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| Journal of Vascular Access 2002; 3: 154 - 157 |
| Roman tunnelling tool |
M. Canzi1, H. De Baz1, F. Roman1
1Nephrology and Dialysis Department, Azienda Ospedaliera “S. Maria degli Angeli”, Pordenone - Italy
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ABSTRACT
Abstract: The aim of this paper is to present an instrument that helps to create a subcutaneous path for central catheters used for hemodialysis, as well as a non traumatic internal introduction of Tesio’s catheters and other systems (Dacron cap). We have designed a tunneling tool which consists of a solid but light weight hand set, connected to an extension that ends with an olive shape dilator to be connected to a trocar. Thus, precise tunneling is guaranteed through a non traumatic procedure, allowing exact anchorage of catheters. (The Journal of Vascular Access 2002; 3: 154-7)
Key Words. Central vascular catheters, Hemodialysis, Roman tool
INTRODUCTION
The diffusion of central vascular catheters for chronic hemodialysis is in someways linked to the overall changes in the characteristics of the population using dialysis centers. The indications for central vascular catheterization now includes pathologies that were once excluded. Increased life span and/or dialysis age, as well as the concomitant pathologies such as uremia, all contribute to reduce the vascular beds available for the creation of arterio-venous fistulas (AVF).
Nevertheless, cardiovascular diseases should not be underestimated, and proximal AVF may contribute to worsen labile cardio-vascular status.
While placement of catheters in acute cases requires little attention because of brief duration in chronic cases, especially when catheter insertion represents the only or even the last resort to access the central vascular system, appropriate positioning becomes an essential issue for a long indwelling life.
When it becomes available, we hope that “The Roman Tunneling Tool” along with other insertion instruments for operators, whether nephrologists, surgeons or anesthesiologists, will allow easier and safer catheters positioning procedure through the subcutaneous path.
MATERIALS AND METHODS
The tool consists of a light hand set of 8.8 cm connected to an extension of 3.5 cm that ends with an oval shaped dilator, on the tip of which there is a riveted hole of a suitable caliber to be hooked to the trocar, to a Galli tunnelizer or something similar (Fig. 1).
This extension is angled at 25 degrees in respect of the hand set to allow easier maneuvers ability in patients with short necks or in others who have difficulty extending the neck during the procedure (Fig. 2).
As far as Tesio’s catheter is concerned, these are the tips to be followed: after local anesthesia has been injected along the designated subcutaneous path, the trocar is inserted, already hooked to the tunnelizer, in the subcutaneous path through a small incision previously made for the insertion of the catheter.
The trocar is pushed through the subcutaneous layer over the fascia, parallel to the sternum, it is then forced to exit the skin at about 8 cm (Fig. 3).
The oval dilator is gently pushed till it reaches the site where the anchorage is to be placed. The trocar is gently pulled to allow the Roman to be unscrewed. It is then connected to the catheter and again pushed forward, exiting the skin together with the catheter, to which it is already attached (Fig. 4).
Thus, the anchorage is placed in the exact position previously decided. The advantage is that tissues are not dilated more than necessary for the insertion of catheters, thus allowing a better anchorage, especially in the first few days following the procedure, before the spontaneous fibrous sheath is formed around the catheter.
For those catheters already equipped with fixed external connectors for which it is necessary to insert the catheter in the tunnel before venous cannulation, a small skin incision of about 3 mm over the planned exit site has to be initially performed. Through this incision the trocar is inserted, connected to Roman, thus the anchorage (usually a dacron cuff) is positioned through a lower approach (Fig. 5).
The tool is then extracted to allow the unscrewing of Roman, the catheter is connected and pulled out in the site where the skin was incised to insert the intravenous guidewires. The next maneuver is a standard cannulation of the vein. There is no need to suture the exit site incision since Roman dilates the skin and the subcutaneous tissue without any laceration. Thanks to the normal elastic proprieties of tissues that will immediately strengthen around the catheter, hemostasis is immediately achieved.
DISCUSSION
In the United States, Raulerson created “The Football Tool” for Medcomp company. This disposable device, which is included in Tesio’s kit, has a limited maneuverability due to lack of a proper hand set and therefore is of limited use.
Roman Tunneling Tool came to life after realizing the necessity to improve the Raulerson Football Tool. Included in the surgical instruments used for central venous cannulation, it provides a real benefit for an easier and a more precise positioning, not only for Tesio’s catheter but also for all other indwelling venous catheters provided with an internal anchorage system (Dacon cuff).
Our experience (1, 2) supported by medical literature (3) revealed that infectious complications are reduced when subcutaneous tunnelization of about 8 cm is performed after the insertion of central venous catheters. The tunnel has to be parallel to the sternum to reduce the “back and forth” movements of catheters due to the movements of the ipsilateral upper limb, the heart beats and the respiratory movements. The correct positioning in this setting requires the anchorage device to be placed in the best site without lacerating adjacent tissues. It is worth mentioning that minimal lacerations due to subcutaneous dilatation by using a forceps could provoke small bleeds that can compromise the reliability of the anchorage system and increase the risk of infection in the subcutaneous tissue. Therefore it is advisable to perform smooth and progressive subcutaneous tunneling. Roman’s Tool represents a smart solution to guide with precision, the anchorage device to its final destination, thanks to its secure and firm handling.
In both the subcutaneous approach (Tesio’s catheters) as well as the cutaneous approach (catheters inserted through the skin exit site), tissues are to be divaricated only until the exact anchorage position is achieved.
Due to their elastic proprieties, the “exhausted” tissues will regain rapidly by strengthening around the catheter. The reinforcement of the catheter position represents an essential issue especially in the first few weeks following insertion.
In conclusion, in our experience the “Roman Tunneling Tool” proved to be suitable for tunneling procedures. Compared to Raulerson Football Tool, it is more manageable and therefore has a better maneuverability. Being a surgical device, it should be included in the standard surgical equipment for the insertion of all types of central vascular catheters. In our Unit all surgical equipment includes one Roman Tunneling Tool for the canulation of central vascular bed using Tesio’s catheters.
Reprint requests:
M. Canzi, IP
Nephrology and Dialysis Dept.
AO Santa Maria degli Angeli
33170 Pordenone, Italy
REFERENCES
1. Panarello G, De Cicco M, Chiaradia V, Tesio F. Microbial colonization of parenteral nutrition catheters. A prospective trial on microbial sources, access routes and tunnelization technique. In: Bambauer R, ed. Acta of an International symposium on vascular access for blood purification methods and catheter technology. Wolfang Pabst Verlag, 1988; 9: 454-9.
2. De Cicco M, Panarello G, Chiaradia V, Tesio F. Source and route of microbial colonization of parenteral nutrition catheters. Lancet 1989; II: 1258-61.
3. Cimochowski GE, Worley E, Rutherford WE, Sartain J, Blondin J, Harter H. Superiority of the internal jugular vein over the subclavian access for temporary dialysis. Nephron 1990; 54: 154-61.
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M. Canzi
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