Radiological placement is consistently more reliable than surgical placement. There are fewer placement complications and fewer catheter infections overall. It is convenient for the patient, quick, time saving, and cost effective Interventional radiologists placement and management research and development of hemodialysis catheters

1. Permcath Placement; Role of
Interventional Radiologist
Dr. Muhammad Bin Zulfiqar
PGR IV FCPS Services Institute of Medical
Sciences / Hospital
radiombz@gmail.com

2. Idea Behind Permcath
• Central venous catheters (CVC) or lines (CVL)
refer to a wide range of central venous access
devices but can broadly be divided into four
categories. They may be inserted by
physicians, surgeons or radiologists.

3. Classification
peripherally inserted central catheters (PICC)
non-tunnelled CVCs
 e.g. used in ICU or ED for emergent or short-term (<7-10
days) access
 e.g. Vascath used for haemodialysis, apheresis, stem cell
collection, etc
tunnelled CVCs
 e.g. Hickman catheters, Broviac line, Permcath
implantable ports
 e.g. Port-a-Cath, Infus-a-Port
 may be located in the chest or arm (brachial)
 may be single or dual lumen
K.D. and Surgical Placement of Central Venous Catheters. Cardiovasc Intervent Radiol (1997) 20:17-22
Scott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658

4. Permacath
• Permacath (or permcath)
are a type of tunneled
central venous catheter. It
is a split catheter - this
means that the two
lumens have unequal
lengths with one opening
a few centimeters distal to
the other giving a
staggered or step tip
appearance. It is often
used for hemodialysis.
1. Funaki B. Central venous access: a primer for the
diagnostic radiologist. AJR Am J Roentgenol. 2002;179 (2):
309-18.

5. Advantage of tunneled and Temporary catheter
• Less infection, Long duration (1-12 months),
less malpositioning, reliable and comfortable.

6. Port Catheter resovoirs
• A Port is a catheter placed in a vein of
the neck, chest or arm under
ultrasound guidance. This long
catheter has it's tip in the main vein
near the heart and has a reservoir
implanted under the skin surface
• long term intravenous therapy like
chemotherapy.
• The reservoir or port can be accessed
through the skin surface with a special
needle.
• Once the tiny incision heals the entire
system is beneath the skin and less
prone to infection. Port catheters can
remain implanted for years.
Scott O. Trerotola, MD. Hemodialysis Catheter
Placement and Management1. Radiology
2000; 215:651–658

7. PICC Catheter
•
A PICC line is a catheter
which is placed in the arm
with ultrasound guidance to
Superior Vena Cava. It has no
reservoir ,exits through the
skin and can only be left in
place for up to six months.
• The venous access catheters
described above are placed
in the angiography room
utilizing both ultrasound and
x-ray guidance under sterile
conditions.

8. Characteristics of an Ideal Catheter
• Easy to insert and remove
• Inexpensive
• Free of infection
• Free of fibrin sheath (“invisible to body”)
• Does not cause venous thrombosis or stenosis
• Delivers high flow (>400ml/min) reliably
• Durable
• Comfortable and acceptable to the patient
Scott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658

9. Sites
• most commonly including:
• internal jugular vein
• subclavian vein
• femoral vein (typically only short-term access)
• For PICCs and implantable ports)
– brachial
– basilic
– cephalic veins
K.D. and Surgical Placement of Central Venous Catheters. Cardiovasc Intervent Radiol (1997) 20:17-22
Scott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658

10. Preprocedure Mapping
• Look for SVC, Right Brachiocephalic vein, Internal
jugular Vein and subclavian vein under USG
guidence for any evidence of
• Stenosis and occlusion
• Thrombosis
• Occlusion
• Variation in anatomy
• Collaterals
• Accessory Veins.
K.D. and Surgical Placement of Central Venous Catheters. Cardiovasc Intervent Radiol (1997) 20:17-22
Scott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658

11. Technique
• Informe and written consent,
• Sedation
• Aseptic measures
• One small incision in the skin commonly in the
lower neck. Using ultrasound guidance, the
vein is punctured with a needle (usually the
jugular vein at the base of the neck), and a
small guide wire is advanced into the superior
vena cava.

12. Technique
• A second small skin incision may be made below the
first, and a tunnel under the skin is then created.
• Using USG guidance, the catheter is placed through
the tunnel into the vein, and the tip of the catheter is
placed into the SVC.
• Finally, stitches applied.

13. Normal Position of Permcath
• Right internal
jugular vein
permacath with
distal tip at the
cavo-atrial
junction. No
pneumothorax.

14. Malpositioned Permcath
• The proximal
permacath tip is
malpositioned in
the right internal
jugular vein.

15. Complications
• pneumothorax
• haemothorax
• infection
• mediastinal haematoma
• infusothorax
• arterial placement
• perforation of vein needing a stent
• pinch off syndrome
• retained guidewire
• guidewire shearing and fragment embolisation
K.D. and Surgical Placement of Central Venous Catheters. Cardiovasc Intervent Radiol (1997) 20:17-22
Scott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658

16. Take Home Message
• Radiological placement is consistently more
reliable than surgical placement. There are fewer
placement complications and fewer catheter
infections overall.
• It is convenient for the patient, quick, time
saving, and cost effective
• Interventional radiologists
– placement and
– management
– research and development of hemodialysis catheters
K.D. and Surgical Placement of Central Venous Catheters. Cardiovasc Intervent Radiol (1997) 20:17-22
Scott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658
Lund G.B. et.al. Outcome of Tunneled Hemodialysis Catheters Placed by Radiologists’ Radiology 1996; 198:467-472