Department of Surgery, Leicester General Hospital, Leicester, UK
Correspondence and offprint requests to: Mr Steven White, MD FRCS, Department of Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
Keywords: haemodialysis; iliac; renal transplantation; vascular access; vein
Introduction
Achieving adequate vascular access is a major impediment to the long-term success of haemodialysis. Central venous cannulation has proven to be one of the more efficient methods either via the internal jugular or subclavian vein. Unfortunately, the latter route is prone to a high incidence of failure because of stenosis or thrombosis and in particular may prohibit the subsequent creation of an arteriovenous fistula in the ipsilateral arm [1]. However, substantial difficulties can arise when both these routes are unsuitable. We describe a new alternative site for secondary central venous access.
Technique
Cannulation of the deep circumflex iliac veins can be performed with either general of local anaesthesia. The patient is placed in the supine position and the external iliac veins approached via an 8 cm muscle cutting incision, placed 2 cm superior to the inguinal ligament. The peritoneum is swept superiorly and the distal external iliac vein is dissected and controlled with vascular slings. Similarly, the deep circumflex iliac vein is controlled using two 3/0 polygalactin ties (Ethicon, Edinburgh, UK). The deep circumflex iliac vein arises from the lateral aspect of the external iliac vein immediately superior to the inguinal ligament, it passes anterior to the external iliac artery (Figure 1). A stab skin incision is made approximately 5 cm from the anterior superior iliac spine and a double-lumen vascular access catheter (Quinton Instrument Co, USA) is tunnelled through both the abdominal wall muscles and the rectus sheath into the iliac fossa. The catheter is introduced into the deep circumflex iliac vein via a small transverse venotomy and is advanced into the external iliac vein so that the tip can be positioned in either the common iliac vein or inferior vena cava (Figure 1
). The catheter is secured with a non-absorbable ligature placed around the vein, and in addition the Dacron® cuff can also be conveniently sutured to the abdominal wall muscles of the lower wound flap. Patency of the catheter is confirmed by flushing with hep-saline. The wound is closed using a mass closure technique with a non-absorbable suture and the skin according to the surgeons preference. The extra-abdominal portion of the catheter is then carefully secured to the skin of the abdominal wall.
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Discussion
With the current shortage of donors for renal allotransplant programmes there is an increasing population of patients who need long-term maintenance haemodialysis. In a proportion of patients, continuous ambulatory peritoneal dialysis is no longer a viable proposition because of obliteration of the peritoneal cavity through recurrent peritonitis and obstruction of the superior vena cava, secondary to numerous attempts at internal jugular/subclavian vein catheterization both making haemodialysis difficult. With this in mind, alternative options for vascular access become extremely limited.
The technique of deep circumflex iliac venous cannulation is simple to perform, either with local or general anaesthesia. The external iliac vein has been previously described as a secondary site for central venous cannulation but has been predominantly practised by percutaneous techniques under radiological guidance, thus increasing the risk of inadvertent puncture of the external iliac artery [2]. However this risk is minimised by using an open surgical technique. Also, by introducing the catheter via a tributary of the external iliac vein the iliac venous system can be preserved without the need for excision or repair and in our experience has not compromised the future prospect of renal transplantation. Nevertheless it must not be forgotten that there is still a risk of sepsis and thrombosis [2] but this technique is still a useful alternative for vascular access when other modalities are not available.
References