in the bloodstream at the time. Infected lines are best managed by removal and insertion of a fresh line on the other side, but occasionally infection can be cleared by changing the catheter over a guide wire, using a new subcutaneous tunnel, combined with intensive antibiotic treatment.

The catheters used for this purpose need to be considerably more robust and are consequentially larger. Insertion is often best undertaken by cannulation of the cephalic vein under local anaesthesia (Fig. 15) 395, although percutaneous insertion into the jugular or subclavian vein is becoming possible even for cuffed catheters by the introduction of ‘peel-away’ insertion sheaths. The direction of the catheter is often incorrect at the first attempt when inserted by the cephalic vein route and radiographic screening should be undertaken during the procedure. Again the catheter should be tunnelled for at least 6 cm from the wound. Although the presence of a tunnel does not seem to influence the sepsis rate it is more convenient for the patient. The inclusion of a Dacron felt cuff is beneficial since the tissue ingrowth holds the catheter in place and may effectively seal the track to bacteria. The catheter tip must be smoothly rounded off and carefully positioned to lie free just at the entrance to the right atrium, since there have been descriptions of catheter perforation and thrombosis of the heart and great vessels. Sepsis is the main complication and attention to aseptic technique during bag changes must be meticulous.

Home total parenteral nutrition is mainly indicated in patients with short bowel syndrome. Meticulous training in catheter and bag changing technique is vital to prevent sepsis, which is the main complication. Suspected sepsis may be confirmed by finding bacterial counts at a ratio of greater than 5:1 in blood samples cultured from the catheter and a peripheral vein respectively. The most common causative organism is Staphyloccus aureus. Sepsis may be cleared by administration of urokinase and appropriate antibiotics via the catheter for 5 days. Occlusion may also occur due to lipid or calcium phosphate encrustation which may respond to local instillation of ethanol or 0.1 M hydrochloric acid respectively (into the catheter only and not systemically).

The treatment of a number of malignancies has been transformed by the advent of effective chemotherapeutic regimens, but the drugs used must be given intravenously at regular intervals, often for many weeks. Many of the therapeutic agents are highly irritant to peripheral veins and need to be delivered into high flow vessels. It has been suggested that constant infusion of chemotherapeutic agents may increase their efficacy and lower toxicity, but firm evidence for this point is lacking. Many chemotherapeutic drugs have toxic effects on the bone marrow and other organs and numerous blood samples need to be taken on a daily basis to monitor toxicity. Perhaps the most demanding example of intensive chemotherapy is that required for treatment of leukaemia, particularly when bone marrow transplantation is also required. There is, therefore, a need for reliable access to the central veins over a period of weeks to months and, in addition, a catheter that will allow both drug delivery and blood sampling at the same time is most useful. The most convenient catheter is a double lumen catheter of the Hickman variety (Fig. 16) 396, which can be inserted under local anaesthesia into the cephalic or external jugular veins.

Patients suffering from leukaemia are often thrombocytopenic and neutropenic, and insertion of a line should only be attempted under full coagulation factor and platelet replacement with antibiotic prophylaxis. The line should normally be tunnelled to minimize infection, although in patients with absent platelets the tunnel may be kept very short.

A variety of alternative routes for delivery of drugs to allow treatment of apparently localized tumours have been described including the recanalized umbilical vein for hepatic perfusion, hepatic artery cannulation, and carotid artery and femoral artery perfusion via fine bore catheters. None has reached the status of accepted treatment and will not be considered further here. Some preliminary studies have examined the use of intraperitoneal delivery of drugs for ovarian cancer, and for this purpose a standard Tenckhoff catheter is ideal (see below).

Similar principles to those used in adults apply to insertion of lines for chemotherapy in children, but it is usually necessary to use the internal jugular vein for line insertion, although successful use of the long saphenous vein to cannulate the inferior vena cava has been described. General anaesthesia is normally required.

The concept of using the peritoneum as a membrane for dialysis arose in the 1920s. It was initially employed to provide temporary renal replacement therapy, for example in cases where recovery of renal function was expected. The catheters used for this purpose were inserted using a ‘blind’ direct puncture technique with a trochar. Acute peritoneal dialysis catheters are still available (Trocath) but are probably used as much for diagnostic or therapeutic peritoneal lavage than for actual dialysis. The development that allowed long-term peritoneal dialysis was again the introduction of silastic non-irritant catheters, with the addition of cuffed tubes and use of a long subcutaneous tunnel. A variety of commercial catheter designs have been marketed, but the original Tenckhoff design is still the most popular and very effective, although the addition of a curl to the end of the catheter may help prevent displacement (Fig. 17) 397. The requirements are for a catheter that allows rapid inflow and outflow of fluid, without leakage from the peritoneum and without allowing the introduction of agents which may cause sepsis. Complications of peritoneal dialysis catheter insertion are listed in Table 7 213.

Continuous ambulatory peritoneal dialysis has the advantage of being relatively cheap, simple to set up, and relatively easy to learn to run. The drawbacks are the relatively high readmission rate for complications, a tendency to obesity due to glucose absorption, and a short useful life, with approximately 50 per cent of catheters failing and requiring removal by 2 to 3 years. It is therefore not usually used for long-term dialysis of young, fit patients, but can be used as an option for patients where transplantation is expected within 2 years. It is also a favoured option for elderly patients, where survival is expected to be limited, and in diabetics and patients with other vasculopathies, where vessels suitable for haemodialysis may not be easily available. In addition, peritoneal dialysis using a smaller version of the Tenckhoff catheter is a good way of providing short- to medium-term dialysis for children, including neonates, and may provide sufficient time for successful transplantation to be performed. For chronic dialysis a double cuff catheter is not recommended as growth may cause puckering of the abdominal wall.

The catheter can be inserted by percutaneous puncture using a peritoneoscope, a technique that has firm advocates, but most surgeons prefer insertion by an open operative technique. Insertion under local anaesthesia is possible, but is only a comfortable procedure if no difficulties are encountered. General anaesthesia with relaxation is probably wiser in most patients. Prophylactic antibiotics are advisable. The catheter should be placed so that the subcutaneous tube and exit site is located either above or below the belt line, preferably on the opposite side to the side on which the patient normally sleeps (Fig. 18(a)) 398. The peritoneum is best reached via the lower rectus sheath. A vertical or transverse incision can be used, opening the anterior rectus sheath. The rectus muscle can either be split or swept laterally to allow access to the posterior rectus sheath/transversalis fascia. A small incision in the peritoneum is then made, and a purse-string suture inserted. The catheter is then lubricated with sterile glycerine, loaded on to a blunt ended introducer and gently inserted along the anterior abdominal wall, over the bladder (and uterus in the female) and then slid down in front of the rectum. Some surgeons prefer to make a bigger peritoneal incision and insert the catheter under direct vision using sponge-holding forceps. A larger peritoneal incision also allows omentectomy to be performed safely, an addition that may reduce catheter failure due to occlusion by omentum. Omentectomy has been described as particularly important for peritoneal dialysis in children, although doubt has recently been cast on this dictum. The purse-string suture is then tied and stitched to the inner Tenckhoff Dacron cuff (Fig. 18(b)) 398. The peritoneum can then be pulled up to allow an encircling ligature below the purse-string that helps prevent leakage of fluid from the stitch-holes. The catheter is then tunnelled to allow a gentle curve away from the peritoneum with the second cuff at least 3 cm from the skin exit. The rectus muscle and sheath should be closed snugly around the catheter so as to keep the catheter pointing into the pelvis (Fig. 18(b)) 398, followed by the skin closure. On completion the catheter flow and absence of leakage should be tested by connection to a peritoneal dialysis bag and exchanging 1 l of saline rapidly.

The indications for catheter removal are repeated episodes of peritonitis, an infected catheter track unresponsive to antibiotics, loss of effective dialysis due to peritoneal thickening and return of renal function or a successful transplant rendering the catheter redundant. Removal can usually be accomplished under local anaesthesia. It is usually necessary to reopen the original insertion wound, freeing both the internal and external Dacron cuffs (where present) using sharp dissection. After removing the catheter the rectus sheath defect should be closed using a non-absorbable suture if there is no infection, to avoid later incisional hernia.

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