"Exotic" Hemodialysis Catheter Sites

You can probably tell that I am working my way through the most recent NephSAP on Vascular Access, as I keep on posting access-related posts. Today while leafing through the section on dialysis catheters, I was amused to read the following sentence:

"When all access sites have been exhausted, exotic sites such as transhepatic or translumbar locations can be used for placement of a tunneled dialysis catheter."

I found the phrase "exotic sites" somewhat amusing since for most people it should conjure up images of the Bahamas and South Pacific islands---definitely a scene involving palm trees, for me--rather than bizarre locations for dialysis catheters. It is a strange world nephrologists live in...

Besides transhepatic and translumbar locations, other "exotic sites" include the brachiocephalic vein (this case series by Falk describes 33 different patients who received a brachiocephalic catheter under ultrasound guidance with generally good results), the iliac vein (this report by Betz et al points out that while successful at providing dialysis, there exists the possibility of vascular damage which could make subsequent renal transplantation problematic), and even the great saphenous vein of the thigh (see article by Yates et al), which may be important in individuals who have stenosed or occluded central veins.