ORL10

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SO a patient needs CRRT is a vasculopath and has had b/l upper extremity fistulas, clotted IJ's, etc.

You have the femoral veins, with an IVC filter, or the subclavian vein in a patient in DIC, but you need dialysis emergently.

Where do you go in the groin with an IVC filter, or in a non-compressible place in a coagulopathic guy with probably some stenosis (prior tunneled catheters)?

Just curious
 

TimesNewRoman

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SO a patient needs CRRT is a vasculopath and has had b/l upper extremity fistulas, clotted IJ's, etc.

You have the femoral veins, with an IVC filter, or the subclavian vein in a patient in DIC, but you need dialysis emergently.

Where do you go in the groin with an IVC filter, or in a non-compressible place in a coagulopathic guy with probably some stenosis (prior tunneled catheters)?

Just curious
Consult palliative.
 

DrBowtie

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Get IR to do a translumbar direct IVC or transhepatic dialysis access.
 

jdh71

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SO a patient needs CRRT is a vasculopath and has had b/l upper extremity fistulas, clotted IJ's, etc.

You have the femoral veins, with an IVC filter, or the subclavian vein in a patient in DIC, but you need dialysis emergently.

Where do you go in the groin with an IVC filter, or in a non-compressible place in a coagulopathic guy with probably some stenosis (prior tunneled catheters)?

Just curious
Try to talk him in comfort care?? Lol.

Is IR any help at your shop?? I might see if they can wire past the IJ clots.

I'd probably toss it in the fem, get things started and come up with a better plan.
 
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ORL10

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IR is helpful form 7a-7p, I wasn't sure if because the catheter is 30cm long going through the femoral with an IVC filter was an absolute contraindication. Its what I did, its flowing, and it doesnt seem like the IVC filter was dislodged, but I shorted the catheter and the guidewire just in case. Anyone have bad experiences with IVC filters and femoral vv access, its few and far between Im going in the groin on anyone these days.

Trust me Im all about palliation, it was a no go here and he was still reasonably young (60's), even though we all know how this will end.
 
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pulmoblast

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I may have done a subclavian too in this patient but depends upon the anatomy, and his bleeding risk...
 

sluggs

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Mostly in emergencies. If I have time I try to at least look at the subclavian vein on both sides to pick the bigger one and see my angle better
 

Hawaiian Bruin

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You could try USG supraclavicular subclavian as well, I've had good success with that in similar scenarios.
 

Ezekiel2517

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How technically difficult is that? I've always wanted to try it but haven't.
U/S guided subclavians are not technically difficult in most pts but obviously you should see someone do one before you attempt. Also need some decent U/S skills. Some good videos online. Scan to see if you can find a good target. Some pts will not have one and so I'll choose another site. But I don't think U/S is useful for subclavians, generally just wastes time. My line of choice is blind left subclavian unless contraindicated.
 
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ORL10

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I do subclavians all the time, but in dialysis patients with who have clotted their IJs they are likely to have some stenosis. You put a dilator through the back wall in the subclavian you now have a hemorrhage in a difficult place to control, nobody wants to go after a subclavian vv perforation. Not to mention this guy is coagulopathic.

When I called my vascular surgeon for his advice he said "i'd never put a line above the diaphragm in a guy like that without a venogram". Then the question becomes should I go femoral with an IVC filter, which I did, but definitely did not feel good about.
 

pulmoblast

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My preferred way is a blind subclavian too...but I usually only do them in a semi resus/urgent situation where I can't get the groin for whatever reason ... With US being standard of care...I imagine it would be tough defending a complication with a blind line in any thing but an urgent/resus situation
 

VentdependenT

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Blind subclavian is my goto line. i do not put them in blindly if pt has DIC or on heparin/argatro ggt. In that case I will do ultrasound guided approach. A US guided is basically an axillary line IMHO.

Stuffing a dialysis catheter in the supraclavicular fossa can be a challenge but I think ive done it before.

My second favorite is US guided supraclavi subclavian. Clean, slick, and easy.
 

engineeredout

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Aren't there intracardiac dialysis lines? Not that any CT or vascular surgeon is gonna place one with the guy in DIC, but was just curious if anyone has had experience with these. Heard about them but never seen one before.

And a 30cm dialysis line? Seems long, I think our longest are 20cm
 
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I'd put that line in his groin and cross my fingers it doesn't molest the IVC filter. I'm not interested in a subclavian approach in someone who is coagulopathic. Truth is there are not good options here. Rearranging deck chairs on the titanic.